This is Professor David Gillatt's second blog on the site. Here, he talks about the indications for salvage radical prostatectomy for prostate cancer, its indications and some of the difficulties encountered in this rarely performed surgery.
David, can you explain what salvage prostate cancer surgery is?
As we all recognise, unfortunately, in a minority of cases treated for prostate cancer the disease will recur despite that treatment. When a man has had radiation treatment for what appears to be prostate cancer confined to the prostate or its immediate surrounds, some will in time show evidence of the cancer reappearing and starting to progress. This will also happen in the less common situation of the cancer being treated with other local therapies such as cryotherapy, high intensity focussed ultrasound or brachytherapy. The disease comes back either because the treatment failed to control the cancer within the prostate or there was disease already microscopically beyond the gland which will eventually lead to spread. If the recurrent cancer is still within the prostate and detected early it may still be at a curable stage. This is the point at which we can consider salvaging the situation by surgically removing the prostate and the recurrent cancer therein.
If a patient has failed another treatment, what are the factors determining suitability for salvage surgery?
Salvage surgery is a local therapy and as such it will only remove or cure a cancer if still within the prostate. Therefore a judgement needs to be made when recurrence has occurred as to whether the disease has a high likelihood of being localised or are there features that suggest the probability of at least micrometastatic cancer.
Recurrence usually is suspected because the serum PSA begins to rise after falling to low levels after initial therapy. A variety of definitions of recurrent cancer after radiation have been used; the ASCO (American Society of Clinical Oncology) defined failure as the lowest PSA (nadir) after therapy plus 2 units of PSA is the most commonly accepted. This is applied by many to all forms of local therapy, apart from surgery, for prostate cancer.
If recurrence is suspected in my view a thorough search for obvious metastatic disease, including CT chest/abdomen/pelvis, isotope bone scan and occasionally PET scanning is mandatory. MRI and occasionally Choline PET scanning may define local recurrence. Antibody labelled isotope scanning (Prostascint for example) has been evaluated but is not in routine usage. The presence of obvious metastatic disease or locally advanced T3/4 N+ cancer will usually be a contraindication to salvage surgery.
A biopsy is again essential to define local recurrence and may be done once imaging has confirmed that the disease has not obviously spread. Confirmation of local recurrence in the absence of spread may be an indication for salvage surgery.
One further factor that must be taken into account is the behaviour of the patient’s PSA. The PSA velocity or doubling time give an indication of how much risk of progression the cancer poses to the individual over their lifetime. A rapid doubling of PSA, less than every 3 months, confers a high risk of the cancer spreading and resulting in early death. A slow doubling, more than one to two years, indicates a risk as low as perhaps 10 % of the cancer progressing over the next 10 years or more. As with many stages of prostate cancer there is a balance between needing to treat successfully those at high risk of causing damage and death and not over treating those with a very low risk of progress.
In summary a man with prostate cancer previously treated with radiation with PSA evidence of recurrence requires specialist assessment. A variety of factors including the stage of the cancer, the PSA behaviour and the life expectancy of the individual need to be considered before embarking on salvage surgery.
Obviously, this is difficult surgery. Can you outline the side effects of the operation?
This type of surgery, whether performed by the open route, laparoscopically or with robotic assistance is undoubtedly far more difficult and complex than primary radical prostatectomy. The effect of radiation, or indeed HIFU or cryotherapy, results in marked tissue reaction around the prostate. The prostate lies very close to many important organs and the effect of radiation is to make dissection of these areas more difficult and the risk of injury to other structures much more likely. Even when injury does not occur the healing of tissues is less certain following radiation. Collateral radiation effects on the distal urethral sphincter, neurovascular bundles and bladder neck may also make functional recovery slower and long term side effects more likely.
The rectum lies close to the posterior prostate and will often be quite stuck after radiation. Surgical dissection needs to be very careful in this region as injury to the rectum increases the risk of infection, fistula (a connection between the bowel and bladder resulting in urine leaking into the rectum) and the need for a colostomy. While this complication is still uncommon it is more so than after radical prostatectomy with no prior radiation.
Incontinence is common in the short term after radical prostatectomy, resolving relatively rapidly in most. After salvage radical prostatectomy, the risk of incontinence is much higher, the time to recovery longer and long-term problems more common. At least 30-40% of men may experience long-term continence issues, some requiring correction, after salvage prostatectomy.
Sexual dysfunction, mainly erectile problems, are very common after salvage prostatectomy as the bundles may well have been compromised by the radiation before embarking upon a difficult salvage procedure.
Because of fibrosis (scarring) around the bladder neck subsequent contractures requiring dilatation are common and in some will further increase the chance of long-term continence problems.
Can the operation be performed by laparoscopic or robotic methods?
The answer is yes; salvage prostatectomy can be performed by any of the recognised methods of radical prostatectomy. Is there evidence in favour of one procedure over another? – There is no evidence as there have been no trials comparing the techniques in this situation. As with many difficult procedures the likelihood of a successful outcome will in large part depend upon the experience of the surgical team dealing with the operation.
You are a high volume prostate cancer surgeon, but this is quite a rare operation. How many of these salvage prostatectomy operations do you perform per year?
Salvage prostatectomy is an uncommon operation even in very large busy prostate cancer centres. Even in US centres where 3-6,000 or more robotic prostatectomies have been performed the number of salvage cases is often far less than 100. The Bristol experience has been around 2000 open radical prostatectomies of which around 65 were salvage and over 1000 robotic cases, in 21 cases these were salvage cases. Our outcomes including functional recovery have been very good. However as these numbers suggest, most specialist units are very selective about to whom they offer salvage radical prostatectomy.
One interesting question is should we be considering more men for salvage RP? Undoubtedly the answer is yes. The perceived morbidity of all salvage treatments and the uncertainty as to which men most benefit from this approach has led many oncologists to take an observational approach. It is the urological cancer surgeons’ role to convince our Medical and Radiation oncological colleagues that appropriate salvage surgery can deliver a high chance of cure to men with locally recurrent prostate cancer at risk of progression in their lifetime with acceptable functional outcomes. It is my belief that minimally invasive surgery, in particular robotically assisted LP, offers the opportunity for the experienced prostate cancer surgeon to deliver salvage surgery safely, effectively and with rapid recovery times.