Salvage Prostatectomy

What is salvage prostatectomy?

Salvage prostatectomy is a surgical procedure performed to remove the prostate gland after initial treatment for prostate cancer — such as radiation therapy or focal therapy — has not been successful.

It is considered a second-line or “salvage” treatment option for patients whose cancer has returned or persisted locally within the prostate.

How it works

Salvage prostatectomy involves the complete removal of the prostate gland, along with some surrounding tissue if necessary. This is most often done through a robotic-assisted laparoscopic approach, which uses small incisions and specialised instruments to minimise trauma, although open surgery may sometimes be required.

Why do you need salvage prostatectomy?

Salvage prostatectomy is usually recommended for men who have undergone radiation therapy or other non-surgical treatments for prostate cancer, but whose cancer has returned (recurrence) or remained in the prostate (residual disease).

It may be considered if:

• PSA (prostate-specific antigen) levels begin to rise after initial treatment
• Imaging or biopsy confirms localised recurrence of prostate cancer
• The cancer has not spread to distant sites (i.e. there is no metastasis)
• You are in good overall health and able to tolerate surgery

The aim of the procedure is to achieve long-term cancer control or potential cure when other treatments have not been effective.

Are there alternatives to salvage prostatectomy?

Yes. While salvage prostatectomy is a recognised option after radiation therapy failure, it is not the only approach. Many patients and clinicians weigh the benefits of surgery against its potential risks and complications, and may opt for non-surgical alternatives such as:

• Observation or active surveillance, especially if the recurrence is slow-growing and the patient is asymptomatic or older.
• Hormone therapy (androgen deprivation therapy), which helps slow disease progression, especially when surgery is not suitable.
• Re-irradiation, such as stereotactic body radiotherapy (SBRT), is an emerging viable salvage option in selected cases. Studies show SBRT can achieve cancer contr

Who should not undergo salvage prostatectomy?

You may not be a suitable candidate for salvage prostatectomy if:

• Your prostate cancer has spread beyond the prostate (metastatic disease): This surgery is intended for localised cancer. If cancer has spread to other parts of the body, systemic treatments like hormone therapy or chemotherapy may be more appropriate.
• You have significant health issues that make surgery high risk: Conditions such as uncontrolled heart disease, lung disease, or other serious comorbidities may increase the likelihood of surgical complications or hinder recovery.
• You have poor urinary or bowel function before surgery: Salvage surgery can worsen continence and bowel symptoms, especially in patients who already have problems in these areas.
• There is extensive damage or fibrosis from previous treatment: Severe scarring from prior radiation or focal therapy may make the procedure technically unfeasible or increase the risk of complications such as rectal injury.
• You are not likely to benefit from surgery due to life expectancy or cancer aggressiveness: If your life expectancy is limited or the cancer is particularly aggressive and unlikely to be cured by surgery alone, other treatment options may be considered.
• You are unwilling or unable to manage the possible side effects: The risks of urinary incontinence and erectile dysfunction are higher after salvage prostatectomy. It is important to be mentally and emotionally prepared for these possible outcomes.

Your urologist and oncology team will carry out a detailed evaluation to determine if salvage prostatectomy is appropriate for you.

What are the risks and complications of salvage prostatectomy?

As with any major surgery, salvage prostatectomy carries potential risks and complications, particularly as the tissues have often been altered by prior radiation or ablative treatments. These include:

• Urinary incontinence (leakage of urine), which may be more common than in first-time prostate surgery
• Erectile dysfunction, due to damage to the nerves that control erections
• Bladder or rectal injury, due to scarring or fibrosis from previous treatments
• Anastomotic stricture (narrowing where the bladder is reconnected to the urethra)
• Infection, bleeding, or blood clots
• Prolonged recovery period due to the complexity of the surgery

Your doctor will discuss these risks with you in detail and help you weigh the benefits of salvage surgery against potential side effects.

What can you expect during a salvage prostatectomy?

Before the procedure

You will be admitted on the day of surgery or the night before. You may be given antibiotics to prevent infection, and anaesthesia will be administered so you remain asleep and pain-free during the operation.

During the procedure

The surgeon will remove the prostate gland and may also remove surrounding tissue or lymph nodes if required. Nerve-sparing techniques may be used where possible to preserve erectile function.

A catheter will be placed in your bladder to help drain urine post-surgery.

After the procedure

You will wake up in the recovery area and may stay in hospital for 2 – 4 days. Pain will be managed with medication.

The urinary catheter typically remains in place for 1 – 2 weeks.

You may experience temporary or longer-lasting side effects such as:

• Urinary incontinence
• Erectile dysfunction
• Fatigue or weakness
• Mild bleeding in the urine

Your care team will monitor you closely and provide guidance on managing these effects.

Care and recovery after a salvage prostatectomy

Most men can return to light daily activities within 4 – 6 weeks.

Full recovery, including regaining urinary control and sexual function, can take several months.

Your recovery time may be longer compared to men undergoing primary prostatectomy due to the complexities of salvage surgery.

Recovery tips

• Follow your doctor’s instructions for wound care and activity limitations.
• Attend follow-up appointments to monitor your PSA levels and recovery progress.
• Pelvic floor exercises (e.g. Kegels) can help improve urinary control.
• Stay active with gentle walking to aid circulation and healing.
• Be patient; emotional support and realistic expectations are key to coping with changes in continence or sexual function.

Recovery will depend on several factors, including the extent of previous treatment and tissue damage, your overall health and age, pre-existing urinary or erectile issues, and how well you follow post-operative advice.