Infla10® Pulse™Also Known As
Salvage radical prostatectomy (SRP), Salvage robotic radical prostatectomy (sRRP), Salvage cystoprostatectomy, Salvage lymphadenectomy, Rescue surgery, Secondary surgical intervention
Definition
Salvage surgery refers to rescue surgical procedures performed after the failure of previous treatments, particularly in the context of cancer recurrence.1 In urological practice, salvage surgery most commonly involves the surgical removal of the prostate gland (salvage radical prostatectomy) or bladder (salvage cystoprostatectomy) following unsuccessful radiation therapy or other non-surgical primary treatments.2 Salvage surgery represents a critical therapeutic option for patients with localized disease recurrence, offering the potential for cure when initial treatments have failed.3 The procedure aims to completely remove residual cancer tissue while minimizing damage to surrounding structures, though it is technically more challenging than primary surgery due to radiation-induced tissue changes and scarring.4
Clinical Context
Salvage surgery is clinically indicated when there is evidence of cancer recurrence or persistence following primary non-surgical treatment, particularly radiation therapy.1 Patient selection is crucial for optimal outcomes, with ideal candidates having a life expectancy of at least 10-15 years, clinical stage ≤T3 disease, biopsy-proven localized recurrence, and no evidence of metastases on pre-operative imaging.3
The decision to proceed with salvage surgery requires careful consideration of several factors, including pre-operative PSA levels, biopsy Gleason score, PSA doubling time, and the interval between primary therapy and recurrence, as these parameters have been shown to predict biochemical recurrence and development of metastatic disease following salvage procedures.1,3
Surgical approaches include open salvage radical prostatectomy, robotic-assisted salvage radical prostatectomy, and salvage cystoprostatectomy with urinary diversion.2 The robotic platform has gained popularity in recent years due to potential advantages including decreased blood loss, shorter hospital stays, and improved visualization of the surgical field, which is particularly valuable given the challenging nature of salvage procedures.3
Historically, salvage surgery has been associated with significant complications, with rectal injury rates approaching 15% and anastomotic stricture rates as high as 32% in early series.3 However, modern surgical techniques and increased experience have substantially improved safety profiles, with contemporary rectal injury rates falling to 2-5%.1,3 Functional outcomes remain a significant concern, with urinary continence (defined as requiring no pads) achieved in 43-56% of patients, and an additional 20% requiring one or fewer pads daily.1 Sexual dysfunction is common following salvage procedures due to the difficulty in preserving neurovascular bundles in the post-radiation setting.4
Long-term oncologic outcomes are encouraging, with overall 10-year cancer-specific survival rates of approximately 65%, and even better outcomes (77% 10-year cancer-specific survival) for patients undergoing salvage radical prostatectomy compared to those requiring more extensive procedures.1 Several pathological features of the removed prostate, including tumor ploidy, percentage of Gleason grade 4/5 disease, and pathological stage, have been identified as strong predictors of survival following salvage surgery.1