Salvage Therapy for Prostate Cancer

Preface
Acknowledgements
Contents
About the Authors
Abbreviations
1: Systematic Review of Open, Laparoscopic and Robotic Salvage Radical Prostatectomy
	1.1	 Introduction
	1.2	 Systematic Review Methods
	1.3	 Results
		1.3.1	 Open Salvage Prostatectomy Results
		1.3.2	 Laparoscopic Salvage Prostatectomy Results
		1.3.3	 Robotic Salvage Prostatectomy Results
	1.4	 Comparison of Outcomes
	1.5	 Discussion
	1.6	 Concluding Remarks
	References
2: Salvage Prostatectomy for Radio-Recurrent Prostate Cancer
	2.1	 Introduction
	2.2	 Histopathological and Morphological Radiation-Induced Modifications of Pelvic Tissues
	2.3	 Radio-Recurrent Prostate Cancer Patients’ Selection
	2.4	 Pre-SRP Staging
	2.5	 Salvage Radical Prostatectomy: Surgical Technique
		2.5.1	 Endopelvic Fascia Incision
		2.5.2	 Posterior Plane Dissection
		2.5.3	 Prostate Apex Dissection
		2.5.4	 Neurovascular Bundle Dissection
		2.5.5	 Role of Experienced Surgeons
	2.6	 Oncological Outcomes
	2.7	 Functional Results
		2.7.1	 Surgical Complications
		2.7.2	 Blood Loss
		2.7.3	 Rectal Injury
		2.7.4	 Anastomotic Leakages
		2.7.5	 Urethral Strictures
		2.7.6	 Continence and Erectile Function Preservation
	2.8	 Future Directions
	2.9	 Conclusions
	References
3: Salvage Robot-Assisted Radical Prostatectomy for Recurrent Localized Prostate Cancer after Radiation Therapy
	3.1	 Current Position of Salvage Radical Prostatectomy
	3.2	 Indication and Preoperative Assessment
		3.2.1	 Indication
		3.2.2	 Preoperative Assessment
	3.3	 Surgical Technique: Contribution of Robotics
		3.3.1	 Patient Positioning and Surgical Approach
		3.3.2	 Lymph Node Dissection / Risk of Oedema
		3.3.3	 Endopelvic Fascia Dissection
		3.3.4	 Posterior Dissection of the Prostate
		3.3.5	 Apical Dissection
		3.3.6	 Vesicourethral Anastomosis
	3.4	 Results
		3.4.1	 Perioperative Outcomes—Intraoperative Data
			3.4.1.1	 Blood Loss and Operative Time
			3.4.1.2	 Rectal Injury
			3.4.1.3	 Recto-bladder Fistula
		3.4.2	 Perioperative Outcomes–Postoperative Data
			3.4.2.1	 Anastomotic Leakage
			3.4.2.2	 Anastomotic Stricture
			3.4.2.3	 Postoperative Complications
	3.5	 Oncological Outcomes
	3.6	 Functional Outcomes
		3.6.1	 Postoperative Continence
		3.6.2	 Postoperative Erectile Dysfunction
	3.7	 Conclusion
	References
4: Disease Recurrence after Radical Prostatectomy
	4.1	 Rising Prostate-Specific Antigen (PSA) after Prostatectomy
	4.2	 Persistent PSA after Prostatectomy
	4.3	 Incidence of Recurrence
	4.4	 Risk Stratification in Patients with Post-Prostatectomy Recurrence or PSA Persistence
		4.4.1	 Post-Prostatectomy Recurrence
		4.4.2	 Persistently Elevated PSA after Prostatectomy
	References
5: Salvage Therapy in Prostate Cancer: Predictors of Recurrence
	5.1	 Research Methods
	5.2	 Systematic Review Results
		5.2.1	 Predictors of Response Post Salvage Whole Gland HIFU
	5.3	 Predictors of Recurrence after Salvage Radiotherapy for Prostate Cancer
	5.4	 Predictors of Recurrence after Salvage Brachytherapy
	5.5	 The Role of Imaging in Predicting Recurrence in Salvage Therapy for Prostate Cancer
	5.6	 Predictors of Recurrence for Salvage Radical Prostatectomy
	5.7	 Predictors of Recurrence for Salvage Cryosurgery
	5.8	 Predictors of Recurrence in Salvage Hormone Therapy
	5.9	 Systematic Reviews Related to Search Terms
	5.10	 Conclusion
	References
6: The Role of MRI in Recurrent Prostate Cancer
	6.1	 Introduction
	6.2	 Multiparametric MRI after Radical Prostatectomy
	6.3	 Multiparametric MRI after Radiotherapy
	6.4	 Multiparametric MRI after External Beam Radiotherapy
	6.5	 Multi-parametric MRI after Brachytherapy
	6.6	 Multiparametric MRI after Focal Therapy
	References
7: Clinical Staging/Diagnostic Imaging in Salvage Therapy for Prostate Cancer
	7.1	 Rising PSA—PSA Recurrence
		7.1.1	 Assessment of Local Recurrences
	7.2	 Persistent PSA Post Radical Prostatectomy
		7.2.1	 Imaging in Patients with Persistently Elevated PSA after Radical Prostatectomy
		7.2.2	 Choline PET-CT
		7.2.3	 Fluciclovine PET-CT
		7.2.4	 PSMA Pet-CT
	References
8: Imaging for Salvage Therapy in Recurrent Prostate Cancer
	8.1	 Introduction
	8.2	 Prostate-Specific Membrane Antigen (PSMA) Imaging
	8.3	 Performance and Impact of PSMA Imaging in Recurrent PCa
	8.4	 Where is the Place of PSMA Imaging before Salvage Lymphadenectomy
	8.5	 Conclusion
	References
9: The Role of PET in Salvage Therapy for Prostate Cancer
	9.1	 Research Methods
	9.2	 Systematic Review Results
		9.2.1	 PSMA PET Versus Choline PET for Salvage Lymph Node Dissection
		9.2.2	 The Role of PET Post Radical Prostatectomy
		9.2.3	 The Role of Fluciclone PET in Detection of Prostate Cancer Recurrence
		9.2.4	 PSMA-PET Guided Salvage Radiotherapy
		9.2.5	 Choline PET Guided Radiotherapy
		9.2.6	 The Role of PET in Salvage Lymph Node Dissection
		9.2.7	 The Role of Choline PET After Radical Radiotherapy for Prostate Cancer
		9.2.8	 The Role of PET Post Salvage Radiotherapy in Prostate Cancer
		9.2.9	 The Role of PET in Salvage Radiotherapy for Oligometastatic Disease
		9.2.10	 The Role of PET in Salvage Lymph Node Dissection
		9.2.11	 The Role of PSMA-PET in Biochemical Failure in Prostate Cancer
		9.2.12	 MRI Versus PSMA PET in Detection of Prostate Cancer Recurrence
		9.2.13	 PSMA PET Versus Choline PET in Detection of Prostate Cancer Recurrence
		9.2.14	 The Role of Choline PET in Detection of Prostate Cancer Recurrence
		9.2.15	 The Role of 18 FDG PET in Prostate Cancer Recurrence
		9.2.16	 PSMA PET Versus Choline PET Versus Standard CT in Prostate Cancer Recurrence
		9.2.17	 MRI Versus Choline PET in Biochemical Recurrence of Prostate Cancer
		9.2.18	 Choline PET Versus ACE PET in the Restaging of Recurrence Prostate Cancer
		9.2.19	 GRPr-PET in Biochemical Recurrence of Prostate Cancer
		9.2.20	 ACE PET in Detection of Recurrent Prostate Cancer
		9.2.21	 Choline PET Versus ACE PET for Recurrent Prostate Cancer
		9.2.22	 SPECT CT Versus PSMA PET in Recurrence of Prostate Cancer
	9.3	 Conclusions
	References
10: Salvage Radiotherapy
	10.1	 Impact of Post-operative RT in Patients with Persistent PSA
	10.2	 Radiotherapy Techniques and Protocols in the Post-prostatectomy Patient
	10.3	 Androgen Deprivation Therapy
	10.4	 Treatment Outcomes
		10.4.1	 Oncological Outcomes
		10.4.2	 Toxicity
		10.4.3	 Quality of Life (QoL)
		10.4.4	 Salvage Radical Prostatectomy
	References
11: Salvage Cryotherapy in Prostate Cancer
	11.1	 Research Methods
	11.2	 Systematic Review Results: Difficulties in Prostate Cancer Diagnostics with Salvage Cryotherapy
	11.3	 Post Salvage Cryotherapy Histological Findings
	11.4	 Outcomes from Salvage Cryotherapy in Prostate Cancer after External Beam Radiotherapy and Brachytherapy
	11.5	 Salvage Cryotherapy after Primary Radiotherapy for Prostate Cancer
	11.6	 Side Effects from Salvage Cryotherapy
	11.7	 Salvage Cryotherapy after Primary Cryotherapy
	11.8	 Outcomes and Toxicity between Salvage Prostatectomy and Salvage Cryotherapy
	11.9	 Predictive Factors for Recurrence in Salvage Cryotherapy
	11.10	 Clinical Factors Associated with Suboptimal Salvage Cryotherapy
	11.11	 Patient Reported Outcome Measures in Prostate Cancer
	References
12: Salvage Treatment after Focal Therapy for Recurrent Prostate Cancer
	12.1	 Introduction
	12.2	 Selection of Patients for Focal Therapy
	12.3	 Definition and How Focal Therapy is Performed
	12.4	 Prostate-Specific Antigen, mpMRI and Prostatic Biopsies for Follow-up After Focal Therapy
	12.5	 Definitions of Recurrence After Focal Therapy
	12.6	 Redo Focal Therapy—To Use the Same or Different Energy
	12.7	 Radiotherapy
	12.8	 Radical Prostatectomy
	12.9	 How Could the Recurrence Rate of Focal Therapy be Improved?
	12.10	 Addressing Prostatic Microenvironment
	12.11	 Conclusions
	References
13: Salvage Re-Irradiation After Locoregional Failure with Primary Radiotherapy for Prostate Cancer
	13.1	 Systematic Review Results: High-Dose-Rate Brachytherapy or Focal Stereotactic Body Radiotherapy for Local Recurrence after Primary Radiotherapy
	13.2	 Cyberknife Radioablation as Re-irradiation Post-Radiotherapy Failure in Prostate Cancer
	13.3	 External Beam Radiotherapy After Prostate Cancer Recurrence Post-Radiotherapy
	13.4	 Radiotherapy to the Prostate Bed—the Salvage Scenario
	13.5	 Ablative re-EBRT using Stereotactic Image-Guided Technique for Isolated Local Recurrence of Prostate Cancer
	13.6	 Side Effects of Salvage Re-irradiation Post-Primary Radiotherapy for Prostate Cancer
	13.7	 High Dose Rate Stereotactic Body Radiation Therapy in Prostate Cancer Recurrence Post Radiotherapy
	13.8	 External Beam Radiotherapy With or Without Brachytherapy Boost Post-Primary Radiotherapy Failure for Prostate Cancer
	13.9	 Conclusions
	References
14: Salvage Brachytherapy—Outcomes from Low- and High-Dose Brachytherapy in Prostate Cancer
	14.1	 Research Methods
	14.2	 Systematic Review Results: Outcomes from Low- and High-Dose-Rate Brachytherapy
	14.3	 Side Effects from Low- and High-dose Salvage Brachytherapy
	14.4	 Salvage Brachytherapy and ADT
	14.5	 Focal Partial Salvage Re-implantation after Permanent Brachytherapy
	14.6	 High-Dose Brachytherapy Outcomes after Radiotherapy
	14.7	 PSA Bounce Post High-Dose-Rate Brachytherapy
	14.8	 Conclusions
	References
15: Salvage Brachytherapy after Primary Brachytherapy in Recurrent Prostate Cancer
	15.1	 Research Methods
	15.2	 Systematic Review Results
		15.2.1	 Outcomes from Salvage Brachytherapy for Prostate Cancer after Primary Brachytherapy
		15.2.2	 Side Effects of Salvage Brachytherapy after Primary Brachytherapy
		15.2.3	 Radiation Dose During Salvage Brachytherapy after Primary Brachytherapy
	15.3	 Conclusions
	References
16: Focal Salvage Therapy for Prostate Cancer Recurrence After Primary Radiotherapy
	16.1	 Introduction
	16.2	 Assessment of Recurrence
		16.2.1	 Assessing of the Distant Metastases
		16.2.2	 Assessing of the Intra-Prostatic Recurrence
			16.2.2.1 Biopsy
	16.3	 Current Focal Salvage Treatment
	16.4	 Focal Salvage HIFU
	16.5	 Focal Salvage Cryoablation
	16.6	 Focal Salvage Stereotactic Body Radiotherapy (SBRT)
	16.7	 Focal Salvage High-Dose-Rate Brachytherapy
	16.8	 Focal Salvage Low-Dose-Rate Brachytherapy (LDRBT)
	16.9	 Focal Salvage Irreversible Electroporation (IRE)
	16.10	 Salvage Vesiculectomy
	16.11	 Conclusions
	References
17: Salvage Lymph Node Dissection
	17.1	 Introduction
	17.2	 Patient Identification
	17.3	 Imaging for Nodal Recurrence
	17.4	 Surgical Aspects of Salvage Lymph Node Dissection
	17.5	 Oncologic Results
	17.6	 Key Points
	References
18: Salvage Re-irradiation Therapy After Loco-regional Failure for Radiotherapy
	18.1	 Introduction
	18.2	 Detection of the Site of Recurrence
	18.3	 Available Treatment Options for Recurrent PCa After Primary RT
	18.4	 Salvage Radiation Treatment Options
	18.5	 External Beam Radiation Therapy
	18.6	 Brachytherapy
	18.7	 Low Dose Rate Brachytherapy
	18.8	 High Dose Rate Brachytherapy
	18.9	 Stereotactic Body Re-irradiation
	18.10	 Conclusions
	References
19: Role of Metastasectomy in Prostate Cancer Patients Following Primary Treatment
	19.1	 Introduction
	19.2	 Metastasectomy in Patients with Recurrence Confined to Non-regional Lymph Nodes
	19.3	 Metastasectomy for Skeletal (M1b) or Visceral (M1c) Disease
	19.4	 Skeletal (M1b Disease)
	19.5	 Lung (M1c Disease)
	19.6	 Liver (M1c Disease)
	19.7	 Testis and Penis (M1c Disease)
	19.8	 Ongoing Trials
	19.9	 Conclusion
	References
20: Incontinence of Urine after the Treatment of Prostate Cancer
	20.1	 Introduction
	20.2	 Anatomy and Physiology
	20.3	 The Effects of Treatment for Prostate Cancer on Outcome in Terms of Urinary Incontinence
	20.4	 Bladder Overactivity
	20.5	 Bladder Neck Obstruction with Chronic Retention and Overflow
	20.6	 Stress Urinary Incontinence
	20.7	 The Incidence of Urinary Incontinence
	20.8	 Investigation of the Patient
		20.8.1	 History
		20.8.2	 Causes of Incontinence in a Male after Prostate Cancer Treatment
		20.8.3	 Investigations
		20.8.4	 Treatment
	20.9	 Pelvic Floor Therapy and Management
		20.9.1	 Prologue
		20.9.2	 The Role of the Specialist Pelvic Health Physiotherapy in the Management of Urinary Leakage Following Prostate Cancer Treatment
		20.9.3	 Pelvic Health Physiotherapy
		20.9.4	 Pre-Operative Pelvic Health Physiotherapy
		20.9.5	 Pelvic Floor Function and Muscle Fibre Specificity
		20.9.6	 Pelvic Floor Exercises
		20.9.7	 How to Assess the Pelvic Floor Muscle Complex and Teach a Specific Pelvic Floor Contraction
		20.9.8	 How Often Should the Pelvic Floor Exercises Be Done and in What Position
	20.10	 An Introduction to the Principles of Pelvic Floor Exercises
		20.10.1	 Long Holds
		20.10.2	 Short Holds
		20.10.3	 The Knack
		20.10.4	 Exercise Frequency
		20.10.5	 Exercise Compliance
		20.10.6	 Post-Operative Pelvic Health Physiotherapy
		20.10.7	 Frequency/Volume Chart (FVC)
		20.10.8	 Subjective Examination
		20.10.9	 Conclusions
	20.11	 Medical Therapy
	20.12	 Surgical Intervention
		20.12.1	 Bulking Agents
		20.12.2	 The Male Sling
		20.12.3	 The Artificial Urinary Sphincter
		20.12.4	 Non-surgical Solutions
		20.12.5	 Conclusion
	References
21: Erectile Dysfunction in Salvage Prostate Cancer Therapies
	21.1	 Salvage Treatments for Radio-Recurrent Prostate Cancer
		21.1.1	 Salvage Radical Prostatectomy
		21.1.2	 Cryotherapy
		21.1.3	 High-Intensity Focussed Ultrasound (HIFU)
		21.1.4	 Brachytherapy
	21.2	 Salvage Treatments for Recurrent Prostate Cancer Post Radical Prostatectomy
		21.2.1	 External Beam Radiotherapy (EBRT)
		21.2.2	 Androgen Deprivation Therapy (ADT)
	21.3	 Treatments for Erectile Dysfunction
		21.3.1	 Structural Changes Post Prostatectomy
		21.3.2	 PDE5 Inhibitors
		21.3.3	 Intracavernosal Injections (ICI)
		21.3.4	 Vacuum Constrictive Devices (VCD)
		21.3.5	 Failure to Respond to Therapy: Penile Implant Surgery
			21.3.5.1	 Psychosexual Counselling
	21.4	 Summary
	References
Index