Surgery

Preoperative pelvic floor exercises

All patients should have access to specialist pelvic floor physiotherapy support prior to surgery, and within three months after surgery. It is the aspiration that this should be face-to-face, especially for men struggling with their continence post-operatively. 

Men should be provided with information to give them an insight into post-operative erectile dysfunction, and different treatment regimes. Consider offering PDE5 inhibitors to those who are very motivated to recover erectile function post op, and if available, they should also have the option to access specialist andrology services. 

A national cancer prehabilitation website is available, providing resources for patients and healthcare professionals at (www.prehab.nhs.scot ) 

Please see the supportive care section of the clinical management pathway for information about other support services that the pre-operative patient may require. 

Patients with prostate cancer who are candidates for radical treatment should have the opportunity to discuss the range of treatment modalities and their serious side effects in relation to their treatment options with a specialist surgical oncologist and a specialist clinical oncologist, all of whom should bear in mind the principles of realistic medicine.

Criteria

Any person who has a life expectancy of 10 years or more who presents with non-metastatic prostate cancer can be offered treatment with a curative intent. The assessment of life expectancy can be difficult and should be based on co-morbidities rather than simply age at presentation. Useful resources for assessing and counselling patients considering radical prostatectomy include the PREDICT Prostate tool   and the Memorial Sloan Kettering Cancer Centre (MSKCC) Nomogram . 

Risk stratification is based on the Cambridge Prognostic Group (CPG) criteria.

1. For people with Clinical Practice Guidelines (CPG) 1 (and some with CPG2) localised prostate cancer:  

• Offer active surveillance as preferred option. 

• Consider radical prostatectomy or radical radiotherapy if active surveillance is not suitable or acceptable to the person. 

2. For people with CPG 2/3 localised prostate cancer:  

• Offer radical prostatectomy or radical radiotherapy and

• Consider active surveillance for people who choose not to have immediate radical treatment. 

3. For people with CPG 4 and 5 localised and locally advanced prostate cancer:

• Do not offer active surveillance.

• Offer radical prostatectomy or radical radiotherapy to people in this cohort where it is likely the person's cancer can be controlled in the long term, accepting that their risk of needing a second line treatment is higher.
  
  
• Whilst there is no evidence of long term benefit of pre-operative treatment with LHRH agonists or antagonists, where surgical waiting times exceed 3 months then use of these agents may be discussed with the patient. 

All patients should have access to physiotherapy and erectile dysfunction support post-surgery. 

Any PDE5 inhibitor prescriptions to be left to physicians' discretion locally. 

If a patient is suffering from incontinence at 9-12 months, then consider urodynamics and onward referral for consideration of incontinence surgery in appropriate specialist centres. 

Please see the supportive care section of the clinical management pathway for information about other support services that the post-operative patient may require. 

Follow-up after treatment with curative intent.

After Radical Prostatectomy, Prostate-specific antigen (PSA) should be undetectable (<0.1ng/ml). A PSA of >0.2ng/ml and rising is associated with recurrent disease. After EBRT +/- Hormones, a PSA increase of >2ng/ml above the nadir is a valuable sign of recurrence.

Implement electronic PSA tracking and consider postal point-of-care testing, where available, to avoid unnecessary attendances. 

Definitions of biochemical relapse (BCR):

Post-surgery - PSA of ≥0.2ng/ml on two separate measurements. 

Recognised risk factors for metastatic relapse following radical prostatectomy: 

• Gleason score 8 or higher 

• Stage pT3b 

• PSA failure to nadir to <0.1ng/ml  

• PSA relapse within 3 years of surgery 

• PSA rising >0.4ng/ml 

• PSA-Doubling Time <3 months.

Investigation once BCR occurs:

If two PSA tests of 0.2 or above PSMA PET +/- MRI is recommended

• Consider PSA doubling time and time to PSA relapse as risk factors for occult metastatic disease. 

PSMA/Choline PET CT - Patients being considered for salvage therapy following negative or equivocal conventional imaging with a PSA relapse should have a PSMA PET, with MRI if required. Results reviewed at MDT. See Radiology section for more detail).

Salvage surgery following radiotherapy or focal therapy 

Imaging – All patients being considered for salvage surgery should undergo full staging with MRI and PSMA PET as soon as possible after biochemical recurrence (PSA  >2.0 above post-treatment nadir). 

Prostate biopsies (Transrectal Ultrasound Scan (TRUS)/Transperineal Biopsy (TPB) - Recommended in all men being assessed for salvage surgery, cryotherapy or focal BT.  

Biopsy recommended as well as full staging - MRI/PSMA PET and MDT discussion. Results of imaging and biopsies reviewed at MDM prior to treatment being discussed. 

Pre and post-operative data should be collected by all centres to allow assessment of recovery of erectile function and continence in alinement with current QPIs. This should be in the form of validated questionnaires (International Prostate Symptom Score/Expanded Prostate Cancer Index Composite (IPSS/EPIC)). 

• NICE guidance - NICE prostate-cancer-diagnosis-and-management-pdf- [PDS only]  
  
  

• GIRFT document - GIRFT-Urology-Towards-Better-Diagnosis-Management-of-Suspected-Prostate-Cancer-FINAL-V1-April-2024 [PDF only]  
  
  
• PREDICT Prostate tool
  
  
• The Memorial Sloan Kettering Cancer Center (MSKCC) Nomogram