How to cite: Inman BA. Salvage prostatectomy in 2025. Grand Rounds in Urology. October 2025. Accessed January 2026. https://grandroundsinurology.com/salvage-prostatectomy-in-2025/
Summary
This presentation provides a contemporary, pragmatic assessment of salvage prostatectomy for locally recurrent prostate cancer in 2025. Brant A. Inman, MD, MS, FRCSC, Professor of Urology and Oncology, Western University, London, Ontario, Canada, reviews how advances in imaging, surgical technique, and patient selection have reshaped the role of salvage radical prostatectomy within an increasingly complex salvage landscape.
Dr. Inman begins the discussion by defining begins by defining local recurrence after primary prostate cancer therapy and contrasts recurrence detection after radiation versus radical prostatectomy. Key challenges include delayed PSA nadir after radiation, the phenomenon of PSA bounce, and the importance of PSA doubling time in risk stratification. Dr. Inman emphasizes PSMA PET as a critical tool for distinguishing local from metastatic recurrence, citing large registry data demonstrating that PSMA PET alters management in the majority of patients and is associated with improved survival when treatment plans are modified accordingly.
Historical concerns surrounding salvage prostatectomy are reviewed, including high rates of rectal injury, incontinence, bladder neck contracture, and cystoprostatectomy reported by early high-volume series. These data explain why salvage surgery never became the default approach after radiation failure. Updated evidence is then presented, highlighting improved outcomes with modern robotic techniques, particularly reduced rectal injury and bladder neck contracture compared with open surgery.
Ideal candidate selection is discussed using contemporary guideline criteria, including PSA less than 10, absence of nodal or metastatic disease on PSMA PET, intermediate-risk disease at initial diagnosis, and adequate life expectancy. Dr. Inman strongly emphasizes biopsy confirmation prior to salvage intervention.
Alternative salvage strategies are reviewed, including cryoablation, HIFU, repeat radiation, and systemic therapy. Comparative data suggest similar cancer-specific survival across modalities, with differing toxicity profiles. Emerging approaches, including repeat radiation trials and systemic intensification with androgen receptor–targeted therapy, are discussed.
Dr. Inman concludes that salvage prostatectomy remains a reasonable option for carefully selected patients, particularly younger men seeking durable local control, with robotic posterior approaches offering improved safety in experienced hands.
About The 12th Urology Today Conference:
Presented by chair Ryan P. Terlecki, MD, FACS, the 12th Urology Today conference was designed to keep urologists, urologic oncologists, and other healthcare providers educated on the most pertinent issues in urology practices. Areas of focus included urologic oncology, men’s health and reconstruction, female urology, pediatric urology, kidney stones and related conditions, and methods of providing the best care amidst the required logistics of the business side of medicine.
ABOUT THE AUTHOR
Brant A. Inman, MD, MS, FRCSC, is Chin-Hardie Chair of Urologic Oncology and Professor of Urology and Oncology at Western University in London, Canada. Dr. Inman’s clinical specialties include cancers of the prostate, bladder, kidney, ureter and renal pelvis, testis, adrenal, penis, and sarcomas. He has a particular interest in inherited genetic syndromes that cause urological cancers and in complex cancers that require multi-disciplinary care. Dr. Inman performs surgery using a wide variety of methods including laparoscopic and robotic minimally invasive surgery, endoscopic surgery, and open surgery.
Dr. Inman earned his Bachelor of Medical Science and MD from the University of Alberta in Edmonton, Canada. He then completed a residency in Urology at l’Université Laval in Québec City, Canada. Dr. Inman subsequently completed a fellowship in Urologic Oncology and earned his Master’s in Clinical and Translational Research at the Mayo Clinic in Rochester, Minnesota.
Dr. Inman has served as a researcher for several projects including the development of new diagnostic tests for cancer, the development and testing of new treatments for cancer, understanding the immune response to cancer, and describing the genetic underpinnings of cancer. His research interests are in the field of urologic oncology, including clinical trials and translational research related to bladder, prostate, and kidney cancer. Dr. Inman has authored and co-authored over 240 publications in his field. He has been a member of Board of Directors of the Society of Urologic Oncology Clinical Trials Consortium, a member of the National Comprehensive Cancer Network bladder and penile cancer panel, a member of the Research Council and Research Grants and Investigator Support Committee of the American Urological Association, and a member of the Urological Research Society.
