Prostate gland has a narrow rim of periprostatic tissue usually less than 1 mm and is surrounded by important structures including rectum and urogenital diaphragm; so excision is likely to be extremely closer to the capsule. The international Society of Urological Pathology (ISUP) have issued recommendations on the handling, staging and reporting on RP specimens [14]. A positive surgical margin can be defined as tumor that extends to the surface of the prostate where the surgeon has excised across the tissue plane. Various studies have shown lack of correlation between margin distance and recurrence and residual cancer [15, 16]. Even when tumour has been 0.1 mm close to the resection margin there is mostly no evidence of tumour progression [15]. Several studies have shown that the extent of tumor however at the surgical margin correlates with postoperative disease recurrence [15, 17].

Removal of prostate for a localised and isolated recurrence with a curative potential may be considered in selected cases of recurrence after radiotherapy and brachytherapy [18], and less commonly after cryotherapy [19], high intensity focused ultrasound (HIFU) [20]. There are a number of options for patients with biochemical recurrence after radiotherapy. They include watchful waiting, androgen-deprivation therapy (ADT), or additional local therapy such as salvage radical prostatectomy (RP), salvage radical cystoprostatectomy, salvage cryotherapy, and salvage brachytherapy [21]. As there is no other definitive radical treatment for recurrence after radiotherapy, SRP remains the main treatment option. Oncologic outcomes in patients treated with salvage radical prostatectomy (SRP) are poorly defined and require further investigation. This is partly due to concerns regarding lack of efficacy and increased morbidity [22]. The published studies are often contain small sample; they are confined to single centres and the studies do not have end-points such as metastatic disease or cancer-specific survival or death.

Higher preoperative PSA levels are associated with disease progression and cancer-specific death after SRP. This means early detection of PSA doubling time followed by performing SRP early in the course of recurrent disease [23]. In a meta-analysis by Chade et al. [24], biochemical recurrence-free probability after SRP ranged from 47 to 82 % at 5 years and from 28 to 53 % at 10 year. Cancer-specific survival (CSS) and overall survival varied from 70 to 83 % and 54 to 89 % at 10 year follow up.

Some authors have described SLND as a treatment option for patients with prostate cancer relapse limited to the lymph nodes; however, more robust data derived from well-designed multicentre clinical trials are needed to validate the role of SLND in this selected patient population [25]. Imaging techniques, such as 11C-choline PET and diffusion-weighted magnetic resonance imaging, appear to enhance the accuracy in identifying LN relapse in patients with biochemical recurrence (BCR) and after RP.

The tumour itself can cause obstruction to the urine flow in the prostatic urethra causing outflow symptoms. In such cases medical therapy with alpha-adrenergic blocking drugs may not be that helpful. The resection is usually limited to widening the urethral passage. In prostates that have tumours infiltrating the pelvic floor musculature, TURP may lead to urinary incontinence. In patients with advanced CaP, palliative TURP can be performed safely with significant improvement in urinary symptoms. However, the rates of postoperative urinary retention and reoperation are higher than in patients undergoing TURP for BPH [26].

Uraemia as a result of malignant ureteric obstruction is a recognised event in men with advanced PCa, which, if left untreated, is quickly a terminal event or result in permanent renal damage [27]. Palliative decompression of the obstructed urinary system, either by percutaneous nephrostomy (PCN), ureteric stent or a combination of both is a recognised method of improving renal function, with presumed low morbidity. The obstruction may be in intramural part of ureter at the ureterovesical junction or extraluminal obstruction due to lymphadenopathy. The stenting probably is a permanent fixture in such cases. Endoscopic retrograde stenting had a success rate of 21 % whereas two-stage antegrade stenting was successful in 98 % of patients. The antegrade approach had minimal morbidity [28].

Removal of testes (orchidectomy) or only testicular tissue leaving behind tunica albugenia (subcapsular orchidectomy) has been one of the widely practiced treatments for metastatic prostate cancer particularly before the introduction of antiandrogen therapy. Subcapsular orchiectomy is associated with significantly fewer postoperative complications than total orchiectomy [29]. The procedure can be done under local or general anesthesia. There is a decline in the number of bilateral subcapsular orchiectomies (BSOs) done due to a shift to earlier stages and younger ages at diagnosis, and the development of antiandrogens. It may be of value in a patient with metastatic prostate cancer with poor compliance and for economic reasons.

Metastatic spinal cord compression (MSCC) is an oncologic emergency (see also Chap. 7) that needs early diagnosis and appropriate treatment. If not treated in time, it can lead to permanent neurologic impairment affecting the quality of life. MSCC should be ideally managed by multidisciplinary team. Nearly 30 % of cancer metastasis are found in the spine [30] and overall 5–10 % of cancer patients will develop metastatic spinal compression [31].

Spinal cord damage is characterised by vascular injury, haemorrhage, oedema of white mater, nerve damage including demylination and axonal damage [32, 33]. The main treatment modalities for the MSCC include steroids, radiotherapy and surgery. Various surgical options for MSCC are tumour cytoreduction, laminectomy and vertebrectomy [34]. Surgery followed by radiotherapy seems to be beneficial, especially for patients who are medically operable and have specific characteristics such as being symptomatic, having an expected survival of more than 3 months with good performance status, and having only one level of spinal cord compression [34].