Which patients is radical prostatectomy (surgical removal of the prostate gland) best for?

Radical Prostatectomy: Patient Selection Criteria

Radical prostatectomy is most appropriate for patients with clinically localized prostate cancer whose life expectancy is 10 years or more, regardless of risk category, as these patients will benefit most from the procedure's mortality reduction benefits. 1

Ideal Candidates by Disease Characteristics

By Disease Stage

• Clinically localized disease (tumor confined to the prostate)
  • Most appropriate for clinical stages T1-T2c 1
  • Can be considered for select patients with locally advanced disease (T3-T4) after careful staging and multidisciplinary discussion 1

By Risk Category

1. Low-risk patients

   • Tumor confined to prostate
   • Gleason score ≤6
   • PSA <10 ng/mL
   • 15-year prostate cancer-specific mortality of only 5% after radical prostatectomy 1
   • Note: Active surveillance should be discussed as an alternative option 1

2. Intermediate-risk patients

   • T2b-T2c disease
   • Gleason score 7
   • PSA 10-20 ng/mL
   • Excellent candidates for radical prostatectomy 1

3. High-risk patients

   • T3a disease
   • Gleason score 8-10
   • PSA >20 ng/mL
   • Can benefit from radical prostatectomy, especially those with:
     • PSA <10 ng/mL
     • Clinical stage <T2b
     • Gleason score <9
     • Lower number of high-grade biopsy cores
     • <50% core involvement 1

4. Very high-risk patients (T3b-T4)

   • Radical prostatectomy with pelvic lymph node dissection may be an option for selected patients with no fixation to adjacent organs 1
   • Should only be considered after careful staging and multidisciplinary discussion 1

Patient Factors for Optimal Outcomes

Age and Life Expectancy

• Life expectancy ≥10 years is the most critical factor 1, 2
• Patients younger than 65 years benefit most (NNT of 7 to avert 1 death vs. 15 for all ages) 1

Comorbidity Status

• Low comorbidity index preferred 3
• Healthy enough to tolerate potential perioperative morbidity 1
• No serious co-morbid medical conditions that would limit survival 2

Functional Considerations

• Patients concerned about preserving urinary continence and erectile function
  • Short-term (2-5 years) outcomes favor radical prostatectomy over radiation therapy for these functions 1
  • Long-term (15 years) functional outcomes become similar between treatments 1

Special Situations

Salvage Prostatectomy

• Can be considered for biochemical recurrence after radiation therapy
• Higher morbidity than when used as initial therapy:
  • Incontinence rates
  • Erectile dysfunction
  • Bladder neck contracture 1
• 10-year survival ranges: 54-89% overall and 70-83% cancer-specific 1

Node-Positive Disease

• Radical locoregional therapy recommended for N1M0 patients suitable for aggressive management 1
• Immediate ADT should be considered for pN1 patients at high risk for progression 1

Surgical Approach Considerations

• High-volume surgeons in high-volume centers generally provide superior outcomes 1
• Approach options:
  • Open (retropubic or perineal)
  • Laparoscopic
  • Robot-assisted
• All approaches are comparable in experienced hands 1
• Minimally invasive approaches may offer:
  • Shorter hospital stays
  • Less blood loss
  • Fewer surgical transfusions
  • Potentially better 12-month urinary continence and potency recovery 1, 4

Potential Complications to Consider

• Urinary incontinence (severe incontinence rate ~1.4% in contemporary series) 3
• Erectile dysfunction (varies by nerve-sparing technique, age, and baseline function) 1
• Anastomotic strictures
• Blood transfusion requirements (significantly lower with minimally invasive techniques) 1, 4
• Hospital readmissions

Long-Term Outcomes

• 15-year prostate cancer-specific mortality of 12% overall (5% for low-risk patients) 1
• 10-year biochemical recurrence-free survival:
  • 85% for organ-confined disease
  • 82% with focal capsular penetration
  • 54% with established capsular penetration and Gleason 2-6
  • 42% with established capsular penetration and Gleason 7-10
  • 43% with seminal vesicle involvement 5

Radical prostatectomy provides excellent long-term cancer control for appropriately selected patients with localized prostate cancer who have a life expectancy of at least 10 years.