What is the best approach for an elderly male patient with a significantly elevated Prostate-Specific Antigen (PSA) level and severe Lower Urinary Tract Symptoms (LUTS), considering a treatment plan of Transurethral Resection of the Prostate (TURP) with bilateral orchiectomy?

Management Approach for Elderly Male with PSA 100 and Severe LUTS

Critical First Step: Rule Out Metastatic Disease Before Any Surgical Intervention

You must obtain tissue diagnosis and staging workup before proceeding with TURP and bilateral orchiectomy, as a PSA of 100 strongly suggests metastatic prostate cancer requiring systemic androgen deprivation therapy rather than surgical castration alone. 1

The American Urological Association guidelines explicitly state that patients with abnormal PSA (particularly one this dramatically elevated) require referral to a urologist for appropriate evaluation before advising treatment. 1 A PSA of 100 ng/mL indicates high-risk or metastatic disease in the vast majority of cases, fundamentally changing your treatment algorithm.

Required Pre-Operative Workup

Immediate Diagnostic Steps

• Obtain transrectal ultrasound-guided prostate biopsy to confirm prostate cancer diagnosis and determine Gleason score, as this is the method of choice when PSA is elevated above the locally accepted reference range. 1

• Order staging imaging including bone scan and CT abdomen/pelvis (or whole-body MRI if available) to assess for metastatic disease, which is highly likely with PSA >100. 2

• Assess renal function and upper urinary tract imaging with ultrasound to evaluate for hydronephrosis or obstructive uropathy, as this is indicated in patients with severe LUTS and potential bladder outlet obstruction. 1

Why This Matters for Your Surgical Plan

The presence of metastatic disease would make bilateral orchiectomy alone insufficient—these patients require systemic androgen deprivation therapy (medical or surgical castration) plus consideration of additional systemic agents. 2 TURP in the setting of locally advanced or metastatic prostate cancer carries higher risks of bleeding, tumor seeding, and may not adequately address the underlying malignancy.

Alternative Management Algorithm Based on Staging

If Localized High-Risk Disease (No Metastases)

• Consider neoadjuvant androgen deprivation therapy for 2-3 months before TURP to reduce prostate vascularity and bleeding risk, though this is not universally required. 2

• Proceed with TURP for severe LUTS as the American Urological Association recognizes that surgical intervention is appropriate for patients with severe symptoms (IPSS >19) with significant bother. 3

• Bilateral orchiectomy can be performed as definitive androgen deprivation therapy, though medical castration with LHRH agonists/antagonists is equally effective and reversible. 2

• Plan for definitive local therapy (radiation ± continued ADT) after LUTS are controlled, as high-risk localized disease requires multimodal treatment for optimal oncologic outcomes. 4

If Metastatic Disease (Most Likely Scenario)

• Initiate systemic androgen deprivation therapy immediately with either bilateral orchiectomy or LHRH agonist/antagonist, as this addresses the systemic disease burden. 2

• Consider medical ADT over surgical castration to allow for potential addition of novel hormonal agents (abiraterone, enzalutamide) or chemotherapy, which may be needed for metastatic disease. 2

• Address severe LUTS with catheter drainage initially if patient is in retention or has significant post-void residual, allowing PSA to decline with ADT before considering TURP. 3, 5

• Reassess need for TURP after 3-6 months of ADT, as prostate volume typically decreases by 30-50% with androgen deprivation, potentially obviating the need for surgical debulking. 3

• If TURP is still required for persistent severe LUTS despite ADT, proceed with surgery but recognize that tissue obtained will show treatment effect and may not reflect initial tumor grade. 5, 4

Critical Pitfalls to Avoid

• Do not proceed directly to TURP and orchiectomy without tissue diagnosis and staging, as this approach fails to identify metastatic disease that requires systemic therapy beyond castration alone. 1, 2

• Do not assume TURP alone will adequately treat the underlying malignancy—with PSA of 100, this patient has cancer requiring definitive oncologic management, not just symptomatic relief. 2

• Do not delay urologic oncology referral, as the American Urological Association recommends urgent referral for patients with abnormal PSA, and PSA of 100 represents an oncologic emergency requiring expedited workup. 1, 3

• Recognize that bilateral orchiectomy, while providing permanent castration, eliminates the option for intermittent ADT and may complicate future use of novel hormonal therapies—medical castration offers more flexibility. 2

Specific Recommendations for Your Case

Defer your planned TURP and bilateral orchiectomy until you complete the following sequence:

1. Obtain prostate biopsy within 1-2 weeks to confirm diagnosis and grade. 1

2. Complete staging workup immediately (bone scan, CT/MRI). 2

3. If patient is in acute retention or has severe obstructive uropathy, place urethral or suprapubic catheter for temporary drainage while awaiting staging results. 3

4. Initiate ADT (medical or surgical) once metastatic disease is confirmed or strongly suspected, as this addresses the systemic disease and begins prostate volume reduction. 2

5. Reassess LUTS severity after 3 months of ADT—many patients experience significant symptom improvement as prostate shrinks. 3, 5

6. Proceed with TURP only if severe LUTS persist despite ADT, recognizing this is palliative rather than curative surgery. 5, 6

The sensitivity of PSA combined with abnormal DRE findings (which you likely have with this degree of elevation) approaches 99.2% for cancer detection, making tissue diagnosis before treatment essential for proper oncologic management. 2