What are the most important scores to consider for a patient with prostate cancer undergoing or post-surgery, and how can post-surgery complications be minimized?

Most Important Scores for Prostate Cancer and Post-Surgery Complications

The Gleason score (or ISUP grade) is the single most critical prognostic factor for prostate cancer outcomes, and for post-surgical complications, urinary incontinence and erectile dysfunction are the most common, affecting approximately one-third and three-quarters of patients respectively.

Essential Pre-Treatment Risk Stratification Scores

Gleason Score/ISUP Grading System

The Gleason grading system is the standard staging system and must be documented for all prostate cancer patients 1. The scoring rules are:

• Gleason score = sum of two dominant grades (range 2-10) 1
• Modified Gleason score should indicate proportion of grade 4/5 disease present 1
• When three grades are present, use the highest grade plus the dominant grade 1

Gleason score is the strongest predictor of oncological outcomes after surgery:

• For distant metastases: 12 of 14 studies showed positive association with hazard ratios ranging from 1.2 to 14.4 1
• For prostate cancer-specific mortality: 10 of 13 studies showed positive association with hazard ratios from 1.35 to 10.8 1
• Gleason ≥8 significantly increases metastatic risk even with PSA <10 ng/mL 1, 2

The newer ISUP grading distinguishes critical prognostic differences:

• ISUP Grade 2 (Gleason 3+4) vs Grade 3 (Gleason 4+3) shows dramatically different outcomes, with Grade 3 having hazard ratios up to 10.82 for distant metastases 1

PSA Level

PSA level correlates directly with disease extent and prognosis 1:

• PSA <4.0 ng/mL: ~80% organ-confined disease 1, 2
• PSA 4.0-10.0 ng/mL: ~70% organ-confined disease, ~5% lymph node metastasis risk 1, 2
• PSA 10.0-20.0 ng/mL: ~50% organ-confined disease, ~18% lymph node metastasis risk 1, 2
• PSA >20.0 ng/mL: ~36% lymph node metastasis risk 1, 2

Each 2-point PSA increase approximately doubles the risk of biochemical recurrence after surgery 1. PSA velocity >2.0 ng/mL/year indicates approximately 10-fold greater risk of prostate cancer death after radical prostatectomy 1, 3.

Clinical T Stage

T stage must be evaluated by digital rectal examination 1. The pathological T stage (pT) after surgery shows variable prognostic significance, with only 7 of 13 studies demonstrating significant correlation with outcomes 1. However, extraprostatic extension, seminal vesicle invasion, and nodal status are critical histoprognostic factors that must be documented 1.

CAPRA Score (Cancer of the Prostate Risk Assessment)

The CAPRA score is a straightforward preoperative risk assessment tool with excellent predictive accuracy 4, 5, 6. It uses five readily available variables:

• PSA level: 0-4 points 4
• Gleason score: 0-3 points 4
• Clinical T stage: 0-1 point 4
• Percent positive biopsy cores: 0-1 point 4
• Age: 0-1 point 4

Total score ranges 0-10, with roughly double the risk of recurrence for each 2-point increase 4. Five-year recurrence-free survival ranges from 85% (score 0-1) to 8% (score 7-10) 4. The concordance index is 0.66-0.81 across validation studies 4, 5.

CAPRA-S Score (Post-Surgical)

For post-operative risk assessment, the CAPRA-S score incorporates pathological findings and provides superior accuracy 7:

• Preoperative PSA: up to 3 points 7
• Pathologic Gleason score: up to 3 points 7
• Surgical margins: 2 points if positive 7
• Extracapsular extension: 1 point 7
• Seminal vesicle invasion: 2 points 7
• Lymph node invasion: 1 point 7

The CAPRA-S concordance index is 0.77, substantially higher than the pretreatment CAPRA score of 0.66 7. Each point increase yields a hazard ratio of 1.54, indicating 2.4-fold increased risk per 2-point increase 7.

Post-Surgery Complications: Critical Rates and Expectations

Urinary Incontinence

Approximately one-third of patients experience bladder control problems after radical prostatectomy 1. More specifically:

• One in ten patients will require diapers due to severe incontinence 1
• Urinary leakage increases by 28% compared to watchful waiting (49% vs 21%) 1
• This is the most common post-surgical complication alongside erectile dysfunction 1

Erectile Dysfunction

Erectile dysfunction is the most common complication after both surgery and radiation 1. Post-prostatectomy rates:

• Only one in four patients (25%) will have erections firm enough for intercourse after surgery 1
• Erectile dysfunction increases by 35% compared to watchful waiting (80% vs 45%) 1
• This represents a 75% rate of significant erectile dysfunction post-operatively 1

Minimizing Post-Surgical Complications

Critical pathological factors documented at surgery independently correlate with prognosis and should guide adjuvant therapy decisions 1:

1. Total tumor volume 1
2. Extent of poorly differentiated tumor (Gleason grades 4/5) 1
3. Tumor localization (transition zone vs peripheral zone) 1
4. Surgical margin status 1
5. Perineural invasion (optional but valuable) 1

Patients should be monitored post-operatively with sensitive PSA assays, with salvage radiotherapy to the prostate bed given for PSA failure 1. However, adjuvant radiotherapy immediately following radical prostatectomy has not been shown to improve survival or freedom from metastatic disease 1.

Common Pitfalls and Caveats

Do not assess tumor grade in patients previously treated with radiotherapy or hormonal therapy 1. The Gleason score becomes unreliable after these interventions.

Positive surgical margins show inconsistent prognostic value: only 2 of 8 studies demonstrated correlation with distant metastases, and none of 8 studies showed correlation with prostate cancer-specific mortality 1. This suggests margin status alone should not drive aggressive adjuvant therapy decisions.

Age is not a significant prognostic factor for prostate cancer-specific outcomes (distant metastases or cancer death), with hazard ratios near 1.0 1. However, age significantly impacts all-cause mortality with hazard ratios of 1.04-2.4 1, which is critical for treatment selection in older patients.

Patients must understand that without treatment, sexual and urinary problems do NOT occur in the majority within five years 1. This is a common misconception—the statement is false 1. Treatment itself causes most functional complications.