What are the treatment options for a patient with prostate cancer who has undergone previous abdominal surgery, resulting in adhesions that make a radical prostatectomy (surgical removal of the prostate) impossible?

Treatment Options for Prostate Cancer When Radical Prostatectomy is Impossible Due to Surgical Adhesions

External beam radiation therapy (EBRT) plus androgen deprivation therapy (ADT) is the definitive treatment for this patient, offering equivalent cancer control to surgery while avoiding the surgical field entirely. 1

Primary Treatment Approach

Radiation therapy is the clear alternative when surgery is not feasible, and the treatment strategy depends entirely on the patient's risk category:

For Intermediate-Risk Disease (Gleason 7, PSA 10-20 ng/mL):

• Deliver external beam radiation therapy with a minimum dose of 66-70 Gy 1, 2
• Add short-course neoadjuvant ADT for 4-6 months to improve local control, reduce disease progression, and improve overall survival 1
• Consider high-dose rate brachytherapy as an alternative or boost to EBRT 1, 2

For High-Risk or Locally Advanced Disease (Gleason 8-10, PSA >20 ng/mL, or T3-T4):

• Deliver external beam radiation therapy plus ADT for at least 2-3 years 1
• This combination has Level I, Grade A evidence demonstrating survival benefit 1
• Neoadjuvant LHRH agonist therapy should start 4-6 months before radiation 1

For Low-Risk Disease (Gleason ≤6, PSA <10 ng/mL):

• Active surveillance is preferred if life expectancy ≥10 years, as no benefit for active treatment has been demonstrated in overall survival 1, 2
• Watchful waiting with delayed hormone therapy is appropriate for men not suitable for radical treatment 1

Staging Requirements Before Treatment

Complete staging workup is mandatory before initiating radiation therapy:

• Obtain pelvic MRI for all intermediate-risk patients receiving radiation therapy 1
• Perform bone scintigraphy for intermediate and high-risk patients 1
• Consider CT abdomen/pelvis for high-risk disease 2, 3

Androgen Deprivation Therapy Details

ADT can be achieved through:

• LHRH agonists (medical castration) - standard approach 1, 4
• Bilateral orchiectomy (surgical castration) - alternative option 2
• Bicalutamide 150 mg daily may be used instead of LHRH agonist if patient prefers its toxicity profile, though data on outcomes are more limited 1

Duration of ADT:

• 4-6 months for intermediate-risk disease 1
• 2-3 years for high-risk disease 1, 2

Brachytherapy as Alternative Option

Permanent seed brachytherapy may be considered for low-risk patients (T1-T2a, Gleason ≤6, PSA <10 ng/mL) with prostate volume ≤50-60 cm³ and good urinary function 1, 5

Contraindications to brachytherapy:

• Previous transurethral resection of prostate (TURP) - absolute contraindication 1
• Prostate volume >50-60 cm³ - relative contraindication 1
• Median lobe hypertrophy - relative contraindication 1

Critical Pitfalls to Avoid

Common errors in this clinical scenario:

• Do not delay treatment while attempting alternative surgical approaches - radiation therapy provides equivalent oncologic outcomes to surgery for localized disease 2, 6, 5
• Do not use ADT alone without radiation for localized disease, as this is not curative 1
• Do not omit ADT in high-risk patients receiving radiation - the combination provides survival benefit that radiation alone does not 1
• Do not use cryotherapy or HIFU as standard initial treatments - these are not evidence-based alternatives 2

Post-Treatment Surveillance

After radiation therapy:

• PSA should reach ≤1.0 ng/mL within 16 months 2
• Measure PSA every 6 months indefinitely 1
• Perform digital rectal examination every 6 months 1
• Biochemical recurrence is defined as PSA nadir + 2 ng/mL (Phoenix definition) 1, 2

Quality of Life Considerations

Counsel patient about radiation-specific side effects:

• Bowel dysfunction (rectal bleeding, urgency, diarrhea) occurs in 3-17% of patients 1
• Urinary symptoms (frequency, urgency, dysuria) are common during treatment 5
• Sexual dysfunction occurs but may be less severe than with surgery 5
• ADT side effects include hot flashes, osteoporosis, metabolic syndrome, and sexual dysfunction 2, 7

For patients on long-term ADT:

• Monitor bone mineral density and consider bisphosphonates or denosumab 7
• Screen for metabolic syndrome (diabetes, cardiovascular disease) 7
• Recommend regular exercise to reduce fatigue and improve quality of life 2