Is DaVinci Single Port surgery better than radiation therapy for a 58-year-old male with Gleason 4+3, PSA 9, and negative PET scan?

Treatment Recommendation for Gleason 4+3 Prostate Cancer

For a 58-year-old male with Gleason 4+3 (Grade Group 3), PSA 9, and negative PET scan, radical prostatectomy is the preferred definitive treatment over radiation therapy, as this patient has intermediate-high risk disease with a life expectancy >10 years where surgery provides complete pathologic staging and the option for salvage radiation if needed. 1

Risk Stratification and Treatment Rationale

This patient has intermediate-high risk prostate cancer based on Gleason 4+3 (primary pattern 4), which carries worse prognosis than Gleason 3+4. 1 The negative PET scan confirms organ-confined disease, making him an excellent candidate for curative-intent local therapy. 1

Why Surgery is Preferred in This Case:

• Age and life expectancy: At 58 years with >20 years life expectancy, this patient will benefit from the long-term oncologic control that surgery provides 1
• Complete pathologic staging: Surgery provides accurate assessment of extraprostatic extension, seminal vesicle invasion, and lymph node status—critical information that imaging cannot reliably provide 2, 1
• Salvage options: If pathology reveals adverse features (positive margins, extraprostatic extension, seminal vesicle invasion), adjuvant or salvage radiation can be added with proven survival benefit, whereas salvage surgery after radiation has much poorer outcomes (only 37% recurrence-free at 4.4 years) 2

Regarding DaVinci Single-Port vs Multiport Surgery

The choice between single-port (SP) and multiport (MP) robotic platforms should NOT drive your treatment decision between surgery versus radiation. The evidence shows these are equivalent in oncologic and functional outcomes. 3

Single-Port Platform Evidence:

• Oncologic outcomes: No difference in positive surgical margin rates or cancer recurrence between SP and MP platforms 3, 4
• Functional outcomes: Erectile and urinary function recovery are similar between platforms 3, 4
• Operative differences: SP has slightly longer operative time (median 14 minutes longer) but potentially less blood loss 4
• Cosmetic benefits: SP may offer improved cosmesis and potentially shorter hospital stay, though not robustly demonstrated across all studies 3, 5
• Safety: SP radical prostatectomy is safe and feasible with acceptable complication rates (8.1% Clavien 2 complications in initial series) 5, 6

Important caveat: All SP studies are from high-volume centers with experienced surgeons during the learning curve phase (2018-2025). 3, 5, 6 The platform choice should be based on your surgeon's experience and volume, not the technology itself.

Surgery vs Radiation: The Critical Comparison

Surgery Advantages:

• Definitive pathologic staging allows risk-stratified adjuvant therapy decisions 2, 1
• Salvage radiation after surgery has proven survival benefit when PSA rises, especially when given early (PSA <0.5 ng/mL achieves 48% 6-year biochemical control) 2
• No bowel toxicity unlike radiation 2

Surgery Disadvantages:

• Higher short-term erectile dysfunction (up to 80%), though long-term rates equal radiation 2, 1
• Urinary incontinence risk up to 49%, higher than radiation 2, 1
• Older men experience higher permanent dysfunction rates 1

Radiation Therapy Considerations:

• Equivalent long-term cancer control to surgery in randomized trials 2
• Bowel complications occur in some men, not seen with surgery 2
• Salvage surgery after radiation failure has poor outcomes (37% recurrence-free) and should only be done at high-volume centers 2
• Would require 4-6 months of androgen deprivation therapy given Gleason 4+3 disease, adding sexual dysfunction and metabolic side effects 1

Treatment Algorithm for This Patient:

1. Confirm surgical candidacy: Assess comorbidities, baseline urinary function (AUA symptom score), and sexual function (SHIM score) 1

2. Proceed with radical prostatectomy (SP or MP based on surgeon expertise) with:

   • Bilateral nerve-sparing if preoperative erectile function is good and cancer appears organ-confined 1
   • Extended pelvic lymph node dissection given Gleason 4+3 1

3. Post-operative surveillance: PSA every 3-6 months to detect biochemical recurrence early (PSA >0.2 ng/mL) 2

4. Adjuvant/salvage therapy based on pathology:

   • Adverse pathology (positive margins, extraprostatic extension, seminal vesicle invasion): Consider adjuvant radiation before PSA rises >1.5 ng/mL 2
   • Biochemical recurrence: Salvage radiation when PSA <0.5 ng/mL for best outcomes 2

Critical Pitfalls to Avoid:

• Do not delay treatment for active surveillance—Gleason 4+3 is NOT appropriate for surveillance 1
• Do not choose radiation to avoid surgical side effects without understanding that salvage options after radiation failure are very limited 2
• Do not use primary androgen deprivation alone—this is not curative 1
• Do not let the "single-port" marketing drive your decision—surgeon experience matters far more than the robotic platform 3, 5