For a man with localized prostate cancer, prostate-specific antigen ≤10 ng/mL, Gleason score ≤7 (grade group 1‑3), and life expectancy ≥10 years, what are the indications for radical prostatectomy versus radiation therapy or active surveillance, and what pre‑operative assessment and post‑operative care should be performed?

Radical Prostatectomy for Localized Prostate Cancer

Direct Recommendation

For a man with localized prostate cancer, PSA ≤10 ng/mL, Gleason score ≤7 (grade group 1-3), and life expectancy ≥10 years, radical prostatectomy is an appropriate treatment option alongside radiation therapy and active surveillance, with the choice depending on risk stratification: very low-risk patients (T1c, Gleason ≤6, PSA <10, <3 cores positive, <50% involvement per core, PSA density <0.15) should undergo active surveillance; low-risk patients (T1-T2a, Gleason ≤6, PSA <10) may choose between active surveillance, radical prostatectomy, or radiation therapy; and intermediate-risk patients (T2b-T2c, Gleason 7, or PSA 10-20) should receive radical prostatectomy with pelvic lymph node dissection or radiation therapy with 4-6 months of androgen deprivation therapy. 1, 2

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Risk Stratification Algorithm

The decision between radical prostatectomy, radiation therapy, and active surveillance is determined by precise risk categorization:

Very Low-Risk Disease

• Criteria: ALL of the following must be present: clinical stage T1c, Gleason score ≤6, PSA <10 ng/mL, <3 positive biopsy cores, ≤50% cancer in any core, PSA density <0.15 ng/mL/g 1, 2
• Recommendation: Active surveillance is the preferred approach for life expectancy 10-20 years 1
• Rationale: Given the indolent nature and potential side effects of definitive therapy, observation of disease progression is appropriate 1

Low-Risk Disease

• Criteria: T1-T2a, Gleason score ≤6, PSA <10 ng/mL 1, 2
• Options: Active surveillance, radical prostatectomy with pelvic lymph node dissection (PLND) if predicted lymph node involvement ≥2%, or radiation therapy 1
• Evidence: Radical prostatectomy improves disease-specific survival compared to watchful waiting (90% vs 85% at 15 years), with overall survival benefit of 5% at 10 years (73% vs 68%, P=0.04) 1

Intermediate-Risk Disease (Your Patient Population)

• Criteria: T2b-T2c, Gleason score 7, or PSA 10-20 ng/mL 1, 2
• Primary options:
  • Radical prostatectomy with PLND if predicted lymph node involvement ≥2% 1
  • External beam radiation therapy with or without 4-6 months of androgen deprivation therapy 1
• Critical caveat: Active surveillance is NOT recommended for intermediate-risk disease with life expectancy >10 years (category 1 recommendation) 1
• Brachytherapy monotherapy: Only appropriate for favorable intermediate-risk features (cT1c, Gleason 7, low volume) 1

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Pre-Operative Assessment

Staging Investigations Required

Bone scan indications (for symptomatic patients or life expectancy >5 years): 1

• T1 disease with PSA >20 ng/mL OR T2 disease with PSA >10 ng/mL
• Gleason score ≥8
• T3-T4 tumors
• Symptomatic disease

Pelvic imaging (CT or MRI) indications: 1

• T3 or T4 disease
• T1 or T2 disease when nomogram indicates >10% chance of lymph node involvement
• Generally not needed if PSA <10 and Gleason <7 1

For your specific patient (PSA ≤10, Gleason ≤7): No additional imaging beyond standard staging is required unless clinical stage is T2b-T2c 1

Essential Pre-Operative Evaluation

• General health assessment: Comorbidities must be evaluated to ensure patient can tolerate surgery 1
• Life expectancy confirmation: Must be ≥10 years to justify perioperative morbidity 1, 3
• Digital rectal examination: To determine clinical T stage 1
• Pelvic lymph node dissection planning: Calculate predicted probability of lymph node metastasis; PLND indicated if ≥2% risk 1

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Surgical Technique Considerations

Approach Options

• Retropubic or perineal approach: Both achieve long-term cancer control 1
• Robotic-assisted or laparoscopic: Comparable to open surgery in experienced hands, with shorter hospital stay, less blood loss, and fewer surgical complications 1
• Volume matters: High-volume surgeons in high-volume centers provide superior outcomes 1

Expected Oncologic Outcomes

10-year cancer control rates by pathologic stage: 4, 5

• Organ-confined disease: 85% PSA-free survival 4
• Focal capsular penetration: 82% PSA-free survival 4
• Established capsular penetration with Gleason 2-6: 54% PSA-free survival 4
• 15-year cause-specific survival: 83% overall 5

For Gleason 7 specifically: 10-year survival rate of 74% 5

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Post-Operative Care and Surveillance

Immediate Post-Operative Monitoring

• PSA measurement: Should be below detection level within 2 months after surgery 2
• First follow-up visit: At 3 months, including PSA measurement, digital rectal examination, and assessment of treatment-related symptoms 2

Long-Term Surveillance Protocol

• PSA monitoring: Use sensitive PSA assay for ongoing surveillance 1, 2
• Frequency: PSA every 3-6 months initially 2
• Biochemical recurrence definition: Detectable and rising PSA after initial undetectable level 1

Management of Biochemical Recurrence

• Salvage radiation therapy: Should be given to the prostate bed in the event of PSA failure 1
• Timing: Early initiation is most effective 6
• Important caveat: Adjuvant radiotherapy immediately following radical prostatectomy has NOT been shown to improve survival or freedom from metastatic disease 1

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Functional Outcomes and Complications

Urinary Function

• Incontinence rate: Modern series report severe incontinence in 1.4% of patients 5
• Comparison to watchful waiting: Radical prostatectomy increases urinary leakage by 28% (49% vs 21%) 1
• Age effect: Older men experience higher rates of permanent urinary incontinence 2

Sexual Function

• Erectile dysfunction: Increased by 35% compared to watchful waiting (80% vs 45%) 1
• Nerve-sparing technique: Dramatically improves potency preservation 3
• Age effect: Older men experience higher rates of permanent erectile dysfunction 2
• Meta-analysis findings: Robotic approach shows statistically significant advantage for 12-month potency recovery compared to open surgery 1

Perioperative Morbidity

• Operative mortality: <0.5% in contemporary series 5, 3
• Hospital stay: Shorter with minimally invasive approaches 1
• Blood transfusion: Less common with robotic/laparoscopic techniques 1

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Critical Caveats and Common Pitfalls

When NOT to Perform Radical Prostatectomy

• Life expectancy <10 years: Risks outweigh benefits 1, 3
• Very low-risk disease with life expectancy 10-20 years: Active surveillance is preferred 1
• Intermediate-risk disease with multiple adverse factors: May require upstaging to high-risk category with consideration of radiation plus ADT 1

Technical Considerations

• Pelvic lymph node dissection: Must be performed if predicted probability of lymph node involvement ≥2% 1
• Multiple biopsies: Radical prostatectomy may become technically challenging after multiple biopsy sets, especially for potency preservation 1
• Salvage surgery after radiation: Associated with 10-fold higher complication risk and limited cure prospects 1, 3

Treatment Selection Pitfalls

• ADT monotherapy: Should NEVER be used as primary treatment for localized prostate cancer—it does not improve survival 1, 2
• Cryotherapy and focal therapies: Not recommended as routine primary therapy due to lack of long-term comparative data 1, 2
• Brachytherapy monotherapy: Inferior to external beam radiation or surgery for Gleason pattern 4/5 or PSA >10 ng/mL 1