Can a 57-year-old man with a PSA (prostate-specific antigen) of 17 ng/mL and a PI-RADS (Prostate Imaging Reporting and Data System) 5 peripheral zone lesion undergo robotic-assisted radical prostatectomy?

Can Robotic-Assisted Radical Prostatectomy Be Performed for High-Risk Prostate Cancer?

Yes, robotic-assisted radical prostatectomy (RARP) is a technically feasible and safe surgical approach for this patient, though radiation therapy combined with long-term androgen deprivation therapy (ADT) remains the preferred treatment for high-risk disease based on superior oncologic outcomes. 1, 2, 3

Critical Pre-Operative Requirements

Before proceeding with any definitive therapy, a tissue biopsy with Gleason grading is mandatory, even with a PI-RADS 5 lesion and PSA of 17 ng/mL, because imaging alone cannot definitively confirm malignancy or determine grade. 3 While one recent study showed 95% cancer detection in PI-RADS 5 lesions without biopsy 4, this contradicts established guideline recommendations that require histologic confirmation before radical treatment. 3

Mandatory Staging Work-Up

• Bone scintigraphy is required because PSA ≥17 ng/mL places this patient at substantial risk for occult bone metastases, even if asymptomatic. 5, 3
• Pelvic MRI or CT must assess lymph node status and local tumor extension (T-stage), as any suspicious nodes should be biopsied before treatment planning. 3
• Digital rectal examination must differentiate T3a (extracapsular extension) from T3b/T4 (seminal-vesicle or adjacent-structure involvement) to guide risk categorization and determine if surgery is appropriate. 3

Treatment Selection Based on Risk Stratification

The Gleason score from biopsy will determine the optimal treatment pathway:

If Gleason 7 (Intermediate Risk)

• RARP is an accepted standard option, with oncologic outcomes comparable to external-beam radiation therapy (EBRT) plus 4-6 months of ADT. 3
• Extended pelvic lymph node dissection (PLND) is recommended when nomogram-based risk of nodal involvement exceeds 10%. 3
• Robotic/laparoscopic techniques are associated with less blood loss than open retropubic prostatectomy. 1

If Gleason 8-10 (High Risk)

• EBRT combined with long-term ADT (2-3 years) is the preferred approach, achieving 91% 9-year disease-specific survival with trimodality therapy (EBRT + brachytherapy + ADT). 3
• RARP with extended PLND may be offered only to highly selected patients, but surgery alone yields progression-free survival of approximately 36% versus 91% with radiation-based regimens. 3
• If surgery is performed, adjuvant radiation is typically required when pathology reveals seminal-vesicle invasion, positive margins, or extraprostatic extension. 2, 3

Technical Feasibility and Safety of RARP

RARP can be performed safely in this 57-year-old patient with acceptable perioperative outcomes:

• Minimally invasive approaches are linked to shorter hospitalizations, reduced need for blood transfusion, and fewer surgical complications compared with open radical prostatectomy. 2
• Mean operative time ranges 132-175 minutes with estimated blood loss 80-200 mL in contemporary robotic series. 6, 7, 8, 9
• Major complication rates are low (0-2.2%), with minor complications occurring in 3.9-15.5% of cases. 6, 8
• Hospital stay averages 1-3 days for healthy individuals. 2

Functional Outcomes to Counsel Patient

Erectile dysfunction occurs in approximately 80% of men after radical prostatectomy, compared with 45% with watchful waiting, representing a 35% absolute increase in risk. 2

Urinary incontinence (any leakage) develops in about 49% of men after radical prostatectomy versus 21% with watchful waiting, an absolute increase of 28%. 2

• Nerve-sparing techniques are recommended when pre-operative MRI shows the tumor is confined and neurovascular bundles are uninvolved, improving the chance of preserving potency. 2
• Preserving maximal urethral length beyond the prostate apex and avoiding injury to the distal sphincter markedly reduces postoperative incontinence. 2
• At 12 months post-RARP, 81.5-92.8% of patients use ≤1 pad per day for urinary control. 8, 9
• Recovery of erectile function is strongly influenced by patient age at surgery, pre-operative erectile status, and extent of cavernous nerve preservation. 2

Oncologic Outcomes with RARP for High-Risk Disease

In elderly patients with high-risk prostate cancer who underwent RARP:

• Biochemical recurrence-free survival was 91% at 12 months and 86% at 36 months in one series of 69 patients ≥70 years with high-risk features. 9
• Biochemical recurrence occurred in 17.4% of patients at median follow-up of 37.7 months. 9
• Extraprostatic extension with negative margins occurred in 39.1%, and organ-confined disease with negative margins in 37.7%. 9

However, these outcomes remain inferior to radiation-based regimens for high-risk disease. 3

Critical Pitfalls to Avoid

Do not proceed to surgery without histologic confirmation; PI-RADS 5 lesions have a non-negligible false-positive rate despite high cancer detection rates. 3

Skipping staging imaging can lead to inappropriate surgery in the presence of metastatic disease; such patients should receive systemic therapy (ADT plus abiraterone, apalutamide, or enzalutamide). 3

Brachytherapy monotherapy is contraindicated for high-risk disease (Gleason ≥8 or PSA >20 ng/mL). 3

When adverse pathological features are present after surgery (pT3, positive margins, Gleason 8-10), adjuvant radiation reduces biochemical recurrence, local recurrence, and clinical progression. 2, 3

Age Considerations

At 57 years of age, this patient is an excellent candidate for definitive therapy:

• Younger or healthier men (<65 years or >10 year life expectancy) are more likely to experience cancer control benefits from prostatectomy than older men. 1
• Radical prostatectomy is recommended for patients with an estimated life expectancy of at least 10 years, given the peri-operative morbidity and long-term benefits. 2
• Older men experience higher rates of permanent erectile dysfunction and urinary incontinence after prostatectomy compared to younger men, but at 57 this patient has better functional recovery potential. 1

Post-Operative Surveillance

Serum PSA should become undetectable (<0.2 ng/mL) within approximately 2 months after surgery. 2

Early salvage radiotherapy (initiated when PSA is <0.5 ng/mL) provides the greatest chance of biochemical control for recurrent disease. 1, 2