When should prostatectomy be considered for a patient with localized prostate cancer or severe benign prostatic obstruction refractory to optimal medical therapy?

When to Consider Prostatectomy

Radical prostatectomy should be recommended as a standard treatment option for patients with intermediate-risk or high-risk localized prostate cancer who have >10-year life expectancy, and for patients with severe benign prostatic obstruction (>60-80g prostate) who have failed medical therapy. 1, 2, 3

For Localized Prostate Cancer

Risk-Stratified Approach

Low-Risk Disease:

• Active surveillance is the preferred initial strategy for most low-risk patients, avoiding treatment-related morbidity while maintaining curative options 2
• Radical prostatectomy is appropriate for younger, healthier patients who prefer surgical intervention over surveillance 2
• Single modality radiation (EBRT or brachytherapy) is equally acceptable if the patient prefers radiation 2

Intermediate-Risk Disease:

• Radical prostatectomy is a standard treatment option for both favorable and unfavorable intermediate-risk disease 1, 2
• For unfavorable intermediate-risk disease, pelvic lymph node dissection (PLND) should be performed concurrently, as it is recommended for these patients 1, 2
• Patients should be counseled about potential adjuvant radiotherapy if locally extensive disease is found at surgery 1, 2
• Active surveillance may be offered to select patients with favorable intermediate-risk disease, but they must understand this carries higher risk of metastases compared to definitive treatment 1

High-Risk Disease:

• Radical prostatectomy with pelvic lymph node dissection is strongly recommended (Strong Recommendation; Evidence Level: Grade A) 1
• This is based on the SPCG-4 trial showing 15-year prostate cancer-specific mortality favored radical prostatectomy (14.6% vs 20.7%, RR 0.62) 1
• Active surveillance should NOT be recommended for high-risk disease 1
• Watchful waiting should only be considered in asymptomatic men with limited life expectancy (≤5 years) 1

Age and Life Expectancy Considerations

Critical decision points:

• Younger patients (<65 years) with >10-year life expectancy derive greater cancer control benefit from radical prostatectomy 2
• For patients with life expectancy ≤5 years, observation or watchful waiting should be recommended regardless of risk category 2
• Older men (>70 years) experience higher rates of permanent erectile dysfunction and urinary incontinence after prostatectomy, making radiation relatively more attractive 1, 2

Pre-existing Urinary Obstruction

A key clinical advantage:

• Prostatectomy can relieve pre-existing urinary obstruction, whereas radiation can exacerbate obstructive symptoms 1
• For patients with localized prostate cancer AND obstructive lower urinary tract symptoms, surgical approaches may be preferred 1

For Benign Prostatic Hyperplasia (BPH)

Indications for Simple Prostatectomy

Robotic-assisted simple prostatectomy (RASP) should be considered for:

• Large prostates (generally >60-80g) causing significant lower urinary tract symptoms 3
• Patients with severe obstructive symptoms who have failed medical therapy 3
• Patients with urinary retention due to large prostate 3

Alternative approaches by prostate size:

• TURP remains the gold standard for smaller prostates (<60g) 3
• For prostates ≤30g, TUIP should be offered 3
• Bipolar TURP and HoLEP are alternatives for large prostates in centers with appropriate expertise 3

Critical Pitfalls to Avoid

Do NOT use neoadjuvant ADT or systemic therapy before radical prostatectomy outside of clinical trials (Strong Recommendation; Grade A evidence) 1, 2

Do NOT omit pelvic lymph node dissection in unfavorable intermediate-risk or high-risk disease, as extended PLND discovers metastases approximately twice as often as limited PLND 1, 2

Do NOT recommend cryosurgery, HIFU, or focal therapy as standard care options, as comparative outcome evidence is lacking 1, 2, 4

Surgical Technique Counseling Points

Patients should be informed:

• Robotic/laparoscopic or perineal techniques are associated with less blood loss than retropubic prostatectomy (Strong Recommendation; Evidence Level: Grade B) 1, 2
• Nerve-sparing is associated with better erectile function recovery than non-nerve-sparing (Strong Recommendation; Evidence Level: Grade A) 1, 2
• Erectile dysfunction occurs in many patients following prostatectomy, and ejaculate will be lacking despite preserved ability to attain orgasm 1, 2
• Temporary urinary incontinence occurs in most patients after prostatectomy and persists long-term in a small but significant subset 1, 2