Role of radical prostatectomy in high-risk prostate cancer

Many methods exist to define high-risk prostate cancer. These include clinical stage, serum PSA, and pathological features such as Gleason score and the number of positive biopsies. Partin tables are widely used to stratify patients according to risk of adverse pathological features at surgery, and to identify those more likely to remain free of recurrent disease following surgery. The priority in most patients with localized prostate cancer remains the selection of a treatment that will provide them with the best chance for cure. While treatment-related morbidity is an important issue, we believe that side effects of surgery or radiation therapy are not increased in patients with high-risk cancer. Results from a small number of population studies indicate a highly significant improvement in disease-specific survival for radical prostatectomy compared to radiotherapy, and it appears that this difference may become more pronounced as the grade of the cancer increases. While acknowledging the need for adjuvant radiotherapy and/or hormonal therapy, we suggest that radical prostatectomy may offer a better primary treatment option for patients with high-grade cancer. However, urologists must be prepared for higher failure rates when performing this surgery in patients with high-risk disease compared to those with low-risk disease.