Is radical prostatectomy primarily a surgical debulking procedure?

Radical prostatectomy has been considered the gold standard for the curative treatment of clinically localized prostate cancer. After an extensive review of the literature, we concluded that surgery probably functions primarily as a tumor debulking procedure rather than a curative one. Morphometric studies suggest that the majority of patients undergoing surgery have tumors too large for cure. Histologic studies demonstrate that 55% of radical prostatectomy specimens show evidence of extraprostatic disease and approximately 15% have tumors so small that a clinical impact on longevity is unlikely. Thus, only 30% of patients have surgery that is clearly beneficial on a histopathologic basis. Given the rather long doubling time of prostate cancers, many patients with residual cancer following surgery die of other causes, giving the false impression of cure. However, long-term studies in men with positive surgical margins have demonstrated that the majority die from prostate cancer. Furthermore, using prostate specific antigen as a measure of progression, the biochemical disease-free survival rates are substantially lower than the cause-specific survival rates. Although radical prostatectomy may be the best tumor debulking procedure available, it is associated with substantial morbidity and cost. This information is important for both physician and patient when deciding on management of prostate cancer.