Neoadjuvant hormonal treatment before radical prostatectomy

Randomized trials evaluating the use of androgen deprivation therapy (ADT) before radical prostatectomy have consistently shown significant decreases in prostate volume and in serum prostate-specific antigen (PSA) levels. All but one study have reported that hormonal pretreatment significantly reduces the incidence of positive surgical margins. However, androgen deprivation does not significantly influence seminal vesicle extension or lymph node involvement nor does it affect tumor grade. The fibrotic reactions that sometimes result from hormonal pretreatment can increase the difficulty of surgery but this has not been associated with a higher incidence of perioperative or postoperative complications. In closely monitored clinical trials, bothersome side effects of neoadjuvant hormonal therapy have been limited. Issues that remain to be addressed are the optimal duration of neoadjuvant treatment and whether the benefits of such therapy will translate into improved disease-free survival. At this time, patients with clinical stage T2b disease, PSA elevations greater than 10 to 20 ng/mL, and a high Gleason grade may be considered candidates for neoadjuvant hormonal treatment before surgery.