Neoadjuvant hormonal treatment prior to radical prostatectomy: facts and open questions

Since the advent of reversible androgen deprivation, its use for a short period of time (usually 3 months) before radical prostatectomy has been advocated by an increasing number of urologists without clear and definitive proof of its advantage. Most authors have demonstrated downsizing of the prostate by some 30-50%. Clinical downstaging was demonstrated in about 30% but this could not be confirmed at final pathological staging although downgrading was noted in some 10% of the series analyzed. Reduction of positive margins in patients receiving neoadjuvant treatment varies between 15% and 25% compared to control group. Several biases may however complicate the analysis of these results, the main cause of misinterpretation being the difficulty encountered by the pathologist to properly grade and score the tumor after hormonal deprivation. Even if some early significant advantages can be observed such as a decrease of positive margins and anecdotal complete disappearance of tumor in some specimens, this may not necessarily alter the metastatic spread and the overall survival rate. Only long follow-up in large prospective randomized studies evaluating biological (PSA) and clinical failures, time to progression and survival will allow definitive conclusions on this still controversial approach.