**RP in PCa with PSA > 20**

Yossepowitch et al. (19) and D'Amico et al. (15) have investigated the results of RP in these patients. In all cases, very good results were seen, with a cancer- specific survival of up to 91% in 10 years in patients treated with RP.

More recently, Inman and co-workers (43) described the long-term outcomes of RP with multimodal adjuvant therapy in men with PSA > 50. Systemic progression-free survival rates at 10 years were 83% and 74% for PSA 50-99 and > 100, respectively, while CSS was 87% for the whole group. These results argue for aggressive management with RP as the initial step.

#### **RP in cT3b-T4 N0**

Provided that the tumour is not fixed to the pelvic wall, or that there is no invasion of the urethral sphincter, RP is a reasonable first step in selected patients with a low tumour volume.

In 2005, The Mayo Clinic reported a series of patients with seminal invasion, treated with RP + HT adjuvant. They had a progression free survival at 5, 10 and 15 years, of 85%, 73% and 67% respectively, and a cancer specific survival of 95%, 90% and 79%.

Despite this, management decisions should be made after all treatments, and should be discussed by a multidisciplinary team, and after balancing benefits and side-effects of each therapy modality by the patient, with regard to his own individual circumstances, decision has to be taken.

### **4.3 Optimal surgical technique for high risk cancer**

Surgeons must understand the important anatomical and surgical principles that will allow them to improve their own technique, particularly when operating in the high-risk setting. Certain principles are important, and apply equally to open, laparoscopic and robotic surgical techniques.

Even in a patient with a high risk of extra prostatic disease, a portion of the neurovascular bundle can often be preserved. (17)

Radical Prostatectomy in High Risk Prostate Cancer 143

boost to the prostatic fossa only) versus no immediate treatment. (55) The cumulative rate of loco regional failure was significantly lower in the irradiated group (*P* <0.0001). However, other clinically important endpoints were not improved. In particular, 5-year metastasis-free survival, cause-specific survival, and overall survival were not affected by

The Southwest Oncology Group (SWOG) trial 8794 included 425 patients with high-risk localized disease, who were randomized to receive either 60–64 Gy to the prostatic fossa or observation only. (56) Biochemical control, disease-free survival, cancer-specific mortality, and overall survival were significantly increased in the adjuvant irradiation arm at a median

Both the EORTC and SWOG randomized trials, provide evidence that adjuvant postprostatectomy irradiation reduces the risk of biochemical recurrence and local clinical failure. It remains uncertain, whether administration of radiation immediately after PSA is

The efficacy of radiotherapy in the setting of a rising PSA after RP is unproven, and its use is highly controversial. Stephenson et al. reported on a large retrospective analysis of salvage

Positive surgical margins, Gleason scores <8, or PSADT >10 months. In such patients, PSA

Regarding cancer-specific survival rate, and the overall survival rate, there are many

First, in terms of morbidity, Berglund and colleagues (58) showed, that recovery from surgery, duration of catheterization, and the overall return of continence were essentially

Another important factor to consider when analyzing survival, is the overstaging sometimes happens in the T3. Therefore, Ward et al report a long-term experience with radical surgery in patients presenting with locally advanced (cT3) prostate cancer, as the best management of such patients remains a problem. They found that, significantly many patients with cT3 prostate cancer were over-staged (pT2) in the PSA era, and RP as part of a multimodal treatment strategy for patients with cT3 disease offers cancer control and survival rates

For short term survival, Loeb et al (35) reported a complication rate of 11% in 288 consecutive high-risk patients treated by RP, which was not different from the rate in a previous study from the same group that included 3,477 consecutive patients with prostate cancer (59) when analyzing intermediate-term cancer control, and quality-of-life outcomes after radical retropubic prostatectomy (RRP), and concluded that RRP offers excellent intermediate-term cancer control for selected men, of all ages, who present with high-risk or locally advanced disease. Both, continence and potency, were preserved in most patients, although the potency rates were significantly greater for the younger men. RRP with appropiate postoperative radiotherapy and/or hormonal therapy is a reasonable treatment

option for selected men with high-risk or locally advanced disease. (35) (Table 4)

detected, could provide equally effective long-term outcomes to patients receiving adjuvant therapy, while sparing such patients from unnecessary irradiation. (17) (48)

relapse-free survival outcomes were in the range of 70% to 80% at 3 years.

adjuvant RT.

follow-up of 10.6 years.

**Salvage radiotherapy** 

**6. Survival** 

irradiation of 501 patients from 5 institutions. (57)

similar to those observed in the low-risk population.

approaching those achieved for cT2 disease. (31)

studies, with different results (table 4).

This approach has been facilitated by recent anatomical descriptions of the periprostatic anatomy. (51)

Dissection of the neurovascular bundles can be done in an intrafascial plane (directly adjacent to the prostatic capsule; complete nerve sparing), an interfascial plane (within the lateral prostatic fascia; partial nerve sparing) and extrafascial plane (outside the lateral prostatic fascia; nerve resection)

Deep dissection beneath Denonvilliers' fascia posteriorly should be performed routinely, as few nerves are present in this area and deep dissection will reduce the incidence of posterolateral margins.

Large, high-grade cancers, near the base of the prostate, or in the anterior transition zone often invade the bladder neck. For anterior cancers, begin division of the bladder neck a centimeter or more from its junction with the prostate. For large posterior tumors or those with seminal vesicle invasion, include the posterior bladder distal to the interureteral ridge in the specimen. (48)
