**2.3 Prostate cancer with PSA > 20**

Different studies show that the RP in patients with a PSA> 20 is associated with a high recurrence rate, D'Amico and colleagues found that males with a PSA level higher than 20 ng/ml had risk recurrence of 50% at 5 years after RP (42). Similarly, Yossepowitch published the results of their series of patients with PSA> 20ng/ml who underwent radical prostatectomy, showing a PSA recurrence rate of 44 and 53% at 4 and 20 years respectively (10). It is perhaps the high preoperative PSA, the factor that best relates to a worse prognosis preoperatively.

On the other hand, Inman and colleagues, in their series of patients with PSA> 50ng/ml who underwent RP with multimodal adjuvant therapy, had biochemical progression-free survival at 10 years of 83% with a cancer-specific survival 87% (43). These highlights the potential benefit of surgery with in a multimodal approach.
