What is the Role of Surgery for Locally Advanced Disease?

Among the optimal options recommended for locally advanced prostate cancer, radical prostatectomy (RP) with or without adjuvant radiotherapy or hormone therapy is a possible but relatively infrequent option. The role of radical prostatectomy in locally advanced prostate cancer is still controversial and has not been extensively assessed despite numerous recent series provided by great US and European institutions. Nevertheless, in selected patients with cT3a tumours, surgery can provide good oncologic results with 10-yr and 15-yr prostate cancer survival rates of about 85% and 75%, respectively. Moreover, approximately 20–30% of patients who initially present with cT3 tumours ultimately have organ-confined disease on pathologic examination. RP for locally advanced prostate cancer provides similar short-term biochemical-free survival compared to the of combination radiotherapy and androgen ablation. Morbidity of the procedure is similar to RP for organ-confined tumours. The impact of radical prostatectomy on local progression and local recurrence is also important in well-selected patients with low- or intermediate-grade tumours. Preoperative analysis of clinical stage, biopsy data, Gleason score, endorectal magnetic resonance imaging, and nomograms may enhance the choice of the best option in young and healthy patients with locally advanced prostate cancer. RP should be considered as a viable alternative to radiotherapy and hormone therapy in patients with long life expectancy presenting with cT3 prostate cancer. Combined treatments with RP have to be prospectively evaluated in terms of oncologic outcome and quality of life. This approach should be investigated in clinical and comparative trials.