Preoperative Assessment

Radical prostatectomy is considered as a curative treatment. It is highly important for preoperative staging to exclude any evidence of locally advanced or distant metastatic disease. The presence of any residual disease after radical prostatectomy denotes treatment failure. The likelihood of post-radical prostatectomy failure is associated with increased pathologic stage9. On the other hand, the clinical staging of prostate cancer is limited using conventional preoperative diagnostic methods.

The likelihood of extracapsular disease is increased in patients with high prostate specific antigen (PSA) levels and Gleason scores. It was demonstrated that the chances of having organ-confined disease in patients with a PSA level of <10ng/ml is 70-80%. The chance decreases to 50% for men with PSA >10ng/ml and to approximately 25% for men with PSA >50ng/ml.10 However, PSA values vary widely within a given stage and overlap between different stages; the predictive value of PSA in determining pathologic stage is weak.11

Digital rectal examination understages organ-confined disease. It was shown that only 52% of patients with cT2 disease and 19% of patients with cT3 disease had organ-confined tumors.10 Although there are reports of cure using radical prostatectomy for men with cT3 disease, the presence of a bulky extraprostatic tumor and the high risk for metastatic disease limits the use of radical prostatectomy in these patients.12 However, patients with cT1 or cT2 tumors that are upstaged to pT3 after the surgery can experience durable cancer remissions.13'14

It is well known that tumor grade is strongly related to stage and clinical prognosis. It was demonstrated that tumors with a Gleason score of 6 on prostate needle biopsy had a 24% risk of capsular penetration and a 29% risk of positive surgical margins. This increased to a 62% risk of capsular penetration and a 48% risk of positive surgical margins for cancers with a Gleason score of 7, and to 85% and 59%, respectively, for cancers with a Gleason score of 8-10.15

Perineural invasion on needle biopsy and increased tumor volume are associated with capsular penetration and extracap-sular extension.16,17 The odds of having extraprostatic disease are increased when all three biopsy cores from a single side of the prostate are positive for cancer on sextant biopsy.

Patient-related factors are also important in decision making for radical prostatectomy. Advancing age and poor health status limit the indications of radical prostatectomy as a treatment option. Risk for incontinence and impotence, hospitalization and recovery period as well as fear of being under anesthesia should be discussed in detail before the surgery.

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