What is the role of surgery in the treatment of metastatic and advanced prostate cancer?

Updated: Dec 29, 2020
  • Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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An indication for immediate bilateral orchiectomy is spinal cord compression. Surgical intervention is mandatory for pathologic fractures involving weight-bearing bones.

In patients with clinical stage T3 prostate cancer at initial presentation, radical prostatectomy (RP) has not historically been considered beneficial, because of the increased probability of incomplete resection of the cancer, likelihood of micrometastatic disease, and increased morbidity.

However, a retrospective review of approximately 840 men with stage cT3 prostate cancer who underwent RP at the Mayo Clinic (median follow-up, 10.3y) reported outcomes similar to those with organ-confined disease (stage T2c) during the same period at this institution. Pathologic stage, Gleason grade, positive surgical margin, and nondiploid chromatin were found to be independently associated with increased progression of disease. [55]

In another Mayo Clinic study, in which the long-term survival of patients with high-risk prostate cancer was compared after RP and after external beam radiation therapy (EBRT), RP alone and EBRT plus ADT provided similar long-term cancer control. [56] However, the risk of all-cause mortality was greater after EBRT plus ADT than after RP.

In the study, RP was used in 1238 men, EBRT plus ADT was used in 344 men, and 265 received EBRT alone. The 10-year cancer-specific survival rates in the study were 92% in patients treated with RP or EBRT plus ADT, and 88% in those receiving EBRT alone, with a median follow-up of 6-10 years.

Current National Comprehensive Cancer Network (NCCN) guidelines recommend RP plus pelvic lymph node dissection as an option for initial therapy in patients with T3a disease. The NCCN considers salvage RP an option for highly selected patients who have local recurrence without metastasis after EBRT, brachytherapy, or cryotherapy. However, salvage RP is associated with high rates of morbidity (ie, incontinence, loss of erection, anastomotic stricture), so the NCCN advises that the operation be performed by surgeons experienced in salvage RP. [20]

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