Is radical prostatectomy the best option for localized prostate cancer? Current opinion and research

Mike D Shelley¹, Malcolm D Mason<sup>2

1</sup>Head of Cochrane Urological Cancers Unit, Research Department, Velindre NHS Trust, Cardiff, UK; ²Cancer Research Wales Professor of Clinical Oncology, School of Medicine, Cardiff University, Velindre NHS Trust, Cardiff, UK

Abstract: Open radical prostatectomy is an effective treatment for prostate cancer with a 5-year biochemical recurrence-free survival rate of about 90% for localized disease. For men with organ confined disease, the 10 year disease-specific survival rate approximates 95% following retropubic prostatectomy. Attempts to improve survival rates by combining androgen deprivation therapy with radical prostatectomy have been unsuccessful. Erectile dysfunction and urinary incontinence are common complications following open radical prostatectomy. In an attempt to reduce morbidity, laparoscopic approaches have been developed with reported 8-year cancer control rates of about 70%. Robotic laparoscopic approaches yield a trifecta rate of achieving continence, potency and being prostate-specific antigen recurrence-free at 2 years of 74%. Comparative studies do not provide evidence that one surgical approach is superior. Few randomized trials have compared surgery with the other primary therapies for prostate cancer. A Scandinavian randomized study has reported that the metastatic rate and overall mortality are significantly better with surgery compared to watchful waiting. However, there are no published data from randomized trials comparing surgery with radiotherapy (external beam or brachytherapy), active surveillance or minimally invasive procedures. There are ongoing randomized trials comparing surgery with radiotherapy, brachytherapy, and active surveillance, but until these are published, there is no conclusive evidence that surgery is the best primary option for localized or locally advanced prostate cancer.

Keywords: prostatectomy, laparoscopic prostatectomy, radiotherapy, watchful waiting, active surveillance