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Treatment Option Overview for Prostate Cancer

    Table 9. Treatment Options by Stage for Prostate Cancer continued...

    (Refer to the Stage II Prostate Cancer Treatment section of this summary for more information.)

    Radical Prostatectomy

    A radical prostatectomy is usually reserved for patients who:[17,18,19]

    • Are in good health and elect surgical intervention.
    • Have tumor confined to the prostate gland (stage I and stage II).

    Prostatectomy can be performed by the perineal or retropubic approach. The perineal approach requires a separate incision for lymph node dissection. Laparoscopic lymphadenectomy is technically possible and accomplished with much less patient morbidity.[20] For small, well-differentiated nodules, the incidence of positive pelvic nodes is less than 20%, and pelvic node dissection may be omitted.[21] With larger, less-differentiated tumors, a pelvic lymph node dissection is more important. The value of pelvic node dissection (i.e., open surgical or laparoscopic) in these cases is not therapeutic but spares patients with positive nodes the morbidity of prostatectomy. Radical prostatectomy is not usually performed if frozen section evaluation of pelvic nodes reveals metastases; such patients should be considered for entry into existing clinical trials or receive radiation therapy to control local symptoms.

    The role of preoperative (neoadjuvant) hormonal therapy is not established.[22,23]

    Following radical prostatectomy, pathologic evaluation stratifies tumor extent into the following classes:

    • Margin-positive disease—The incidence of disease recurrence increases when the tumor margins are positive.[7,10,24] Results of the outcome of patients with positive surgical margins have not been systematically reported.
    • Specimen-confined disease—The incidence of disease recurrence increases when the tumor is not specimen-confined (extracapsular).[7,10]
    • Organ-confined disease—Patients with extraprostatic disease (not organ-confined) are suitable candidates for clinical trials such as the Radiation Therapy Oncology Group's (RTOG [RTOG-9601]) trial, for example. These trials include evaluation of postoperative radiation delivery, cytotoxic agents, and hormonal treatment using luteinizing hormone-releasing hormone (LH-RH) agonists and/or antiandrogens.

    Radical prostatectomy compared with other treatment options

    In 1993, a structured literature review of 144 papers was done in an attempt to compare the three primary treatment strategies for clinically localized prostate cancer:[25]

    1. Radical prostatectomy.
    2. Definitive radiation therapy.
    3. Observation (watchful waiting or active surveillance).
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