Radical prostatectomy for clinical T3 disease: expanding indications while optimizing cancer control and quality of life

Background A 61-year-old male presented with a history of gradually rising PSA over several years. His PSA had increased from 3.3 to 7 ng/ml over 3 years. Investigations Digital rectal examination, prostate biopsy, bone scan, and endorectal MRI were carried out to confirm the diagnosis and evaluate the extent of the cancer, with subsequent histopathologic examination of the radical prostatectomy specimen. Diagnosis Preoperative clinical stage (based on the digital rectal examination alone) was cT3a. Biopsy demonstrated extraprostatic extension in one core (Gleason 9 [4 + 5]). Endorectal MRI suggested a large volume cancer with probable extraprostatic extension in the posterior midline at the apex. Examination of the radical prostatectomy specimen demonstrated a pT3aN0 prostate cancer (Gleason 4 + 3 = 7 with a minor component of Gleason pattern 5). Extraprostatic extension was seen in the right posterior apex in the area of the dominant tumor mass. Surgical margins and seminal vesicles were negative for cancer. Management Radical retropubic prostatectomy with preservation of both neurovascular bundles plus bilateral pelvic lymph node dissection was performed. Postoperative PSA has been nondetectable. The patient is continent and, with the aid of vardenafil HCl, has erections sufficient for intercourse.