there are many effective treatments for clinically localized prostate cancer.
randomized clinical trials eliminate selection bias.
the treatment outcomes in any patient series may be influenced by the malignant potential of the tumors as well as the treatment used.
most patients diagnosed with prostate cancer receive the same treatment.
outcome measures are similar.
the potential benefits of surgery do not outweigh potential complications in men with a life expectancy of less than 10 years and a low-grade prostate cancer.
a prospective, randomized clinical trial demonstrated similar local cancer progression and metastasis rates for patients with clinically localized prostate cancer managed with deferred treatment and radical prostatectomy.
in most watchful waiting studies, only about 15% of patients develop objective evidence of tumor progression within 5 years.
an accurate assessment of clinically insignificant or indolent cancers is determined by biopsy results.
watchful waiting allows timely intervention as long as patients with localized prostate cancer are followed up semiannually with digital rectal examination and PSA levels.
Any positive repeat biopsy
More than 10% of a biopsy core involvement
PSA velocity less than 0.5 ng/mL/year
Gleason pattern 4 or 5 present
Previous cryotherapy of the prostate gland
Preservation of the external sphincter muscle that yields urinary continence rates in excess of 90%
Discovery that the pudendal nerves are responsible for urinary continence
Magnification provided by robotic-assisted prostatectomy
Frequent use of saturation biopsy under general anesthesia
Elimination of pelvic lymphadenectomy in patients with low-risk tumor features
Perineal: more blood loss and a longer operative time than the retropubic approach
Laparoscopic: lowest complication rate
Robotic: three-dimensional visualization
Retropubic: higher risk for rectal injury and postoperative fecal incontinence
Laparoscopic: lowest positive surgical margin rate
Biochemical recurrence-free probability
Cancer-specific survival probability
perform a retrograde dissection to identify the neurovascular bundles at the bladder neck.
release the endopelvic fascia after the neurovascular bundle dissection.
use bipolar electrocautery to transect the urethra.
dissect the neurovascular bundles free of the posterolateral surface of the prostate gland.
use a harmonic scalpel to release neurovascular bundles.
Performance of nerve-sparing surgery
Bladder neck–sparing dissection
Pathologic tumor stage
Preoperative renal function
absence of antihypertensive therapy.
absence of preoperative hormonal therapy.
absence of postoperative radiation therapy.
absence of a smoking history.
It is strongly associated with an intermittent androgen ablation therapy.
It usually occurs within 2 years of radiation therapy.
It does not exceed an increase of 2 ng/mL following radiation therapy.
It should be treated immediately with combined androgen blockage therapy.
It is more commonly associated with external beam radiation therapy.
Three consecutive rises of PSA following radiation therapy with at least one PSA bounce
Three PSA increases measured 12 months apart and back-dates the time of cancer progression to halfway between the first and the second rising PSA levels
Three consecutive rises of PSA following radiation therapy and back-dates the time of cancer progression to halfway between the second and third rise of PSA levels
Three consecutive PSA increases measured 6 months apart and back-dates the time of cancer progression to halfway between the PSA nadir and the first rising PSA level
Three consecutive PSA increases of total 2 ng/mL after reaching a PSA nadir
Serum PSA less than 2 ng/mL
Previous transurethral resection of prostate (TURP)
History of hematospermia
Lower urinary tract symptoms
Previous radical retropubic prostatectomy
Positive surgical margin
Extracapsular tumor extension
Preradiation PSA greater than 2 ng/mL
Preoperative PSA less than 10 ng/mL
PSA doubling time of more than 3 months
Concurrent hormonal therapy
Previous robot-assisted laparoscopic prostatectomy
Lymph node metastasis
Initiation of salvage radiotherapy after PSA has risen above 2 ng/mL
PSA doubling time of less than 6 months
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