Surgery for high-risk prostate cancer and metastatic prostate cancer.

Prostate cancer has the highest incidence among solid organ cancers in men and has the second highest oncologic mortality among men worldwide. High-risk prostate cancer, per the American Urological Association guidelines, is defined as a prostate-specific antigen (PSA) level Z20 ng/mL, clinical stage ZT2c, or Gleason score Z8 or a combination of any of them. The European Association of Urology, as well as the National Comprehensive Cancer Network, has similar definitions with 1 exception: high-risk clinical stage is T3a or higher. A further subset of prostate cancer, termed very high risk by Oderda et al includes patients with clinical stage ZT3, PSA Z50 ng/mL, or any recurrent disease after primary treatment. Currently, many patients with high-risk disease, most with very high-risk disease, and almost all patients with known metastatic disease are treated with combined hormonal therapy and radiation therapy (RT). Historically, surgery was not recommended for high-risk disease given the presumed postoperative morbidities in the setting of high-risk metastatic disease. However, with great improvements in surgical technique and decreased morbidity of the operation over the past decade, there has been a resurgence of interest regarding surgery and its role in multimodal therapy for these patients. There are no randomized trial data regarding surgery vs radiation treatment alone for the cure of high-risk cancer as monotherapy. In this article, we focus on the role of surgery in high-risk and metastatic prostate cancer, surgical approaches, and perioperative considerations in this subset of patients.