In this episode, Dr. Aditya Bagrodia speaks with Dr. David Penson about the role of surgery in managing high-risk prostate cancer, including how to identify appropriate candidates and balance treatment options. Dr. Penson outlines the traditional criteria for high-risk disease—PSA >20 ng/mL, Gleason grade ≥8–10, and T2–T3 staging—and explains how evolving definitions have broadened the spectrum of patients considered high risk. He highlights the importance of pathologic assessment and MRI for staging, noting how some patients underestimate the seriousness of high-risk disease due to misleading online information. Both physicians stress the value of providing patients with accurate educational resources, such as WellPrept, and review staging tools including PSMA PET, bone scan, and prostate MRI. They also discuss shifts in neoadjuvant therapy, including the limited benefit of GnRH agonists and the emergence of newer agents like PARP inhibitors.
The conversation then explores decision-making between radical prostatectomy and radiation therapy (RT). Dr. Penson reviews the trade-offs: surgical risks such as incontinence and sexual dysfunction, versus the limitations of post-RT salvage surgery and potential urinary side effects. He cautions that nerve-sparing prostatectomy may compromise oncologic control in high-risk cases and outlines key contraindications to surgery, including rectal involvement, extensive bladder neck involvement, severe cardiac disease, prior multiple abdominal surgeries, and high-volume nodal disease. Ideal candidates are patients with organ-confined T2 high-grade tumors and those with baseline lower urinary tract symptoms (LUTS).
Finally, the doctors discuss the role of nomograms in predicting outcomes. While useful for estimating mortality risk, Dr. Penson finds them less reliable for assessing cure and instead bases prognosis on postoperative pathology. Features such as positive surgical margins or bladder neck involvement may prompt referral for adjuvant radiation therapy, underscoring the importance of collaboration with radiation oncologists and participation in multidisciplinary tumor boards.
Contributors:
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Dr. David Penson is a professor and chair of urologic oncology at Vanderbilt University in Nashville, Tennessee.
