Why Prostate Cancer Patients Are Treated Surgically Even With Advanced Disease

Yes, that's correct. Orchidectomy is a cost-effective, one-time procedure, and increasingly patients in developing countries are also getting health insurance that covers the ongoing medications, so when it comes to overall treatment, orchidectomy can even be considered superior in efficacy compared to injectable treatment, and there's no harm in doing it. However, losing a testicle is a point of real psychological impact for a man, so if a patient can afford it or the treatment is available, I would suggest androgen deprivation therapy via injections or medication as preferable — orchidectomy remains a well-suited procedure specifically for patients with stage 4 disease.

What you're describing is the androgen depletion syndrome — you have abolished testosterone, so the patient develops post-menopausal-type symptoms. In our practice, for patients who have undergone androgen deprivation, we educate them not to panic, start gabapentin and sometimes an anti-anxiety medication, and for central obesity and related issues advise calcium and vitamin D supplements, a high-protein, low-fat diet, regular exercise, and sunlight exposure, since bones become fragile and there is increased risk of coronary artery disease and hypertension. We sometimes also use denosumab if the patient is very incapacitated by hot flashes and sweating. You did the right thing for your patient — surgical castration is the most practical option where injectable androgen analogues or antagonists aren't reliably available.

False positivity of PSA is very common, so I would follow this patient regularly, first checking for infection. I would repeat the PSA after 6 weeks — if the high PSA was due to infection, a course of antibiotics should show a downward trend by then; if it doesn't trend down, you should have a high suspicion of prostate cancer. You can also check the free-to-total PSA ratio — if it's less than 25%, that supports the diagnosis. If the DRE is normal and there's no biopsy facility, you can follow the patient for a year and check PSA velocity — if it goes beyond 0.75 per year, refer to a centre with TRUS-guided biopsy or MRI facilities. With a PSA of 10-20, there is roughly a 10-30% chance of harbouring prostate cancer, so this should be investigated further rather than dismissed.

This is a sign of chronic prostatitis — patients with chronic infection in the prostate get calcium deposited in the glandular secretions over time, which is the mechanism behind the calcification. If the patient is asymptomatic and PSA is normal, I would not worry. If symptomatic, try medical management first, and only if that fails should you consider a surgical procedure. Prostatic calcification itself does not cause any harm — it is simply a telltale sign of chronic infection in the prostate.

In our country this facility is not widespread and is not yet widely accepted by the urology community here, though it is practised in the West by urologists, medical oncologists, and interventional radiologists. I would add that prostate cancer is usually slow-growing, but the prostate also has BPH growing alongside it, and patients with even locally advanced or oligometastatic disease often die from the obstructive mass effect of the prostate on the bladder neck and ureters rather than from the cancer itself — which is why, as a surgeon, I usually still consult even locally advanced or oligometastatic candidates for robotic radical prostatectomy, aiming for clear margins, early continence, and preserved erectile function.

Alongside cancerous growth, the prostate also continues to grow due to benign prostatic hyperplasia, which poses its own mechanical problem by blocking the urethra and, eventually, the ureteric orifices as patients age.

Patients with even metastatic or locally advanced prostate cancer often do not die because of the cancer itself, but because of the obstructive effects of the enlarged prostate on the urinary tract, which can lead to kidney failure if untreated.

Removing the prostate addresses both the cancer and the mechanical obstruction risk in a single procedure, which is why many patients are consulted for radical prostatectomy rather than hormone therapy alone.

Leaving the enlarged prostate in place can allow the obstruction to worsen even after the cancer itself has been controlled with radiation or hormonal treatment.