Focal Therapy (HIFU) vs Robotic Surgery vs Open Surgery

Ideally a kidney biopsy would first establish the histological subtype (clear cell, chromophobe, papillary, or another type) to guide systemic treatment, immunotherapies such as nivolumab, or TKIs such as sunitinib or pazopanib if immunotherapy isn't available. These agents are distinct from chemotherapy, and immunotherapy is increasingly recommended in guidelines for advanced and metastatic disease. This particular patient, with liver metastases, is not a surgical candidate, and a realistic prognosis should be given. Nephrectomy with IVC thrombectomy is appropriate when disease is still localised or locally advanced, since a kidney tumour extending through the IVC is still considered as such, but once there are multiple metastases in the liver and elsewhere, surgery is not the right approach.

The backbone remains continuous ADT, agents like degarelix or leuprolide, combined with newer anti-androgens such as abiraterone or enzalutamide, known as ARPIs (androgen receptor pathway inhibitors), plus genetic testing, where a BRCA mutation supports adding a PARP inhibitor such as olaparib, with many patients now on doublet, triplet or even quadruplet combinations rather than ADT alone. Oligometastatic (limited stage 4) disease confined mainly to the prostate and pelvis can still be surgically debulked alongside roughly one to one-and-a-half years of ADT; widespread stage 4 disease has no surgical indication. When these lines of treatment fail, options include immunotherapy, docetaxel- or paclitaxel-based chemotherapy, and lutetium (PSMA) radioligand therapy, which tags rapidly-dividing, PSMA-expressing tumour cells for targeted internal radiotherapy, plus other immunotherapies such as pembrolizumab. Targeted gene therapy itself isn't yet in commercial clinical use, what is used is genetic testing to select the most effective molecule for a given patient's mutation profile, such as PARP inhibitors for BRCA2-positive cancer.

The patient needs a realistic sense of hope appropriate to their stage. A PSA above 1000 indicates metastatic disease, and in that setting the approach shifts from surgical cure to bringing the cancer under control with ADT and other systemic molecules.

Transurethral procedures such as bipolar enucleation, bipolar resection, TURP, or HoLEP are all for benign prostate enlargement. Radical prostatectomy is a different operation for cancer of the prostate, done robotically. There is also a robotic option for very large benign glands: whenever the prostate is bigger than 200 to 250 grams, a robotic simple prostatectomy is performed instead of a transurethral procedure.

Outcomes vary by patient. In one case, a patient in his early sixties found to have a Gleason 4+4 tumour during routine follow-up for an unrelated condition could not be kept on active surveillance despite being young and sexually active. Given a realistic estimate of about an 80% chance of good erections afterward, he was started on tadalafil to prime the tissue before robotic surgery; within about four weeks of catheter removal he reported a full return of intimacy with his wife. Preservation depends on how sexually active and physically strong the patient was beforehand and on the tumour stage: early-stage tumours allow both neurovascular bundles to be spared, with tadalafil and, if needed, self-stimulation techniques or intracavernosal injections used during rehabilitation; in advanced cases where nerves cannot be spared, a penile implant remains an option. Cancer cure always comes first, since the patient must survive before sexual function can be addressed.

Only a small subset of patients, about 2 to 5%, where a complete systematic biopsy confirms one well-circumscribed nodule and the rest of the prostate is genuinely free of tumour.

Yes - robotic surgery achieves better margins and better preservation of sexual function, since the neurovascular bundles are more easily identified with better precision and magnification.