Managing Locally Advanced Prostate Cancer with Neoadjuvant ADT

Prostate cancer is usually multifocal, so focal therapy only suits a small subset of patients, about 2 to 5% of the whole pool, where a complete systematic biopsy confirms one localised, well-circumscribed nodule with the rest of the gland genuinely tumour-free; this treatment is available in India when that scenario applies. Because most prostate cancer is multifocal, robotic surgery remains the treatment of choice, with a time-proven cure rate of roughly 95%. Focal therapy treats one spot, but a new nodule can appear elsewhere later, and prior radiotherapy or focal therapy makes a subsequent robotic surgery more difficult and reduces the chance of preserving nerves and sexual function, so focal therapy is not an alternative to robotic surgery, just a different treatment for a different kind of patient.

Open prostate surgery today has almost no role. Robotic surgery achieves better surgical margins even in locally advanced disease. Having practised through the open, laparoscopic and now exclusively robotic eras, and never having converted a robotic case to open surgery, the real question in locally advanced disease is whether surgery is appropriate at all, not which technique to use. If disease is essentially metastatic, surgery offers no benefit and should not be done, but there is no patient suitable for robotic surgery who would somehow do better with an open approach instead.

Yes, robotic surgery preserves sexual function better than laparoscopic or open surgery, because the neurovascular bundles are more easily identified, the dissection is more precise, and the magnification is far better; hydrodissection of the neurovascular tissue is sometimes used to help preserve the plane. Robotic surgery scores over other options on preservation of sexual function.

Orchidectomy should not be the answer for localised prostate cancer, it causes more harm than benefit, leaves the patient without erections, and the disease may still, over time, develop bone or other metastasis. Since MRI is available in Ethiopia even without bone or PET scans, an MRI of the lumbar spine and pelvis can screen for bony metastasis; orchidectomy is justified only if metastasis is found. Otherwise, patients with early-stage disease should be told clearly that the correct treatment, excision of the diseased organ rather than the testes, isn't currently available locally, and encouraged to pursue it overseas, including with help arranging financial support and other resources.

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.

Androgen deprivation therapy given before surgery to shrink the prostate and improve the PSA response; oral relugolix is one option, preferred over injectable agonists like degarelix or leuprolide/goserelin for ease of administration.

No - surgery has a role even in oligometastatic disease, where patients with locally advanced or limited-spread cancer can still achieve cure.