Treatment Options for Localised and Locally Advanced Prostate Cancer

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.

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.

ADT alone, radiotherapy combined with ADT, or radical prostatectomy - radical prostatectomy offers the best chance of cure.

Patients typically go home after about three days, keep a catheter for up to roughly 20 days, and generally have acceptable continence afterward.