EURURO Vol. 71 No. 4

623 692

metastases >5% is an indication to perform an extended
nodal dissection (ePLND). This includes removal of the
nodes overlying the external iliac artery and vein, the nodes
within the obturator fossa located cranially and caudally to
the obturator nerve, the nodes medial and lateral to the
internal iliac artery, and the nodes overlying the common
iliac artery and vein up to the ureteral crossing. It is
recommended that for each region the nodes should be sent
separately for pathologic analysis. With this template, 75%
of all anatomic landing sites are cleared, resulting in
improved pathological staging compared with a limited
pelvic lymph node dissection, but at the cost of three-fold
higher complication rates (19.8% vs 8.2%), mainly related to
significant lymphoceles
In men with pN+ PCa, early adjuvant androgen-
deprivation therapy (ADT) was shown to achieve a 10-yr
CSS rate of 80% . Improving local control with pelvic
radiation therapy (RT) combined with ADT appeared to be
beneficial in pN1 PCa patients treated with an ePLND. Men
with minimal-volume nodal disease (fewer than three
lymph nodes) and GS 7–10 and pT3–4 or R1 as well as men
with three to four positive nodes were more likely to benefit
from combined ADT and RT after surgery .
9.2. Low-risk prostate cancer
The decision to offer RP should be based on the probabilities
of clinical progression, side effects, and potential survival
benefit. No lymph node dissection is needed.
9.3. Intermediate-risk localised prostate cancer
Data from SPCG-4 and a preplanned subgroup analysis
(PIVOT) highlight the benefit of RP compared to WW.
The risk of having positive nodes is 3.7–20.1% . An
ePLND should be performed if the estimated risk for pN+
exceeds 5% . In all other cases, nodal dissection can be
omitted while accepting a low risk of missing positive
nodes.
9.4. High-risk and locally advanced prostate cancer
Patients with high-risk and locally advanced PCa are at an
increased risk of PSA failure, need for secondary therapy,
metastatic progression, and death from PCa. Provided that
the tumour is not fixed and not invading the urethral
sphincter, RP combined with an ePLND is a reasonable first
step in a multimodal approach. The estimated risk for pN+ is
15–40% . Regarding each individual high-risk factor in
patients treated with a multimodal approach, a GS 8–10
prostate-confined lesion has a good prognosis after RP. In
addition, frequent downgrading exists between the biopsy
and the specimen GS . At 10- and 15-yr follow-up, the
CSS is up to 88% and 66%, respectively . A PSA
>20 ng/ml is associated with a CSS at 10 and 15 yr ranging
between 83% and 91% and 71% and 85%, respectively
. Surgery has traditionally been discouraged for cT3N0
PCa, mainly because of the increased risk of positive
margins and lymph node metastases and/or distant relapse.
Retrospective case series demonstrated a CSS at 10 and
15 yr between 85% and 92% and 62% and 84%, respectively;
10-yr OS ranged between 76% and 77% . The overall
heterogeneity of this high-risk group was highlighted by a
large retrospective multicentre cohort of 1360 high-risk
patients treated with RP in a multimodal approach . At
10 yr, a 91.3% CSS was observed. CSS was 95% for those
having only one risk factor (ie, GS >7, cT category higher
than cT2, or PSA >20 ng/ml), 88% for those having a cT3–4
and a PSA >20 ng/ml, and reduced to 79% if all three risk
factors were present.
9.5. Side effects of radical prostatectomy
Postoperative incontinence and erectile dysfunction (ED)
are common problems following RP. There is no major
difference based on the surgical approach with an overall
continence rate between 89% and 100% when a robotic
procedure was conducted compared to 80–97% for the
retropubic approach .
A prospective controlled nonrandomised trial of patients
treated in 14 centres was published recently. At 12 mo after
robotic surgery, 21.3% were incontinent, as were 20.2% after
open. The adjusted OR was 1.08 (95% CI, 0.87–1.34). ED was
observed in 70.4% after robotic and 74.7% after open. The
adjusted OR was 0.81 (95% CI, 0.66–0.98) .
10. Definitive radiation therapy
Dose-escalated intensity-modulated radiation therapy
(IMRT), with or without image-guided RT, is the gold
standard for external-beam radiation therapy (EBRT)
because it is associated with less toxicity compared to
three-dimensional conformal radiation therapy (3D-CRT)
techniques . However, whatever the technique and
their degree of sophistication, quality assurance plays a
major role in the planning and delivery of RT.
RCTs have shown that escalating the dose into the range
74–80 Gy leads to a significant improvement in 5-yr
biochemical-free survival In men with intermedi-
ate- or high-risk PCa, there is also evidence to support an OS
benefit from a nonrandomised but well-conducted propen-
sity matched retrospective analysis covering a total of 42
481 patients
Biological modelling suggests that PCa may be sensitive
to an increased dose per fraction resulting in the
investigation in RCTs of hypofractionation (HFX) in local-
ised disease. The largest reported [10_TD$DIFF]randomised trial, using
IMRT in predominantly intermediate[11_TD$DIFF]-risk localised PCa,
(CHHiP trial) demonstrates 60 Gy in 20 fractions (3 Gy/
fraction) is non-inferior to 74 Gy in 37 fractions with 5-[12_TD$DIFF]yr
recurrence free rates of 90%. A third arm using 57 Gy in
19 fractions (3 Gy/fraction) was not demonstrated to be
non-inferior in terms of biochemical control. No significant
differences in the proportion or cumulative incidence of 5-
[12_TD$DIFF]yr toxicity were found when using the 3 Gy per fraction
schedules . Other trials have demonstrated increased
toxicity with HFX. In the RTOG 0415 study, 70 Gy in
28 fractions (2.5 Gy/fraction) was investigated in low risk
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