High intensity focused ultrasound with Focal-One® device: Prostate-specific antigen impact and morbidity evaluation during the initial experience

OBJECTIVE

We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One^® device.

MATERIAL AND METHODS

Retrospective review of the prospectively populated database. Between June 2014 to October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One^® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification.

RESULTS

The median PSA was 7.79ng/ml (IQR 6.32-9.16), with a median prostate volume of 38cc (IQR: 33-49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0-7) and bladder catheter was removed on day 2 (1-6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2-8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent.

CONCLUSIONS

Focal-One^® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Current practice and access to prostate MR imaging in France

PURPOSE

To obtain an overview of the degree of discrepancy between current clinical practice of prostate magnetic resonance imaging (MRI) in France and recommendations.

MATERIALS AND METHODS

A brief survey was sent to 1229 members of the French society of urology in order to identify their indications of prostate MRI and its impact on patient management. The urologists were asked to answer several questions regarding age, practice modality, prostate MRI examinations (technique, indication before first biopsy, second biopsy, cancer staging, active surveillance, recurrence, focal therapy) and quality of reports.

RESULTS

A total of 445 responses were received (participation rate of 36%). The mean delay for obtaining an appointment for prostate MRI ranged between 15-30 days in 54%. Fifty-four percent of MRI reports contained a PIRADS score and 23% a Likert score. The indications of multiparametric-MRI were tumor detection/location prior to repeat biopsy (90%), cancer staging (85%), management of patients under active surveillance (85%), selection of candidates to focal therapy (63%), tumor detection/location in biopsy naïve patients (53%), detection of local recurrence after radical (51%). Only 119 urologists (28.6%) had access to image fusion (MRI and transrectal ultrasound) and 351 (85.4%) used cognitive fusion. Mostly, targeted biopsies are done by urologists alone (nearly 80%), a very few are done by radiologists (8%) or by the two of them in collaboration (12%).

CONCLUSION

The majority of urologists consider that prostate MRI is essential for the management of patients with prostate cancer. Practices are ahead of recommendations particularly before the first biopsy and in active surveillance.

Endocrine Manifestations in a Monocentric Cohort of 64 Patients With Erdheim-Chester Disease

CONTEXT

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis, characterized by infiltration of foamy histiocytes in multiple organs. Endocrine involvement has mostly been described in case reports.

OBJECTIVE

We performed systematic endocrine evaluation in a large cohort of patients with ECD.

DESIGN

This was a single-center observational study conducted between October 2007 and May 2013.

SETTING

The evaluation was conducted in Pitié-Salpêtrière Hospital (Paris, France), a tertiary care hospital.

PATIENTS

Sixty-four consecutive patients with ECD (sex ratio, 3.6; mean age, 57.6 years [range, 20-80 years]). Thirty-six patients had follow-up assessments.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

Clinical, biological, and morphological evaluations of pituitary, gonadal, adrenal, and thyroid functions, as well as metabolic evaluation, were performed.

RESULTS

Diabetes insipidus was found in 33.3% of patients, frequently as the first manifestation of ECD. Anterior pituitary dysfunction was found in 91.3% of patients with full anterior pituitary evaluation, including somatotropic deficiency (78.6%), hyperprolactinemia (44.1%), gonadotropic deficiency (22.2%), thyrotropic deficiency (9.5%), and corticotropic deficiency (3.1%). Thirty-five patients (54.7%) had ≥2 anterior pituitary dysfunctional axes, rising to 69.6% (16 of 23) when only patients with complete evaluations were considered. Two patients had panhypopituitarism. Infiltration of the pituitary and stalk was found with magnetic resonance imaging in 24.4% of patients. Testicular insufficiency was found in 53.1% of patients, with sonographic testicular infiltration in 29% of men, mostly bilateral. Computed tomography adrenal infiltration was found in 39.1% of patients, and 1 case of adrenal insufficiency was observed. No patient was free of endocrine hormonal or morphological involvement. Endocrine dysfunctions were most often permanent, and new deficits appeared during follow-up.

CONCLUSION

Endocrine involvement is very frequent in ECD and should be evaluated carefully at diagnosis and during follow-up.

Multiparametric Magnetic Resonance Imaging Predicts Postoperative Pathology but Misses Aggressive Prostate Cancers as Assessed by Cell Cycle Progression Score

PURPOSE

We identified prognostic biomarkers in prostate cancer by a radiogenomics strategy that integrates gene expression using the cell cycle progression score and medical images.

MATERIALS AND METHODS

We obtained institutional review board approval and written informed consent from 106 men with prostate cancer, including 60% at low risk, who underwent multiparametric magnetic resonance imaging before radical prostatectomy was done and a cell cycle progression score was determined. The correlation between the results of multiparametric magnetic resonance imaging and Gleason grade or cell cycle progression score was assessed by logistic regression.

RESULTS

Patients with primary Gleason grade greater than 3 had a longer median maximal tumor diameter (13 vs 10 mm) and a lower median apparent diffusion coefficient (0.745 vs 0.88×10(-3) mm2 per second, each p=0.0001) than those with primary Gleason grade 3 or less. Maximal diameter 10 mm or greater (OR 4.9, 95% CI 1.7 to 14.0, p=0.0012) and apparent diffusion coefficient 0.80×10(-3) mm2 per second or less (OR 7.5, 95% CI 3.0 to 18.7, p<0.0001) were significantly associated with primary Gleason grade greater than 3. The combined measure of maximal diameter less than 10 mm and apparent diffusion coefficient greater than 0.80×10(-3) mm2 per second identified only index lesions harboring primary Gleason grade 3. However, 7 of those lesions showed a molecular pattern of high risk lethal prostate cancer (cell cycle progression score greater than 0).

CONCLUSIONS

Multiparametric magnetic resonance imaging is able to predict low and high risk Gleason scores in the tumor. However, the cell cycle progression score did not completely match the imaging result. These findings suggest that management of early stages prostate cancer could strongly benefit by performing magnetic resonance imaging targeted biopsy coupled with molecular analysis.

[Functional outcomes obtained after vesicoureteral reimplantation surgery in adults: A review]

OBJECTIVES

Vesico-ureteral reimplantations (VUR) for adults are complex procedures, often practicing for distal ureteral lesions. Our goal was to synthesis the main indications for VUR, different techniques and their functional outcomes.

MATERIAL AND METHODS

A literature review in English by Medline, Embase and Google scholar was performed using the following keywords: ureter; laparoscopy; robotics, reimplantation; surgery; obstruction; morbidity; complications; psoas hitch; Boari flap; ureteroneocystostomy.

RESULTS

In more than half of the cases, aetiology was a iatrogenic ureteral lesion. When the ureteral defect was less than 2 cm, direct or non-refluxing VUR was the technique of choice. If defect was superior than 2 cm the Boari flap or vesicopsoas hitch were preferred. Several surgical approaches were feasible: open, laparoscopic only, robot assisted laparoscopic. Estimated blood loss, pain and mean hospital stay seemed better with conventional or robotic coelioscopy. Nevertheless, complications, pre-/post-operative renal function and mean operative time seemed similar. The most frequent major complication was the anastomotic urine leakage.

CONCLUSIONS

The VUR techniques are well codified now even if it's a rare procedure. Functional outcomes are satisfied according to literature and morbidity is more and more decreasing but the level of evidence of the studies is low.

Influence of pathological factors on oncological outcomes after robot-assisted radical prostatectomy for localized prostate cancer: Results of a prospective study

PURPOSE

To assess the prognostic significance of lymphovascular invasion (LVI), maximum tumor diameter (MTD), high-grade prostatic intraepithelial neoplasia, perineural invasion, and length of positive surgical margins after robot-assisted radical prostatectomy (RARP).

METHODS

A single-institution prospective analysis of all patients who underwent RARP for localized prostate cancer was performed between January 2005 and June 2013. The primary end point was biochemical recurrence-free survival (BRFS). BRFS was estimated using the Kaplan-Meier method and compared to that from the log-rank test. Cox׳s proportional hazards regression univariate and multivariate analyses were performed to define the prognostic factors.

RESULTS

Overall, 742 men were included. After a median follow-up of 31.4 months, biochemical recurrence occurred in 80 patients (10.8%). BRFS was 93%, 87%, and 80.7% at 1, 3, and 5 years, respectively. Progression to local recurrence occurred in 49 patients (6.6%). During the follow-up period, 3 patients experienced progression to metastatic disease and were treated with hormonotherapy. No patient died of disease during the study period. In multivariate analyses, Gleason score was the strongest predictor of BRFS (hazard ratio [HR] = 3.4; P<0.001). There were 3 other predictive factors of BRFS were LVI (HR = 7.64; P = 0.005), MTD (HR = 4.04; P =0.009), and margin length ≥ 3 mm (HR = 1.25; P = 0.04).

CONCLUSION

In the era of serum prostate-specific antigen testing maturity in conjunction with a single approach to extirpation of the prostate gland by RARP, LVI, MTD, and positive surgical margins ≥ 3 mm are prognostic factors associated with BRFS after RARP. Consideration could be given to incorporate them in the pathology report of the radical prostatectomy specimens and they could assist physicians in clinical decision making.

Influence of statin use on clinicopathological characteristics of localized prostate cancer and outcomes obtained after radical prostatectomy: a single center study

INTRODUCTION

To assess the impact of statin use on biochemical recurrence (BCR) of prostate cancer after radical prostatectomy (RP).

MATERIALS AND METHODS

Data from all men treated with robot-assisted laparoscopic RP (RALRP) for localized prostate cancer between 2009 and 2014 at our institution were prospectively collected: age, body mass index (BMI), statin-use status, preoperative prostate-specific antigen (PSA) level, clinical T stage, biopsy Gleason score (bGS), D'Amico risk group, pathological T stage, specimen Gleason score (sGS), multifocality, peri neural invasion, positive surgical margins and time to BCR. Univariate and multivariate analysis were performed to test associations between statin use and prognostic factors of prostate cancer and/or BCR.

RESULTS

Overall, 591 patients with a median follow up of 42.3 months [25.8-59.9] were included in the current study and split in two cohorts: statin users (n = 156) and statin non-users (n = 435). When comparing statin user and non-users, no significant difference was found in terms of clinical, biochemical and pathological characteristics except for BMI (median 29 versus 26, respectively; p = 0.04). Regarding BCR, there was no significant difference between men using statin versus those not using them (4.5% versus 4.6%, p = 0.65). In univariate analysis, statin use was not significantly correlated to any prognostic factors of prostate cancer recurrence. Furthermore, there was no significant difference in the 5 years biochemical-free survival rates between statin users and non-users (75% versus 73%; p = 0.7).

CONCLUSIONS

From the current study, statin daily intake was not significantly associated with any prognostic factors of prostate cancer and with BCR after RARLP.

Accuracy of Magnetic Resonance Imaging/Ultrasound Fusion Targeted Biopsies to Diagnose Clinically Significant Prostate Cancer in Enlarged Compared to Smaller Prostates

PURPOSE

We assessed the accuracy of magnetic resonance imaging/transrectal ultrasound fusion biopsies to diagnose prostate cancer according to gland size.

MATERIALS AND METHODS

A prospective study was performed in 232 men with a first round biopsy, multiparametric magnetic resonance imaging with a lesion, a Likert score of 2 or greater and prostate specific antigen less than 10 ng/ml. All men underwent a standard 12-core protocol plus a protocol of 2 or 3 targeted cores. Significant prostate cancer was defined as at least 1 core with a Gleason score of 7 (3 + 4) or 6 with a greater than 4 mm maximal cancer core length.

RESULTS

Mean ± SD patient age was 64 ± 6.4 years, mean prostate specific antigen was 6.65 ± 1.8 ng/ml and mean prostate volume was 40 ± 24.3 ml. The overall detection rate of clinically significant prostate cancer was 44%. The detection rate of clinically significant prostate cancer by magnetic resonance imaging-transrectal ultrasound fusion guided biopsy was 77% for prostate glands less than 30 cm(3), and 61%, 47% and 34% for glands 30 to less than 38.5, 38.5 to less than 55 and 55 to 160 cm(3), respectively (p = 0.001). Differences in prostate cancer detection rates between the standard and targeted protocols were not significant for patients with a prostate volume of 40 cm(3) or less (p = 0.8). Conversely 12 patients with a prostate volume greater than 40 cm(3) had clinically significant prostate cancer using the targeted but not the standard protocol and in 3 prostate cancer was detected by the standard but not the targeted protocol (p = 0.04).

CONCLUSIONS

Magnetic resonance imaging-transrectal ultrasound fusion biopsies increased the yield of first round prostate biopsies in patients with a prostate volume greater than 40 cm(3).

Accuracy of the prostate health index versus the urinary prostate cancer antigen 3 score to predict overall and significant prostate cancer at initial biopsy

BACKGROUND

It remains unclear whether the Prostate Health Index (PHI) or the urinary Prostate-Cancer Antigen 3 (PCA-3) score is more accurate at screening for prostate cancer (PCa). The aim of this study was to prospectively compare the accuracy of PHI and PCA-3 scores to predict overall and significant PCa in men undergoing an initial prostate biopsy.

METHODS

Double-blind assessments of PHI and PCA-3 were conducted by referent physicians in 138 patients who subsequently underwent trans-rectal ultrasound-guided prostate biopsy according to a 12-core scheme. Predictive accuracies of PHI and PCA-3 were assessed using AUC and compared according to the DeLong method. Diagnostic performances with usual cut-off values for positivity (i.e., PHI >40 and PCA-3 >35) were calculated, and odds ratios associated with predicting PCa overall and significant PCa as defined by pathological updated Epstein criteria (i.e., Gleason score ≥7, more than three positive cores, or >50% cancer involvement in any core) were estimated using logistic regression.

RESULTS

Prevalences of overall and significant PCa were 44.9% and 28.3%, respectively. PCA-3 (AUC = 0.71) was the most accurate predictor of PCa overall, and significantly outperformed PHI (AUC = 0.65; P = 0.03). However, PHI (AUC = 0.80) remained the most accurate predictor when screening exclusively for significant PCa and significantly outperformed PCA-3 (AUC = 0.55; P = 0.03). Furthermore, PCA-3 >35 had the best accuracy, and positive or negative predictive values when screening for PCa overall whereas these diagnostic performances were greater for PHI >40 when exclusively screening for significant PCa. PHI > 40 combined with PCA-3 > 35 was more specific in both cases. In multivariate analyses, PCA-3 >35 (OR = 5.68; 95%CI = [2.21-14.59]; P < 0.001) was significantly correlated with the presence of PCa overall, but PHI >40 (OR = 9.60; 95%CI = [1.72-91.32]; P = 0.001) was the only independent predictor for detecting significant PCa.

CONCLUSIONS

Although PCA-3 score is the best predictor for PCa overall at initial biopsy, our findings strongly indicate that PHI should be used for population-based screening to avoid over-diagnosis of indolent tumors that are unlikely to cause death.

First round of targeted biopsies using magnetic resonance imaging/ultrasonography fusion compared with conventional transrectal ultrasonography-guided biopsies for the diagnosis of localised prostate cancer

OBJECTIVES

To assess the accuracy of magnetic resonance imaging (MRI)/transrectal ultrasonography (TRUS) fusion to guide first-round biopsies in the diagnosis of localised prostate cancer (PCa) in men with a prostate-specific antigen (PSA) ≤10 ng/mL.

PATIENTS AND METHODS

A prospective study was conducted on men who met the following criteria: first-round biopsy, multiparametric MRI (mpMRI) showing a lesion with a Likert score ≥2 and a PSA <10 ng/mL. All men underwent a extended 12-core protocol plus a protocol of two or three targeted cores on the mpMRI index lesion. The UroStation (Koelis, Grenoble, France) and a V10 ultrasound system with an end-fire three-dimensional TRUS transducer were used for the fusion imaging procedure. Significant PCa was defined as: at least one core with a Gleason score of 3 + 4 or 6 with a maximum cancer core length ≥4 mm.

RESULTS

A total of 152 men, whose median PSA level was 6 ng/mL, were included in the study. The proportion of positive cores was significantly higher with the targeted-core protocol than with the extended 12-core protocol (P < 0.001). The proportion of men with clinically significant PCa was higher with the targeted-core protocol than with the extended 12-core protocol (P = 0.03). The proportion of patients having at least one positive biopsy (targeted-core protocol) was significantly different among the Likert score categories (P < 0.001).

CONCLUSIONS

For the first round of biopsies, MRI/TRUS-fusion targeted biopsies detected more men with clinically significant PCa than did standard extended 12-core biopsy alone.

[Prostate cancer surgical margin: review by the CCAFU (Oncology Committee of the French Association of Urology)]

OBJECTIVE

Literature showed the impact of surgical margin status on prognosis after radical prostatectomy (mostly on biochemical survival). Margin status is an easy self-evaluation of surgical practice to assess. The aim of this paper was to define what a positive surgical margin (PSM) is and how to prevent the occurrence, to precise the impact on survival and how to treat.

METHOD

A literature analysis with Pubmed has been performed to 2012, furthermore conclusions of the main congresses with selection committee and review publication have also been studied.

RESULTS

PSM is defined as "tumor cells touching the ink on the specimen edge". The most frequent reported incidence is between 15 to 20%. Margin status remains one of the major criteria to determine the need of adjuvant radiotherapy after surgery. Quality of life is not or only lightly modified by radiotherapy with the current techniques. Adjuvant radiotherapy improves biological survival but is synonymous with overtreatment in many times. Salvage radiotherapy has to be quickly performed after Prostate Specific Antigen (PSA) relapse (PSA<1 ng/mL even<0.5 ng/mL).

CONCLUSION

This literature review did not allow to suggest superiority of one surgical technique over another. In the same way, the kind of dissection i.e. bladder neck or neurovascular bundle preservation does no clearly modify PSM rate. However, it seems logical to "customize" dissection according to prostate cancer characteristics (D'Amico criteria for instance) guided with multiparametric MRI. Intrafascial dissection has to be applied only to low risk. Lastly, the debate between adjuvant or salvage radiotherapy is always ongoing.

Low accuracy of routine ultrasound-guided systematic 12-core biopsies in prostate tumor mapping

INTRODUCTION

To determine the accuracy of a 12-core biopsy protocol in assessing the location of prostate tumors within radical prostatectomy (RP) specimens.

MATERIALS AND METHODS

A consecutive series of patients with T1c stage prostate cancer who had undergone 12 ultrasound-guided prostate biopsies prior to RP was considered. The locations of the biopsies from prostate gland mapping were compared with the locations of tumor tissues obtained after analysis of the prostate specimens.

RESULTS

Overall, 78 patients (27.4%) were included. The median PSA level was 6 ng/mL. The median prostate weight was 45 g (range 22 to 102). Overall, 936 biopsies were performed in the 78 men, of which 254 biopsies were positive. The mean number of positive biopsies per patient was 3.7 (range 1 to 12). Pathologic examination of the surgical specimens revealed that 58 (74.4%) patients had pT2 disease and 20 patients (25.6%) had locally advanced disease (pT3). The biopsy protocol's sensitivity, specificity and positive predictive value for tumor location were 0.34, 0.83 and 0.84. The performance of the protocol was modest in assessing the exact tumor location (area under curve (AUC) 0.581, 95% confidence interval (CI) 0.489-0.719).

CONCLUSIONS

Routine, ultrasound-guided, systematic 12-core biopsies lack precision in prostate tumor mapping.

Is there a contemporary role for percutaneous needle biopsy in the era of small renal masses?

OBJECTIVE

To evaluate based on the best available data whether there is a contemporary role for percutaneous needle biopsy in the era of small renal masses.

PATIENTS AND METHODS

SRMs are acknowledged to be tumours less than 4cm and account for 48%-66% of new kidney cancers. Renal mass biopsy (RMB), traditionally limited to specific clinical scenarios and with inherent diagnostic accuracy problems has increased in popularity in recent years and is a potential valuable tool in the assessment of SRMs. Our discussion focuses on these issues. We performed a thorough Medline literature review using a combination of the following keywords; small renal mass, renal biopsy, percutaneous renal biopsy, renal mass biopsy and renal cell carcinoma. We identified the seminal articles with data/information pertaining to renal mass biopsy in small renal masses.

RESULTS

The facts that 1) a significant number of SRMs are diagnosed in an elderly patient cohort, 2) 20% of SRMs are benign on formal histology, 3) there are various management strategies now available and 4) modern RMB has a diagnostic accuracy >90% with few complications, are all reasons why there has been renewed interest in RMB.

CONCLUSION

  There is a contemporary role for RMB in the era of SRM as the incorporation of molecular profiling of tissue from RMB would augment our ability to risk stratify SRMs on an individual patient basis and adopt management accordingly. However, clinical judgement is paramount as there remains an unpredictable non-negligible risk of disease progression and metastasis whilst on surveillance.

Accuracy of high resolution (1.5 tesla) pelvic phased array magnetic resonance imaging (MRI) in staging prostate cancer in candidates for radical prostatectomy: results from a prospective study

OBJECTIVE

To evaluate the role of pelvic phased array MRI in staging prostate cancer (CaP).

MATERIALS AND METHODS

We prospectively collected data over 12 months on CaP patients who underwent preoperative MR imaging with a pelvic phased array before radical prostatectomy. MR images were analyzed prospectively by 2 radiologists. MR imaging findings were then correlated with pathologic findings.

RESULTS

Overall, 101 patients were included with a mean PSA level of 8 (range 1.8-30). Reader 1 (AUC 0.895, 95% CI 0.791-0.999) had a higher performance than reader 2 (AUC 0.687, 95% CI, 0.555-0.819) and than DRE (AUC 0.728, 95% CI, 0.599-0.857) in discriminating T2 from T3 CaP (P = 0.01). The κ-index of inter-observer agreement was 0.56. A model that combines MRI findings, DRE, PSA, and Gleason score was the most competitive for staging (AUC 0.895, 95% CI, 0.791-0.999). For the multivariate analysis, 3 criteria were significantly associated with extracapsular extension: asymmetry of the neuro-vascular bundles (P = 0.001), asymmetric enhancement of neurovascular bundles (P = 0.02), and bulging of the capsule (P = 0.0003).

CONCLUSION

Pelvic phased array MRI presented satisfying results in its ability to adequately stage CaP and notably in detecting the extracapsular extension of tumors. It is likely to provide reliable information but rather in the hands of an experienced radiologist.

[Pre-kidney-transplant evaluation of donors and recipients]

The pretransplant imaging evaluation of recipients is mainly achieved with CT and has two objectives: detection of iliac artery calcifications that may have an impact on the site of the transplant and the type of arterial anastomosis; detection of a primary malignancy that would be a contraindication to transplantation. The pretransplant imaging evaluation of living donors relies on noninvasive techniques. CT angiography and MR angiography both allow the simultaneous evaluation of arteries, excretory tract and renal parenchyma. The goal is to achieve anatomical and functional renal evaluation in order to select the best donor and plan the surgical procedure.

[Oncologic and functional outcomes after radical prostatectomy in T3 prostate cancer]

According to current literature, the gold standard treatment for T3 prostate cancer is the combination of radiotherapy and extended hormonotherapy. Clinical staging based on digital rectal examination seems useless nowadays, since 20% of T3 prostate cancer is overevaluated during physical examination. Prostatic MRI is extensively needed to evaluate extraprostatic extension during preoperative work-up. EAU guidelines recommend radical prostatecomy only in selected patients: less than or equal to cT3a, PSA less than 20 ng/ml and biopsy Gleason score less than or equal to 8. Carcinologic control obtained after radical prostatectomy is variable from one series to another, with biochemical free survival rate at 5, 10 and 15 years that range from 45 to 62%, 43 to 51%, and 38 to 49%. Specific survival rates at 5, 10 and 15 years are, respectively, of 84 to 98%, 85 to 91% and 76 to 84%. Surgical margins rate differ from 22 up to 61% corresponding to several operative techniques and surgeon's own experience. Regarding urinary continence, functional outcomes are in line with those of prostatectomy for localized prostate cancer. Considering erectile dysfunction, rates are linked with the type of surgery, which can be extensive or not. There is no impact on overall or specific survival of neoadjuvant treatments. One current question remains the efficacy of early adjuvant treatment after prostatectomy, especially adjuvant irradiation. Radical prostatectomy can be considered in selected cases as a viable alternative first-line treatment option. However, patients have to be warned that they may undergo complementary treatments during the postoperative course of the disease.