active surveillance

  • Prediction of the Pathologic Gleason Score to Inform a Personalized Management Program for Prostate Cancer.

    Active surveillance (AS) is an alternative to curative intervention, but overtreatment persists. Imperfect alignment of prostate biopsy and Gleason score after radical prostatectomy (RP) may be a contributing factor.

    Published August 20, 2016
  • Predictors of Adverse Pathology in Men Undergoing Radical Prostatectomy Following Initial Active Surveillance.

    To report pathological outcomes and predictors of adverse pathology in men undergoing radical prostatectomy (RP) after an initial period of active surveillance (AS).

    We studied pathological outcomes in men who underwent RP after some time on AS.

    Published September 9, 2015
  • Preliminary results from the monitoring programme of the active surveillance for prostate cancer in Spain of the Society Spanish of Urology.

    To present a National Registry of patients with prostate cancer as monitored through active surveillance, with the intention of testing the hypothesis that cancer-specific mortality in very low-risk and low-risk patients is less than 5% at 15 years.

    Published September 4, 2015
  • Primary Gleason Pattern Upgrading in contemporary D'Amico low-risk prostate cancer patients: Implications for future biomarkers and imaging modalities.

    To retrospectively assess the rate of primary Gleason upgrading (HGPGU) to primary Gleason pattern 4 or 5 in a contemporary cohort of D'Amico low-risk prostate cancer (PCa) and PRIAS active surveillance (AS) patients and to develop a tool for HGPGU prediction.

    Published July 5, 2016
  • Prognostic Biomarkers Used for Localised Prostate Cancer Management: A Systematic Review.

    Prostate cancer stratification is based on tumour size, pretreatment PSA level, and Gleason score, but it remains imperfect. Current research focuses on the discovery and validation of novel prognostic biomarkers to improve the identification of patients at risk of aggressive cancer or of tumour relapse.

    Published August 8, 2017
  • Prognostic influence of 5 alpha reductase inhibitors in patients with localized prostate cancer under active surveillance.

    The incidence of prostate adenocarcinoma (PCa) is increased with the use of prostate-specific antigen (PSA). In the current study, we aimed to investigate the impact of 5- alpha- reductase inhibitors (5-ARI) on pathological progression in patients followed by active surveillance (AS).

    Published March 12, 2018
  • Prognostic Significance of the Disparity Between Biopsy and Pathologic Gleason Score After Radical Prostatectomy in Clinical Candidates for Active Surveillance According to the Royal Marsden Criteria.

    We identify the biochemical outcome according to biopsy Gleason score (bGS) among patients who are clinical candidate for active surveillance. We found that different adverse pathologic outcomes and biochemical outcomes were shown according to biopsy pattern although the patients have the same pathologic Gleason score (pGS) 3+4 after RP.

    Published March 10, 2016
  • Progression and treatment rates using an active surveillance protocol incorporating image guided baseline biopsies and multi-parametric MRI monitoring for men with favourable risk prostate cancer.

    To assess early outcomes since the introduction of an active surveillance (AS) protocol incorporating mpMRI guided baseline biopsies and image based surveillance.

    A new AS protocol mandating image-guided baseline biopsies, annual mpMRI and 3 monthly PSA but which retained protocol re-biopsies was tested.

    Published February 16, 2018
  • Promise and Implementation of Proteomic Prostate Cancer Biomarkers.

    Prostate cancer is one of the most commonly diagnosed malignancy and the fifth leading cause of cancer mortality in men. Despite the broad use of prostate-specific antigen test that resulted in an increase in number of diagnosed cases, disease management needs to be improved.

    Published September 6, 2018
  • Prospective Quality of Life in Men Choosing Active Surveillance Compared to Those Biopsied but not Diagnosed with Prostate Cancer.

    Active surveillance (AS) is an important alternative to definitive therapy for men with low-risk prostate cancer (PCa). However, the impact of AS on health-related quality of life (HRQoL) when compared to men without cancer remains unknown.

    Published March 18, 2016
  • Prostatic intraepithelial neoplasia-like ductal prostatic adenocarcinoma: A case suitable for active surveillance?

    In contrast to typical prostatic ductal adenocarcinoma, prostatic intraepithelial neoplasia (PIN)-like ductal adenocarcinoma is a rare variant of prostate cancer with low-grade clinical behavior. We report a case of a 66-year-old African-American male with an elevated serum prostate-specific antigen who underwent multiparametric prostate magnetic resonance imaging (MRI) and MRI/ultrasound fusion-guided biopsies.

    Published March 3, 2017
  • Quality of care and economic considerations of active surveillance of men with prostate cancer.

    The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.

    Published May 28, 2018
  • Quality of life among men with low-risk prostate cancer during the first year following diagnosis: the PREPARE prospective cohort study.

    As many as 40% of men diagnosed with prostate cancer have low-risk disease, which results in the need to decide whether to undergo active treatment (AT) or active surveillance (AS). The treatment decision can have a significant effect on general and prostate-specific quality of life (QOL).

    Published February 13, 2018
  • Quality of Life Outcomes after Primary Treatment for Clinically Localised Prostate Cancer: A Systematic Review.

    Current evidence-based management for clinically localised prostate cancer includes active surveillance, surgery, external beam radiotherapy (EBRT) and brachytherapy. The impact of these treatment modalities on quality of life (QoL) is uncertain.

    Published August 9, 2017
  • Radiomic features on MRI enable risk categorization of prostate cancer patients on active surveillance: Preliminary findings.

    Radiomic analysis is defined as computationally extracting features from radiographic images for quantitatively characterizing disease patterns. There has been recent interest in examining the use of MRI for identifying prostate cancer (PCa) aggressiveness in patients on active surveillance (AS).

    Published March 2, 2018
  • Randomized trial evaluating the role of weight loss in overweight and obese men with early stage prostate Cancer on active surveillance: Rationale and design of the Prostate Cancer Active Lifestyle Study (PALS).

    Active surveillance (AS) is increasingly used to monitor patients with low-risk prostate cancer; however, approximately 50% of AS patients experience disease reclassification requiring definitive treatment and little is known about patient characteristics that modify the risk of reclassification.

    Published May 9, 2019
  • Randomized Trial of Partial Gland Ablation with Vascular-Targeted Phototherapy versus Active Surveillance for Low-risk Prostate Cancer: Extended Follow-up and Analyses of Effectiveness.

    The prospective trial PCM301 randomized 413 men with low-risk prostate cancer to partial gland ablation with vascular-targeted photodynamic therapy (n=207) or active surveillance (n=206). Two-year outcomes were reported previously.

    Published June 8, 2018
  • Real-life use of diagnostic biopsies before treatment of kidney cancer: results from a Norwegian population-based study.

    Interest in renal mass biopsies (RMBs) has increased in recent years. However, most publications are low-volume and/or single-center studies, so their generalizability is questionable. The aim of this study was to describe population-based, real-life use of diagnostic RMBs for localized and advanced kidney cancer (KC).

    Published March 14, 2018
  • Recommendations of Active Surveillance for Intermediate-risk Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists.

    While active surveillance (AS) for intermediate-risk prostate cancer (PCa) remains controversial, perceptions of AS and treatment recommendations among PCa specialists are largely unknown. Thus, we performed a national survey of radiation oncologists (ROs) and urologists (UROs) to elicit attitudes and AS recommendations for intermediate-risk PCa.

    Published April 27, 2019
  • Renal tumor biopsy: indicators, technique, safety, accuracy results, and impact on treatment decision management.

    Renal tumor biopsy (RTB), as distinct from the more common renal biopsy for medical renal disease, is an option for patients with renal masses. It is mainly used for small renal masses (SRM) but it may also be indicated for larger masses and even in the presence of metastatic disease.

    Published August 1, 2018
  • Reporting Magnetic Resonance Imaging in Men on Active Surveillance for Prostate Cancer: The PRECISE Recommendations-A Report of a European School of Oncology Task Force.

    Published data on prostate magnetic resonance imaging (MRI) during follow-up of men on active surveillance are lacking. Current guidelines for prostate MRI reporting concentrate on prostate cancer (PCa) detection and staging.

    Published July 15, 2016
  • Risk of Pathological Upgrading and Upstaging among Men with Low-Risk Prostate Cancer Varies By Race: Results from the National Cancer Data Base.

    The impact of African American (AA) race on oncological outcomes for low-risk prostate cancer is unclear due to conflicting data. We sought to better understand the effect of AA race on pathological upgrading and/or upstaging at prostatectomy in men with clinically low-risk prostate cancer.

    Published September 8, 2016
  • Role of Active Surveillance for Localized Small Renal Masses.

    Stage migration of organ-confined renal masses is occurring as a result of incidental diagnosis, especially in the elderly. Active surveillance (AS) is gaining clinical traction as a treatment alternative to surgery and focal therapy.

    Published May 20, 2019
  • Routine transition zone biopsy during active surveillance for prostate cancer rarely provides unique evidence of disease progression, "Beyond the Abstract," by Sven Wenske, MD

    BERKELEY, CA (UroToday.com) -

    Immediate re-biopsy and transition zone biopsy during active surveillance

    Published March 25, 2013
  • Ruling out clinically significant prostate cancer with negative multi-parametric MRI.

    To evaluate the negative predictive value (NPV) of a negative prostate multi-parametric magnetic resonance imaging (mpMRI) in ruling out clinically significant prostate upon 12-core systematic biopsy.

    Published November 22, 2017
  • Sociodemographic and clinical predictors of switching to active treatment among a large ethnically diverse cohort of men with low-risk prostate cancer on observational management.

    To determine the clinical and sociodemographic predictors of beginning an active treatment among an ethnically diverse population of men with low-risk prostate cancer initially on observational management.

    Published April 27, 2016
  • Surgical removal of renal tumors with low metastatic potential based on clinical radiographic size: A systematic review of the literature.

    Many patients with small renal masses (SRM) undergo surgical resection of benign and potentially indolent renal masses. We review the available literature to quantify the proportion of renal tumors that are low-risk based on clinical radiographic size, and quantify the number of low-risk masses surgically removed in the United States.

    Published June 18, 2019
  • Surveillance of Small Renal Masses.

    The wide spread utilization of abdominal imaging has led to an increasing incidence of small renal masses (SRMs) characteristic for renal cell carcinoma. However, at least 20% are benign. Nevertheless, nephron-sparing surgery is considered the standard treatment for these SRMs without pretreatment characterization with biopsy.

    Published July 14, 2016
  • Systematic identification of functionally relevant risk alleles to stratify aggressive versus indolent prostate cancer.

    Novel approaches for classification, including molecular features, are needed to direct therapy for men with low-grade prostate cancer (PCa), especially men on active surveillance. Risk alleles identified from genome-wide association studies (GWAS) could improve prognostication.

    Published March 29, 2018
  • Targeted Prostate Biopsy in the Era of Active Surveillance.

    Targeted prostate biopsy using magnetic resonance imaging (MRI) guidance is improving accuracy of prostate cancer (CaP) diagnosis. This new biopsy technology is especially important for men undergoing active surveillance, improving patient selection for enrollment and enabling precise longitudinal monitoring.

    Published October 2, 2017
  • The cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer.

    Radical prostatectomy is the most common treatment for localised prostate cancer in New Zealand. Active surveillance was introduced to prevent overtreatment and reduce costs while preserving the option of radical prostatectomy.

    Published August 18, 2017
  • The Efficacy of Multiparametric Magnetic Resonance Imaging and MRI-Targeted Biopsy in Risk Classification for Patients with Prostate Cancer on Active Surveillance.

    PURPOSE - To determine if multiparametric-MRI (mpMRI)-targeted biopsies may replace systematic biopsies to detect higher grade prostate cancer (Gleason score ≥ 7), and whether biopsy may be avoided based on mpMRI among men with Gleason 3+3 prostate cancer on active surveillance (AS).

    Published February 29, 2016
  • The importance of active surveillance, and immediate re-biopsy in low-risk prostate cancer: The largest series from Turkey.

    To evaluate long-term outcomes of active surveillance (AS) applied in low-risk prostate cancer patients, and the impact of re-biopsy results on the prediction of progression.

    In our clinic, patients who had undergone AS for low-risk localized prostate cancer between the years 2005-2013 were included in the study.

    Published September 19, 2016
  • The Influence of Psychosocial Constructs on the Adherence to Active Surveillance for Localized Prostate Cancer in a Prospective, Population-Based Cohort.

    To evaluate the influence of psychosocial factors such as prostate cancer (PCa) anxiety, social support, participation in medical decision-making (PDM), and education level on patient decisions to discontinue PCa active surveillance (AS) in the absence of disease progression.

    Published February 24, 2017
  • The pathological upgrading after radical prostatectomy in low-risk prostate cancer patients who are eligible for active surveillance: How safe is it to depend on bioptic pathology?

    Active surveillance (AS) is one of the treatment alternatives in low-risk prostate cancer (PCa). The pathological upgrading after radical prostatectomy (RP) were investigated in patients who were eligible for AS in the present study.

    Published July 9, 2019
  • The presence of primary circulating prostate cells is associated with upgrading and upstaging in patients eligible for active surveillance.

    Active surveillance (AS) is a considered treatment option for men with low or very low-risk prostate cancer. However, on repeat biopsy some 25% were upgraded and recommended for active treatment. We compare the presence or absence of primary circulating prostate cells (CPCs) with the clinical pathological findings after radical prostatectomy in men fulfilling the criteria for active surveillance and the risk of reclassification for active observation (AO).

    Published February 9, 2017
  • The Quality of Life among Men Receiving Active Surveillance for Prostate Cancer: An Integrative Review.

    Prostate cancer is very common among men in the United States. The current literature on active surveillance (AS) suggests that it is a promising treatment option for men with low-risk prostate cancer.

    Published February 4, 2019
  • The relationship between intolerance of uncertainty and anxiety in men on active surveillance for prostate cancer.

    PURPOSE - Anxiety may serve as a major barrier to participation in AS. Intolerance of uncertainty-the tendency to perceive the potential for negative events as threatening-has been linked to cancer-related worry.

    Published February 15, 2016
  • The Role of Multiparametric Magnetic Resonance Imaging in Active Surveillance for Men with Low-risk Prostate Cancer: A Cost-effectiveness Modeling Study.

    Active surveillance (AS) has limitations that include missing high-risk tumors and performing unnecessary biopsies. The use of multiparametric magnetic resonance imaging (mpMRI) in AS may overcome these limitations, but its cost-effectiveness remains uncertain.

    Published June 13, 2019
  • The Role of Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion Biopsy in Active Surveillance.

    Multiparametric magnetic resonance imaging (mpMRI)/ultrasound fusion biopsy (targeted biopsy or TB) may improve detection of high-grade cancers when compared to systematic biopsy (SB).

    To assess TB in active surveillance (AS).

    Published May 30, 2016
  • The role of whole-lesion apparent diffusion coefficient analysis for predicting outcomes of prostate cancer patients on active surveillance.

    To explore the role of whole-lesion apparent diffusion coefficient (ADC) analysis for predicting outcomes in prostate cancer patients on active surveillance.

    This study included 72 prostate cancer patients who underwent MRI-ultrasound fusion-targeted biopsy at the initiation of active surveillance, had a visible MRI lesion in the region of tumor on biopsy, and underwent 3T baseline and follow-up MRI examinations separated by at least one year.

    Published April 19, 2017
  • The Value of an Extensive Transrectal Repeat Biopsy with Anterior Sampling in Men on Active Surveillance for Low-risk Prostate Cancer: A Comparison from the Randomised Study of Active Monitoring in Sweden (SAMS).

    A systematic repeat biopsy is recommended for men starting on active surveillance for prostate cancer, but the optimal number and distribution of cores are unknown.

    To evaluate an extensive repeat transrectal biopsy with anterior sampling in men starting on active surveillance.

    Published April 1, 2019
  • Timing of Adverse Prostate Cancer Reclassification on First Surveillance Biopsy: Results from the Canary Prostate Cancer Active Surveillance Study.

    During active surveillance (AS) for localized prostate cancer (PCa), first surveillance biopsy timing varies. We analyzed the Canary Prostate Cancer Active Surveillance Study (PASS), to determine biopsy timing influence on rates of PCa adverse reclassification at first AS biopsy.

    Published November 7, 2016
  • Treatment for Localized Prostate Cancer

    Selection of the appropriate treatment requires assessment of the tumor's potential aggressiveness and the general health, life expectancy, and quality of life preferences of the patient. The treatment outcomes in patients may be influenced by the malignant potential of the tumors as well as by the treatment used. 

    Conservative Treatment: 

    Watchful Waiting refers to monitoring the patient until he develops metastases that require palliative treatment.  

    • Watchful waiting has been reserved for men with a life expectancy of less than 10 years and a low-grade (Gleason score 2 to 5) prostate cancer.

    Active surveillance allows delayed primary treatment if there is biochemical or histologic evidence of cancer progression. 

    • Active surveillance is being evaluated as a management strategy in younger patients with low-volume, low- or intermediate-grade (up to Gleason score 3 + 4 = 7) tumors to avoid or to delay treatment that might not be immediately necessary.
    • Monitoring of the patient for progression for either watchful waiting or active surveillance patients are usually observed with semiannual PSA determinations, DRE, and annual biopsies.  
    • Intervention is recommended if Gleason pattern 4 or 5 is present, more than two biopsy cores are involved, or more than 50% of a biopsy core is involved. 
    • Progression is more likely in patients who have cancer present on every biopsy procedure. 
    • The absence of cancer on repeated biopsy significantly decreases the likelihood of progression. 
    • Biopsy criteria used in active surveillance have been reported to be more accurate than PSA criteria in predicting progression. 
    • No study has found DRE or imaging studies to independently predict progression.
    • In most studies of active surveillance, approximately 25% to 50% of patients, depending on their individual risk factors, develop objective evidence of tumor progression within 5 years.  
    • Presently, no tumor marker can identify indolent tumors with certainty.
    • Additional clinical and laboratory research are needed to define the parameters for safe use of active surveillance in younger men, including the appropriate selection criteria, follow-up procedures, and trigger points for intervention.
    • All prostate cancer patients are at risk for progression.
    • If the PSA level is rising, the DRE suggests tumor growth, or surveillance biopsy specimens show evidence of increased involvement by cancer, treatment should be instituted.
    •  Patients may change their minds about remaining on an active surveillance protocol; therefore the physician should review management options on follow-up visits.
    • In discussing treatment for prostate cancer, it is important to consider patient factors such as age and general performance status as well as tumor factors such as Gleason score, initial serum PSA, and estimated clinical volumes/stage of the tumor. 
    • If a patient has less than a 50 percent chance of surviving 10 years, it is difficult to measure the positive effect of treatment. 
    • The side effects of different therapies also have to be considered. It is optimal when patients come to a treatment decision based on consultation and input from both surgical and radiation oncology services.

    The current treatment paradigm

    • Multiple guidelines endorse active surveillance for low-risk prostate cancer, but concerns regarding biopsy under-sampling and under-staging have limited its acceptance.

    • Today, more than 90 percent of these low risk patients undergo immediate treatment such as radical prostatectomy or radiation, despite less than a 3% chance of low risk disease progressing 

    Genomic Prostate Score (GPS)

    • The Oncotype DX prostate cancer test (Genomic Prostate Score) is a biopsy-based genomic test that, when combined with other measures, can be used to predict the aggressiveness of prostate cancer
    • The GPS test is a standardized, validated biopsy-based test that measures the level of expression of multiple genes across multiple pathways that predict aggressive prostate cancer

    more on genomics: 

    Radical or complete prostatectomy

    • This is the treatment choice for patients with organ-confined disease and a life expectancy of more than 10 years. Generally, age 70 is used as a relative cutoff for strongly recommending surgery and 75 years of age is certainly the upper accepted end of the age limit. 
    • The patient goals are the cure of his cancer (survival), the preservation of his potency, and to remain continent.  Patients want all three outcomes. 
    • The indications for LRP and RALP are identical to that for open surgery (patients with ≤ clinical stage T2 with no evidence of metastasis either clinically or radiographically.
    • The radical perineal prostatectomy is associated with reduced blood loss as the dorsal venous complex is not divided. It may be the preferred approach in very obese men or in those with a history of abdominal or pelvic surgery where significant retropubic scarring and fibrosis are suspected.
    • The disadvantages are that it does not provide access for a pelvic lymph node dissection, there is a higher rate of rectal injury, and there is occasional postoperative fecal incontinence that does not occur commonly with other approaches.
    • It is more difficult to spare the cavernous nerves through the perineal approach.The open retropubic approach is preferred by many urologists because of their familiarity with the surgical anatomy, the lower risk for rectal injury and postoperative fecal incontinence, the wide exposure and ready access provided for pelvic lymphadenectomy and prostate excision with preservation of the neurovascular bundles, and the lower risk for positive surgical margins.
    • Significant urinary incontinence may be encountered in up to 4 to 8 percent of patients, and bladder neck contractures can occur in 2 to 6 percent of patients. 
    • Surgical mortality is less than 0.2 percent but 1 to 2 percent of patients may develop pulmonary emboli. 
    • When laparoscopic prostatectomy (LRP) is performed by a skilled laparoscopic surgeon, reported incontinence and anastomotic stricture rates are comparable to those achieved with open surgery. 
    • It has been claimed that nerve sparing is equivalent or even better with laparoscopic surgery, but direct comparisons and validated results are lacking. 
    • The early reported rates of positive surgical margins have been higher with laparoscopic prostatectomy, and the adequacy of cancer control is as yet uncertain because of lack of long-term results.
    • Remotely controlled laparoscopic surgery or the robot-assisted laparoscopic prostatectomy has becoome popularized because of its greater technical ease for the surgeon, especially for tying sutures and performing the vesicourethral anastomosis.
    • The availability of three-dimensional visualization is an advantage over standard laparoscopic techniques.
    • Early reported results are favorable, but have not been validated.
    • It is also more difficult to perform a lymph node dissection with laparoscopic approaches.
    • Pelvic lymphadenectomy is optional in patients at low risk for lymph node metastases.

    Postoperative patient care

    • Patients should ambulate with assistance beginning on the afternoon or evening of surgery.
    • The catheter may be removed 3 to 21 days after surgery, depending on the integrity and the amount of tension on the vesicourethral anastomosis. The more days the catheter is in place the greater the risk of urinarty tract infection (CaUTI).  Removal of the catheter before 7 days is associated with a 15% to 20% risk of urinary retention - View Protocol.  View all CaUTI resources at www.cautichallenge.com

    • After the catheter has been removed, Kegel exercises should be initiated. A protective pad is used until complete urinary control is achieved. The postoperative serum PSA level should be undetectable by 1 month after the operation. 
    • The return of urinary continence is associated with the patient's age: approximately 95% of men younger than 60 years can attain pad-free urinary continence after surgery; 85% of men older than 70 years regain continence. Few require implantation of an artificial urinary sphincter or a sling procedure for stress urinary incontinence.
    • The return of erectile function after radical retropubic prostatectomy correlates with the age of the patient, preoperative potency status and the extent of nerve-sparing surgery.
    • In candidates in whom preoperative potency is normal and bilateral nerve-sparing surgery can be performed, up to 95% in their 40s, 85% in their 50s, 75% in their 60s, and 50% in their 70s can attain recovery of erections sufficient for penetration and intercourse. In most instances, erections are not as good as they were preoperatively.
    • In patients, erections usually begin to return as partial erections 3 to 6 months after surgery and may continue to improve for up to 3 years or more.  

    External beam radiation therapy

    • This is an option for localized prostate cancer and is the treatment of choice for T3 disease. 
    • There is evidence from prospective, randomized trials that dose escalation and three-dimensional definition improve results considerably.
    • External beam radiotherapy involves the use of beams of gamma radiation, usually photons, directed at the prostate and surrounding tissues through multiple fields.
    • The most sophisticated form of 3D-CRT, called intensity-modulated radiation therapy (IMRT), can provide localization of the radiation dose to geometrically complex fields.
    • Heavy-particle therapy is another form of 3D-CRT in which the radiation beam can be virtually “stopped” within the tissue, allowing high doses of radiation to be delivered to a localized region. 
    • Proton beam therapy is more expensive than other forms of 3D-CRT, and limited long-term results have been reported.
    • Currently, doses of 76 to 80 Gy or more have been shown to improve cancer control.
    • Low-risk patients are now frequently treated with 70 to 72 Gy, intermediate-risk patients with 75 to 76 Gy, and high-risk patients with 80 Gy or more. Doses above 75 Gy are now considered to be indicated; however, doses above 80 Gy have not been demonstrated to be beneficial.
    • In general, it is administered in divided doses ranging from 70 to 80 Gy and is well tolerated. 
    • Approximately 3 to 5 percent of patients will experience persistent rectal or bladder symptomatology and greater than 50 percent of patients develop erectile dysfunction within 2 years. Hematuria or hemorrhagic cystitis is a late development in a small percentage of patients. Techniques of conformal therapy have reduced unwanted radiation to the bladder and rectum.
    • CT imaging is considered the standard imaging modality for 3D-CRT and 3D-IMRT, but CT is less precise than MRI.
    • A prior transurethral resection of the prostate is a relative contraindication to brachytherapy and external beam radiation therapy because the prostate does not hold the seeds well, and radiation after transurethral resection of the prostate is associated with an increased risk for urethral stricture. 
    • The presence of severe obstructive urinary symptoms is also a relative contraindication because of the risk for acute urinary retention, which is an even greater risk in patients treated with brachytherapy. 
    • Another relative contraindication is inflammatory bowel disease.
    • Approximately half of patients develop erectile dysfunction after radiotherapy for prostate cancer. This is caused by injury to the vasculature of the cavernous nerves and to the corpora cavernosa of the penis, usually beginning about 1 year after the completion of treatment. 
    • Younger patients with good baseline erectile function are more likely to retain adequate erections. PDE-5 inhibitors are useful in ameliorating the erectile dysfunction associated with radiotherapy. Lower doses of radiation to the penile bulb have been investigated as a means of minimizing radiation-induced erectile dysfunction. The use of adjuvant hormone therapy also adversely affects erectile function.
    • Evaluation of the outcomes of radiotherapy is challenging because cancer cells are not killed immediately after exposure to ionizing radiation. Rather, they sustain lethal DNA damage but do not die until their next attempt to enter into cell division. The PSA level gradually decreases for up to 2 to 3 years after the completion of radiotherapy. 
    • The PSA level is usually monitored at 6-month intervals until it reaches a nadir. In patients treated with external beam radiotherapy, the prostate gland is not completely ablated, and the remaining prostate epithelium continues to produce PSA.
    • In high-risk patients, external beam radiotherapy has also been combined with brachytherapy. The brachytherapy is usually given first, so that the external beam therapy can be discontinued if the patient begins to experience toxicity.


    • Radioactive sources (seeds or needles) are implanted directly into the prostate gland, and sometimes into the surrounding tissues, to deliver a high dose of radiation to the tumor while sparing, to the extent possible, the bladder and the rectum.
    • The most commonly used permanent implants are iodine-125 or palladium-103 seeds.
    • Ultrasound-guided transperineal brachytherapy has become an accepted modality for the treatment of localized prostate cancer using 1251 or 103 Pd radiation sources. The radiation doses delivered to the prostate are approximately 145 Gy for iodine and 125 Gy for palladium.  
    • Optimal candidates have a serum PSA of less than 10 ng/mL, and a Gleason score of 6 or lower. Many centers utilize short-term neoadjuvant hormonal blockade given the difficulty in treating prostate glands larger than 50 g. Conversely, glands smaller than 20 g are difficult to implant. 
    • Urinary retention occurs in up to 22% of patients.
    • Short-term complications include urinary retention, urethritis, and irritative voiding symptoms, especially in patients with a history of lower urinary tract obstructive symptoms. Long-term major complications include stricture or contracture development and proctitis. Incontinence is uncommon but averages 20 percent in men with a history of transurethral resection of the prostate. 

    Stereotactic Radiotherapy (“Cyberknife”)

    • More data is needed to include in this section 

    Adjuvant Radiotherapy after Radical Prostatectomy

    • Retrospective cohort studies have shown that postoperative radiotherapy reduces recurrence rates in patients with pathologic stage T3 disease and positive margins. 
    • A trial of adjuvant radiation after radical prostatectomy of men with stage pT3 prostate cancer or positive margins revealed that adjuvant radiation reduced the recurrence rate and that positive margins were the strongest predictor of benefit.  
    • Side effects of adjuvant radiotherapy also include a 5% to 10% risk of radiation proctitis and a 50% probability that return of erectile function will be materially compromised.
    • It is impossible to compare the results of surgery with those of radiotherapy because of the difference in the end points used for treatment failure, that is, undetectable PSA for surgery versus the ASTRO or Phoenix criteria for radiotherapy.

    Primary Hormone Therapy

    • Primary androgen-deprivation therapy may be appropriate for older men, those with significant medical comorbidities precluding the use of curative therapy, and those who do not wish to undergo curative therapy.
    • Cardiovascular evaluation is recommended prior to treatment of men at risk for cardiovascular complications.
    • Hormone therapy is never curative; nevertheless, many patients experience long-term remissions. Luteinizing hormone–releasing hormone analogs are commonly used. 
    • Antiandrogens produce less sexual dysfunction and osteoporosis but have a greater risk for adverse cardiovascular complications.


    • Current technology uses argon gas circulating through hollow needles to freeze the prostate and helium gas to warm the urethra. 
    • Cryoablation has been used as primary treatment for salvage after radical prostatectomy or radiotherapy. 
    • A prior transurethral resection of the prostate is considered a relative contraindication to cryoablation.
    • An undetectable PSA level is seldom attainable after cryoablation.Pelvic pain persists.
    • Complications associated with salvage cryoablation were much more frequent than for primary treatment.
    • Complications of salvage cryotherapy included 4.4% incontinence, 1.2% rectal fistula, and 3.2% requiring a transurethral resection of the prostate for obstruction.

    High-Intensity Focused Ultrasound (HIFU)

    • Transrectally applied high-intensity focused ultrasound (HIFU) can elevate the tissue temperature of the prostate up to 100° C.
    • Treatment is performed under general or spinal anesthesia and takes 1 to 4 hours, depending on the prostate volume, which should not exceed 40 cc.
    • Most patients require a urethral or suprapubic catheter for several days.
    • The procedure is usually well tolerated; the most common side effect is acute urinary retention, occurring in about 20% of patients. 
    • Other potential complications are urinary fistula, incontinence, urethral stricture, and perineal pain. 
    • Erectile dysfunction has been reported in 27% to 61%.
    • Clinical trials are continuing in the USA and other countries.  


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    • Van der Kwast TH, Bolla M, Van Poppel H, et al: Identification of patients with prostate cancer who benefit from immediate postoperative radiotherapy: EORTC 22911. J Clin Oncol  2007; 25:4178-4186.
    • Zelefsky MJ, Chan H, Hunt M, et al: Long-term outcome of high dose intensity modulated radiation therapy for patients with clinically localized prostate cancer. J Urol  2006; 176:1415-1419.
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    Published June 12, 2013
  • Treatment of Incidental Prostate Cancer by Active Surveillance: Results of the HAROW Study.

    OBJECTIVE - To report on a cohort of patients with incidental prostate cancer (IPC) that was treated by an active surveillance (AS) protocol in the HAROW study.

    Published July 28, 2015
  • Trends in the Management of Small Renal Masses: A Survey of Members of the Endourological Society.

    Treatment modalities for small renal masses (SRMs) include open or minimally invasive radical or partial nephrectomy, and laparoscopic or percutaneous ablations. Members of the Endourological Society were surveyed to evaluate how practitioner and clinical practice characteristics may be associated with the management of SRMs over time.

    Published August 4, 2017
  • Tumor Volume on Biopsy in Low-Risk Prostate Cancers Managed on Active Surveillance.

    Contemporary clinical guidelines recommend use of active surveillance (AS) in men with low-risk prostate cancer. Low-risk disease spans any potential volume of Gleason score 6 cancer without sufficient attention to tumor volume in the past.

    Published October 31, 2017
  • Use and early mortality outcomes of active surveillance in patients with intermediate-risk prostate cancer.

    Certain patients with intermediate-risk prostate cancer (PCa) may be appropriate candidates for active surveillance (AS). In the current study, the authors sought to characterize AS use and early mortality outcomes for patients with intermediate-risk PCa in the United States.

    Published June 6, 2019
  • Use of a 17-gene prognostic assay in contemporary urologic practice: results of an interim analysis in an observational cohort.

    To study the impact of genomic testing in shared decision making for men with clinically low risk prostate cancer (PCa).

    Patients with clinically low-risk PCa were enrolled in a prospective, multi-institutional study of a validated 17-gene tissue-based RT-PCR assay (Genomic Prostate Score™; GPS).

    Published May 5, 2017
  • Use of delayed intervention for small renal masses initially managed with active surveillance.

    A number of patients who elect active surveillance of their small renal masses (≤4 cm) subsequently pursue delayed intervention (DI). The indications, timing, and rates of DI have not been well determined prospectively.

    Published November 19, 2018

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