Clinical Practice Guidelines for the management of locally advanced ...

for surgery, suggesting that surgery may have provided some benefit over sub-optimal-dose
radiotherapy using old techniques. Patients treated with surgery had significantly higher incontinence
rates and lower long-term urinary difficulty and gastrointestinal toxicity rates compared to those
treated with radiotherapy.
In a more recent update of this trial with a median follow-up of 102 months, surgery was associated
with better survival and progression outcomes however none of these benefits were statistically
significant. 85
Biochemical progression-free survival rates for the surgery and radiotherapy groups were 76.2%
versus 71.1% respectively. Thus biochemical progression-free rates were better in the surgery group,
as were the clinical progression-free rates of 83.5% versus 66.1%, and the cause-specific survival
rates of 85.7% versus 77.1%. The overall survival rates were 67.9% versus 60.9%. There was a
significantly higher incontinence rate in the surgery group, but no other significant difference in
toxicity was reported.
In 2003 Clark et al 99 reported a total of 123 patients who were randomised to an extended node
dissection on the right side and a limited dissection on the left. However, only nine patients were T2b
or T3 and no long-term survival was reported.
Thomas et al 1992 100 in a small study randomised men with T3 or T4 prostate cancer and urinary
retention to transurethral resection of the prostate and orchidectomy, or orchidectomy alone. On the
basis of the outcomes of the study, the authors recommended, because of the morbidity associated
with the transurethral resection group, that surgery should take place only if the men failed to void
after the initial orchidectomy.
Evidence summary Level References
For the treatment of locally advanced disease there are no RCTs
comparing surgery with modern higher-dose radiotherapy or ADT.
For locally advanced disease there are no RCTs examining the
efficacy of extended lymph node dissection compared with
standard lymph node dissection.
In one small RCT for men with urinary retention the addition of TURP
to orchidectomy resulted in increased morbidity
33
Locally advanced disease
II 100