A 68-year-old man from rural Maharashtra presents with lower urinary tract symptoms (LUTS) for 6 months. Digital rectal examination reveals a hard, irregular prostate with loss of the median groove. PSA is 18 ng/mL (normal <4 ng/mL). Transrectal ultrasound-guided biopsy shows adenocarcinoma of the prostate with a Gleason score of 7 (3+4). Staging CT abdomen/pelvis and bone scan are negative for metastases. What is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** This patient has localized prostate cancer (cT2 disease, Gleason 7, PSA 18 ng/mL) with no evidence of metastatic spread — this is intermediate-risk disease by D'Amico classification. **High-Yield:** Intermediate-risk prostate cancer (Gleason 7 or PSA 10–20 or cT2b–T2c) requires definitive local therapy with curative intent. The two standard options are radical prostatectomy (RP) or external beam radiation therapy (EBRT) ± ADT. ## Why Radical Prostatectomy Is Correct In this patient: - Age 68 with no comorbidities mentioned → good surgical candidate - Localized disease (no nodal/distant metastases) - Gleason 7 (intermediate grade) → benefit from complete tumor removal - Pelvic lymph node dissection is indicated for intermediate-risk disease (Gleason ≥7) to stage and potentially improve oncologic control [cite:Campbell-Walsh Urology 12e Ch 104] - RP offers definitive pathologic staging and excellent long-term oncologic outcomes in this cohort **Clinical Pearl:** Radical prostatectomy with extended pelvic lymph node dissection is the gold standard for fit men with intermediate-risk localized prostate cancer, as it provides complete tumor removal, accurate pathologic staging, and the opportunity for adjuvant therapy if adverse features are found. ## Why Other Options Are Suboptimal | Option | Reason for Rejection | |--------|---------------------| | EBRT alone | Monotherapy without ADT is insufficient for intermediate-risk disease; combined modality (EBRT + ADT) would be used if RP were contraindicated | | ADT alone | Hormone therapy is palliative, not curative; used for metastatic or high-risk disease, not as sole therapy for localized intermediate-risk cancer | | Active surveillance | Appropriate only for low-risk disease (Gleason ≤6, PSA <10, cT1c–T2a); Gleason 7 and PSA 18 mandate definitive treatment | **Warning:** Do not confuse intermediate-risk disease with low-risk disease. Active surveillance is a trap answer here — it is only for very low-risk, slow-growing cancers.