A 68-year-old man from Delhi presents with lower urinary tract symptoms (LUTS) for 6 months. He reports nocturia (4–5 times per night), weak urinary stream, and incomplete emptying. Digital rectal examination (DRE) reveals a hard, irregular prostate with loss of the median sulcus. PSA is 18 ng/mL (normal <4 ng/mL). Transrectal ultrasound-guided biopsy shows adenocarcinoma with a Gleason score of 7 (3+4). Staging CT abdomen/pelvis shows no distant metastases. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has **localized prostate cancer** (Gleason 7, PSA 18 ng/mL, no distant metastases) with significant LUTS and a hard nodular prostate on DRE — all features of intermediate-risk disease. ## Risk Stratification **Key Point:** Prostate cancer risk groups are defined by: - PSA level - Gleason score - Clinical T stage (DRE findings) This patient falls into the **intermediate-risk category** (Gleason 7, PSA 18 ng/mL, T2–T3 disease). ## Management Options for Intermediate-Risk Localized Prostate Cancer | Approach | Indication | Rationale | |----------|-----------|----------| | **Radical prostatectomy ± PLND** | Intermediate/high-risk, life expectancy >10 years | Gold standard for localized disease; allows pathological staging and lymph node assessment | | **EBRT + ADT** | Intermediate/high-risk, older patients or surgical risk | Equivalent oncologic outcomes to RP in some series; avoids surgery | | **Watchful waiting** | Low-risk only (Gleason ≤6, PSA <10, T1–T2a) | NOT appropriate for Gleason 7 or PSA >10 | | **ADT monotherapy** | Metastatic or palliative disease | Not curative; used for advanced/hormone-sensitive disease | **High-Yield:** For intermediate-risk localized prostate cancer in a fit patient with life expectancy >10 years, **radical prostatectomy with pelvic lymph node dissection (PLND)** is the gold standard. PLND is essential because: 1. Gleason 7 and PSA 18 carry ~15–20% risk of lymph node involvement 2. Pathological staging guides adjuvant therapy decisions 3. Therapeutic benefit if nodes are involved ## Why Radical Prostatectomy Here? **Clinical Pearl:** This patient is 68 years old with no mention of comorbidities, likely life expectancy >10 years, and localized intermediate-risk disease — the ideal candidate for RP. The hard, irregular prostate with loss of median sulcus suggests extraprostatic extension (T3), making complete surgical resection critical. [cite:Harrison 21e Ch 97] [cite:Campbell-Walsh Urology 12e Ch 104]