cancer following treatment for localized disease is characterized by lack of consensus and active investigation. The mainstay of treatment for metastatic prostate cancer remains androgen deprivation, with chemotherapy reserved for androgen-independent prostate cancer.

Treatment for Localized Prostate Cancer (T1, T2)

Several management options exist for localized disease, including radical prostatectomy, external beam radiation therapy (EBRT),brachytherapy,or active surveillance, as described in a recent guideline from the American Urological Association.35 No randomized controlled trials during the PSA era exist to compare treatment outcomes among these options. However, outcomes for surgical and radiation therapy,when stratified by risk,are similar across several retrospective cohorts. Again, patients may be classified into risk groups accordingtoclinicalstage,pretreatmentPSA,andGleason grade. Large series of low-risk groups exhibit approximately 85–90% freedom from biochemical recurrence,as compared with 75% and 35–50% for men with intermediateand high-risk features, respectively.Recent data suggest that pretreatment PSA velocity (>2 ng/mL/year) and PSADT may also have prognostic significance, although further research is needed to clarify how this information should be incorporated into pretreatment risk models.33,34

Radical Prostatectomy

Radical prostatectomy is the mainstay of surgical therapy for prostate cancer, and is typically

performed using a retropubic approach,although some practitioners will perform perineal prostatectomy in selected patients. The retropubic approach permits sampling or removal of the pelvic lymph nodes. In low-risk men, node sampling may not be necessary, but should be considered in intermediate risk patients, and is considered standard of care for men with highrisk disease. Perioperative morbidity and mortality for the procedure are low, with operative mortality <0.05% at centers of excellence. Data from Medicare claims suggest that outcomes are better at facilities which perform at least 40 radical prostatectomies annually.

The major adverse effects of radical prostatectomy are incontinence and impotence. Patients may expect urinary incontinence during the first few months of recovery, but by 1 year after surgery, published series from expert centers typically report continence rates of 90–98%. Erectile function can be significantly impaired following radical prostatectomy. For men with low-volume disease, nerve-sparing prostatectomy offers the best opportunity for recovery of erectile function following surgery, with equivalent oncologic outcomes in appropriately selected patients. Among patients with good erectile function prior to surgery, expert centers report that 50–90% will recover significant erectile function with a bilateral nerve-sparing procedure. However, patients frequently note that the quality (rigidity and durability) of erections may not be equal to preoperative erectile function. A recent systematic review by the AUA Prostate Cancer Guidelines panel noted high variability in reporting of erectile function in radical prostatectomy series,with rates of “intact erectile function” ranging from 9% to 86%.36 Recently, experts have advocated use of phosphodiesterase inhibitors, intracavernous or