Radical prostatectomy is the standard treatment for patients with localized prostate cancer (PCa) and selected patients with locally advanced diseases. Nevertheless, high-risk and very high-risk PCa are considered challenging in surgical treatment due to the need for cancer control. We report the short-term and long-term outcomes of radical prostatectomy in patients with very high-risk prostate cancer.

Patients with very high-risk prostate cancer, according to the latest NCCN criteria for 2025, underwent radical prostatectomy at Cho Ray Hospital from January 2011 to December 2024. Very high-risk prostate cancer is defined as having at least two of the following: (1) cT3-4, (2) Gleason Group 4-5, (3) PSA > 40 ng/ml. Demographic, clinical, and subclinical parameters, as well as surgical outcomes, were recorded. Kaplan-Meier survival analysis was utilized to calculate Biochemical Progression-Free Survival (BPFS), Progression-Free Survival (PFS), and Overall Survival (OS) rates.

A total of 37 patients with very high-risk PCa underwent radical prostatectomy, including Robot (59.5%), laparoscopic (16.2%), and open (24.3%) procedures. Mean age was 68.8 ± 6.2 (54-82) years, mean PSA was 57.6 ± 30.3 (8-143) ng/ml, and mean prostate volume was 42.6 ± 20.0 (20-116) ml. Tumor stage was cT3-4 in 91.9% of cases, with Gleason Group 4-5 at 73%, and the incidence of positive lymph nodes was 16.2%. Mean operative time was 365 ± 370 (160-630) minutes, and estimated blood loss was 370 ± 300 (50-1000) ml. Only one case involved a rectal injury, which was repaired by simple sutures intraoperatively. Positive surgical margin and PSA persistence rates were 29.7% and 32.4%, respectively. Biochemical recurrence rate was 16%, with a median time to BCR being 19.8 ± 10.5 months. Metastatic disease was observed in 10.8% after a median follow-up time of 27.3 ± 15.4 months. Mean follow-up time was 53.8 (3.7 – 170.9) months. The BPFS, PFS, and OS at 5 years were 85.8%, 79.2%, and 91%, respectively. Thirteen (35%) patients were treated with adjuvant therapy, and 11 (30%) patients were treated with salvage therapy by androgen deprivation therapy with or without radiotherapy and chemotherapy. Adjuvant therapy prolonged progression-free survival significantly compared to salvage therapy, 150 vs 40.5 months (p=0.036).

Radical prostatectomy, which brings beneficial outcomes and safety, has remained a valuable first step in multimodality treatment in patients with very high-risk prostate cancer. Adjuvant therapy should be considered in patients with very high-risk prostate cancer, given the possibility that a significant reduction in progression risk exists.