What is the "true" incidence of active surveillance and brachytherapy candidates in men undergoing robot-assisted radical prostatectomy?

Purpose: To correlate clinical low-risk prostate cancers with pathologic outcomes in men who are considered for active surveillance (AS), interstitial radiation therapy, or radical prostatectomy (RP). Patients and Methods: Clinical and pathologic data of 76 consecutive patients who underwent RP by a single surgeon between October 2001 and July 2008 were reviewed. The retrospective review identified men with clinical low-risk disease-defined as a prostate-specific antigen (PSA) level <10ng/mL, no Gleason pattern >3, no >2 cores positive, and no core >50%-who would also have been considered for AS and/or brachytherapy based on these features. Pathologic specimens were examined for Gleason primary, secondary, and tertiary patterns, perineural invasion, capsular involvement, margins, nodal disease, and seminal vesicle involvement. Results: Of the patients who underwent RP, 42/76 (55%) had low-risk clinical staging; 8/76 (19%) had low-risk features on final pathologic staging. Fifty-four of 76 (71%) were pT_2c; 10% were pT₃. Gleason 6 was seen in 41/76 (53%) of RP specimens; Gleason 7 and 8 in 41% and 4%, respectively. Favorable brachytherapy parameters were identified in 63% of those who underwent surgery, but 39 of 48 (81%) would have been inappropriately selected based on features of the pathologic specimen. Conclusion: Clinical staging based on PSA level and biopsy findings correlates poorly with pathologic outcome when stratifying for low-risk features in men who may be candidates for brachytherapy and/or AS.