BJUI BJU INTERNATIONAL © 2012 THE AUTHORS BJU INTERNATIONAL © 2 0 1 2 B J U I N T E R N A T I O N A L | doi:10.1111/j.1464-410X.2012.11372.x 1 What’s known on the subject? and What does the study add? Despite a lack of randomised controlled trials, most men with locally advanced prostate cancer are recommended to undergo external beam radiotherapy (EBRT), often combined with long-term androgen-deprivation therapy (ADT). Many of these men are not offered radical prostatectomy (RP) by their treating urologist. Additionally, it is know that EBRT with long-term ADT does provide good cancer control (88% at 10 years). We have previously published intermediate-term follow-up of a large series of men treatment with RP for cT3 prostate cancer. We report long-term follow-up of a large series of men treated with RP as primary treatment for cT3 prostate cancer. Our study shows that with long-term follow-up RP provides excellent oncological outcomes even at 20 years. While most men do require a multimodal treatment approach, many men can be managed successfully with RP alone. OBJECTIVE • To present long-term survival outcomes after radical prostatectomy (RP) for patients with cT3 prostate cancer, as the optimal treatment for patients with clinical T3 prostate cancer is debated. PATIENTS AND METHODS • We identified 843 men who underwent RP for cT3 tumours between 1987 and 1997. • Survival was estimated using the Kaplan–Meier method. • Cox proportional hazards regression models were used to evaluate the association of clinicopathological features with outcome RESULTS • The median (range) postoperative follow-up was 14.3 (0.1–23.5) years. • Down-staging to pT2 disease occurred in 26% (223/843) at surgery. • Local recurrence-free, systemic progression-free and cancer-specific survival for men with cT3 prostate cancer after RP was 76%, 72%, and 81%, respectively, at 20 years. • On multivariate analysis, increasing RP Gleason score (hazard ratio [HR] 1.8; P = 0.01), non-diploid chromatin content (HR 1.8; P = 0.01), positive surgical margins (HR 2.1; P = 0.007), and seminal vesicle invasion (HR 2.1; P = 0.005) were associated with a significant risk of prostate cancer death, while a more recent year of surgery was associated with a decreased risk of cancer-specific mortality (HR 0.88; P = 0.01) CONCLUSIONS • RP affords accurate pathological staging and may be associated with durable cancer control for cT3 prostate cancer, with 20 years of follow-up presented here. • RP as part of a multimodal treatment strategy therefore remains a viable treatment option for patients with cT3 tumours. KEYWORDS clinical T3, prostate cancer, radical prostatectomy, extraprostatic extension, seminal vesicle invasion Study Type – Therapy (case series) Level of Evidence 4 20-year survival after radical prostatectomy as initial treatment for cT3 prostate cancer Christopher R. Mitchell, Stephen A. Boorjian, Eric C. Umbreit, Laureano J. Rangel*, Rachel E. Carlson* and R. Jeffrey Karnes Departments of Urology and *Health Sciences Research, Mayo Medical School and Mayo Clinic, Rochester, MN, USA INTRODUCTION A significant stage migration has occurred with the introduction of routine PSA screening for prostate cancer. Accordingly, most newly-diagnosed tumours are now organ-confined (cT2), with only a small subset of patients presenting with locally advanced (cT3) disease [1]. As a result, the optimal treatment for these patients remains unclear and highly controversial. Interestingly, despite a lack of prospective randomised clinical trials comparing treatment methods for men with high-risk prostate cancer, these patients have been found to be significantly less likely to undergo surgery [2,3]. Indeed, external beam radiotherapy (EBRT) combined with hormonal therapy has been associated with 5-year cancer-specific survival (CSS) rates of 94% for men with locally advanced prostate cancer, and in fact has become a preferred treatment in this setting [4]. The use of concomitant long-term androgen-deprivation therapy (ADT) has been found to be critical in optimising outcomes for high-risk tumours treated with EBRT, as results from the EORTC Phase III trial 22961 found a 10-year Accepted for publication 19 April 2012