[3] Thompson IM, Goodman PJ, Tangen CM, et al. The influ- ence of finasteride on the development of prostate cancer. N Engl J Med 2003;349:215–24. [4] Denberg TD, Melhado TV, Steiner JF. Patient treatment preferences in localized prostate carcinoma: The influ- ence of emotion, misconception, and anecdote. Cancer 2006;107:620–30. [5] Klotz L. Active surveillance with selective delayed inter- vention: using natural history to guide treatment in good risk prostate cancer. J Urol 2004;172(5 pt 2):S48–50, discussion S50–1. Yair Lotan The University of Texas, Southwestern Medical Center, Dallas, TX, USA DOI:10.1016/j.eururo.2006.09.040 Re: Poorly Differentiated Prostate Cancer Treated With Radical Prostatectomy: Long-Term Outcome and Incidence of Pathologic Downgrading Donohue JF, Bianco Jr FJ, Kuroiwa K, Vickers AJ, Wheeler TM, Scardino PT, Reuter VA, Eastham JA J Urol 2006;176:991–5. Expert’s summary: Donohue and coworkers examined clinical and pathologic features, outcome, and the incidence of pathologic downgrading in a series of 238 patients treated with radical retropubic prostatectomy for clinically localized prostate cancer with a Gleason score of 8–10 in the biopsy specimen. The incidence of pathologic downgrading was reported at 45%, with the probability of downgrading increasing with lower clinical stage and lower biopsy Gleason score. The overall 5- and 10-yr biochemical recurrence- free survivals were 51% and 39%, respectively, and patients in whom cancer was downgraded were at significantly lower risk of biochemical recurrence versus those with a confirmed Gleason score of 8–10 in the prostatectomy specimen. Nevertheless, no statistically significant difference between the two groups with regards to organ-confined rate, extra- capsular extension, seminal vesicle involvement, or lymph node involvement was noticed. The rate of positive surgical margins, however, was statistically higher in the group not downgraded (38%) versus that of the downgraded group (25%). The authors relate this difference to the larger volume of cancer present in the former group, but unfortunately they do not analyze whether positive margins have a prognostic impact in their series. Expert’s comments: Whether or not to perform radical prostatectomy in patients with poorly differentiated prostate cancer represents a matter of great controversy. The authors of this retrospective study conclude that radical prostatectomy also has a therapeutic role in this clinical setting for two distinct reasons. First, they report encouraging 5- and 10-yr biochemical recurrence–free survivals of 51% and 39%, respec- tively, which are in agreement with those rates reported in other series [1–3]. Second, they report a substantial degree of pathologic downgrading (45%), probably related to the low median of positive cores (two) in their series but still within the range reported in the literature, which may further drive surgeons to choose the surgical approach with the possibility of finding a Gleason score  7 at the final pathologic examination [4,5]. Indeed, we think that the promising results presented by Donohue and coworkers, along with those presented by others, led us to offer radical prostatectomy in patients with clinically localized poorly differentiated prostate cancer [1–3]. In con- trast, alternative nonsurgical therapies such as three-dimensional conformal external beam radio- therapy ( whole pelvic irradiation), either alone or associated with adjuvant androgen suppression therapy, have proven to be less effective and are associated with a not-negligible complication rate [6,7]. Undoubtedly, these patients must be carefully counselled and, if the decision is to perform surgery, we have found that radical retropubic prostatec- tomy using the antegrade approach minimized the risk of positive surgical margins and increased the incidence of specimen-confined disease in those patients diagnosed as having non–organ-confined prostate cancer at the pathologic examination [3]. References [1] Lau WK, Bergstralh EJ, Blute ML, Slezak JM, Zincke H. Radical prostatectomy for pathological Gleason 8 ore greater prostate cancer: influence of concomitant patho- logical variables. J Urol 2002;167:117–22. [2] Mian BM, Troncoso P, Okihara K, et al. Outcome of patients with Gleason score 8 or higher prostate cancer following radical prostatectomy alone. J Urol 2002;167: 1675–80. [3] Serni S, Masieri L, Minervini A, Lapini A, Nesi G, Carini M. Cancer progression following anterograda radical prosta- european urology 51 (2007) 565–571 568