In any gentleman where surgery is the best treatment, minimally invasive surgery is always an option. This is regardless of the PSA level or the extent of the cancer in the prostate itself or of the gleason score which is the reflection of the aggressiveness of the cancer.

At the time of the operation, the surgeon uses standard anatomical landmarks to assure complete removal of the prostate and seminal vesicles, as well as pelvic lymph nodes in select, typically higher risk, cases. If there are findings at the time of surgery suspicious for disease extending beyond what was resected, the surgeon can obtain real-time feedback from the pathologists by sending a small sample of suspicious tissue for frozen section analysis, though this is not a routine feature of prostate cancer surgery. If these are sent and show residual cancer, the surgeon may remove additional tissue, where possible. When the specimen is removed, it is submitted for pathological analysis, which typically takes a few business days. The pathologists report back to the surgeon the Gleason score (which occasionally may differ from what was sampled on the biopsy) as well as the microscopic extent of the tumor: whether it was confined to the prostate (stage T2), penetrated the capsule of the prostate (stage T3a) or seminal vesicle (stage T3b), or, rarely, directly invaded into the bladder tissue (stage T4). The pathologists will also microscopically examine the edges of the specimen, termed the "surgical margins" to see if any cancer cells abut the edge of what was surgically removed. In addition, any lymph node tissue removed at surgery is microscopically examined for involvement with cancer cells. Based on this pathology report, the patient and his doctor get a much more comprehensive picture of the risk of the prostate cancer, including the potential risk for recurrence. Some men with T3a/T3b disease and/or positive surgical margins may benefit from a course of radiation therapy following surgery (considered "adjuvant" radiation), as supported by several clinical trials, and men with these results should inquire with their surgeon if they may wish to have a consultation with a radiation oncologist. The standard process for monitoring for disease persistence or recurrence after surgery is outlined below, in the following answer -http://talkabouthealth.com/after-a-prostate-cancer-patient-finishes-treatment-with-no-evidence-of-cancer-what-are-the-screening-recommendations. We typically measure the first post-surgery PSA at roughly 3 months after surgery.

The surgery options for prostate cancer are essentially different approaches to radical prostatectomy. The original form of radical prostatectomy, first performed in the late 19th century, is perineal--performed through an incision between the scrotum and anus. Open retropubic radical prostatectomy is performed through an incision below the belly button, and laparoscopic or robotic prostatectomy is performed by inflating the abdominal cavity with carbon dioxide to create a space to insert a scope and instruments through a number of small incisions. The fundamental risks of radical prostatectomy (bleeding, infection, anesthesia, injury to adjacent structures, urinary incontinence and erectile dysfunction) are present regardless of approach, and the surgical approach is best determined by which one the surgeon has the most experience with, as well as occasionally patient-specific factors that favor one approach over another. It is important to appreciate that surgery is one among several treatment options for localized prostate cancer--radiation therapy in the form of external-beam radiotherapy with or without hormone therapy, or radioactive seed implantation (brachytherapy) are other standard treatment options, also with risks of side effects related to urinary, sexual and bowel function, as is active surveillance, as outlined in the response to this answer -http://talkabouthealth.com/in-what-situations-is-active-surveillance-a-treatment-option-for-prostate-cancer-patients. When a patient receives the diagnosis of prostate cancer, he may wish to seek consultation not only with a urologist (the specialty also typically involved in performing the initial evaluation of elevated PSA, including the performance of biopsy) to discuss surgery options but also a radiation oncologist. In our practice, newly diagnosed prostate cancer patients typically have a multidisciplinary consultation with urology, radiation oncology, and when indicated for high risk or advanced disease, medical oncology at the same visit to review all available options in detail with experts in each respective option.

Advantages of radiation therapy include: its non-invasive nature, very low risk of urinary incontinence, better retention of sexual function compared with surgery, no risk of post-operative complications such as pulmonary embolism. Disadvantages: Can take 2 months of daily treatments, low risk of rectal injury leading to occasional episodes of rectal bleeding

Advantages of surgery include: additional information can be obtained by having the whole prostate to examine rather than just a biopsy, very low risk of rectal injury. Disadvantages: Can affect urinary control, has the risks associated with major surgery.

Note that both surgery and radiotherapy have very high cure rates, but if the first treatment does not cure the cancer, the other treatment can be offered as a back-up treatment. Occasionally, one hears that surgery cannot be performed after radiation therapy, but there are many urologists who are comfortable performing such procedures.

Finally, one should remember that some patients with localized prostate cancer are candidates for active surveillance with the hope that treatment can be avoided totally or perhaps delayed for a number of years.

The advantages of having minimally invasive surgery are many fold; primarily the main advantage is that minimally invasive surgery and robotic surgery specifically is advantageous in that it is more accurate and precise. It has less blood loss associated with it and it is a more consistent surgery. Also, the surgeon can see things better because of the magnification which is about 12 fold. In addition, because of the way the instruments work we have a much better chance of treating surrounding tissues delicately. This leads to less nerve damage and less damage to surrounding tissues. A recent consensus meeting of expert surgeons both open and robotic was held at City of Hope in the summer of 2011; the results of that meeting was recently published in a series of articles in a journal known as “European Urology” – the highest impact journal within the specialty of urology. That group, of which I was a member, clearly found that robotic prostatectomy is equivalent to open surgery in terms of cancer control but appears to have a significant advantage in terms of recovery of bladder control and sexual function. It is important to note that the skill and experience of the surgeon and the institution where the surgery is being performed has significant impact on the outcomes and results of robotic surgery.

The long-term results from robotic and open surgery are identical. Therefore, neither should be recommended as better than the other. The most important thing is the experience of the surgeon with a particular method.In general, results are best when the volume of operations performed in a career is at least 200 and the number of procedures performed per year is at least 50. Again, the personal experience of the surgeon using the technique recommended should be scrutinized carefully. Good surgeons will be able to provide outcome data regarding cancer control, urinary control and potency preservation. This data should be their personal data and not relevant to the experience of another surgeon or of a cancer treatment center as a whole.

The most important measures of the success of prostate surgery are, in this order, cancer control, urinary control and potency preservation.

Cancer control should be measured and reported two years, five years and ten years after operation. Freedom from recurrent disease is measured using PSA. Of all patients who are not cured, 50% will recur in the first two years, 80% in the first five years, and almost 100% in the first ten years. Hence, the success of prostate surgery is assessed best by long-term PSA-proven cure. Urinary control recovery is measured by pad usage. An excellent surgeon should have 99% of their patients socially continent, meaning that they wear no pads, a security minipad, one minipad, or up to two minipads per day. Various quality-of-life instruments also are available to assess urinary control and bladder function. Potency is defined by the ability to achieve vaginal penetration with or without oral agents. There are two metrics used commonly — the UCLA instrument and the Sexual Health Inventory for Males (SHIM). The recovery of erectile function is very much age-dependent. An excellent surgeon should rarely have a patient become impotent when that patient is under 50 when the surgery is performed. Men in their fifties should have a recovery-of-erection rate greater than 80%, men in their sixties a rate greater than 60% and men in their seventies a rate greater than 40%.

Pelvic lymphadenectomy is the removal of lymph nodes that lie adjacent to the prostate and bladder in the pelvis at the time of surgery to remove the prostate. The pelvic lymph nodes are the first site of cancer spread. By removing these lymph nodes, the surgeon can assess if the cancer has spread or remains confined to the prostate. If only 1 or 2 lymph nodes of the many removed are involved, their removal alone may be curative. Presence of cancer in the lymph nodes may direct the surgeon to institute additional therapy following the surgery such as hormone therapy or even radiation therapy in some instances.

Typically when a patient is diagnosed with prostate cancer, several things are looked at. They include serum PSA, Gleason’s grade, and findings on a digital exam. Based on these 3 factors patients are classified as low, intermediate and high risk of having disease outside the prostate. Additional features include number of positive biopsies, number of biopsies with a high Gleason’s grade, % of tumor involved in each biopsy core. The rate of change of PSA within the last year is also helpful in determining aggressiveness. Having a Gleason’s grade of 4 or 5, or a PSA >20 or an abnormal rectal exam may determine that a patient has high-risk disease. These patients will get additional scans to ensure that the disease has not spread outside the prostate. Typically this group gets aggressive therapy with more than 1 mode of treatment such as surgery with or without radiation, or radiation with hormonal therapy.

Active research is ongoing evaluating biomarkers in blood and urine to determine if aggressiveness can be better determined when one is diagnosed with prostate cancer.