Dear Sir,

  There have been a number of articles recently, addressing treatment of the primary prostate tumour in presence of metastases. This is clearly a very important unaddressed topic, which impacts significantly on our management.

   A retrospective multi-institutional analysis of radical prostatectomy (RP) alone^[1], looking at 345 patients with T3 disease, found a 10-yr disease free survival rate of only 57%^[2]. For patients with well-differentiated, moderately differentiated, and poorly differentiated tumours, were 73%, 67%, biochemically free survival rates were and 29%, respectively^[3].

   When RT (radiotherapy) and RP are used in combination, survival rates exceed those for RT alone and compared to those post androgen-deprivation therapy and external beam RT (Bolla historical series; 5-yr OS 78%)^[4]. RP has a place in the treatment of locally advanced prostate cancer is supported by a few studies recently conducted in the United States^[5]. RP, combined with adjuvant or salvage treatment when needed, may result in better outcomes than RT alone, similar to the combination of RT plus HT therapy. There is ongoing controversy- this is a historical comparison.

   RP has a place in the treatment of locally advanced prostate cancer is supported by a few studies recently conducted in the United States^[5]. RP, combined with adjuvant or salvage treatment when needed, may result in better outcomes than RT alone, similar to the combination of RT plus HT therapy.

   There is a constant ongoing controversy, whether cytoreductive surgery in these cases, will benefit the patient. However, Culp found there was a survival benefit conferred. This high risk surgery, will almost always involve multimodal therapy therefore compounding side effects from hormone and radiotherapy.

   The basis of cytoreductive surgery is resection of the primary tumour mass. This results in less tumour cell shedding, and reduction in tumour-associated growth factors from the primary tumour^[6]. The question arises, whether we should be performing bilateral pelvic lymphadenopathy–both from a prognostic and therapeutic viewpoint. These issues which are contentious are based on prognostic and therapeutic studies. We owe it to our patients of future. The problem here, are that most of these series are retrospective and from the studies which have been done the sample sizes are relatively small. In addition, there are no criteria present, to identify patients most likely to benefit from therapy^[7].

  In conclusion, these questions that remain unanswered, point towards a requirement for a trial. With kind regards,

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