Table 1 presents all patients’ parameters which are necessary for evaluation. , The median age was 79 years (75-87) the median PSA levels were 22.1 ng/ml (3.7-233 ng/ml), and the median ASA score was 1.8 (1-3). 156 patients (79.5%) were thought to have a positive DRE. PCa was detected in 115 patients (59%), from this 84.3% being defined as clinically significant (p<0.05) and 60.8% (p<0.05) as high-grade PCa. A Gleason score of 6 was evident in 45 patients (39.1%), a Gleason 7 in 23 patients (20%), a Gleason 8 in 25 patients (21.7%) and a Gleason score of 9 in 22 patients (19.9%). On multivariate analysis, we found that an increased PSA level > 10 mg/dl (p<0.05) and a positive DRE finding (p<0.05) were independent markers for high-grade or significant PCa (p< 0.001). After diagnosis, patients underwent therapy (N=56) with a curative intent (48.6%).- Therefore, 30 patients underwent radiation therapy (26.1%) and 26 RPE (22.5%). 49 patients (42.6%) who underwent therapy with a palliative intent were treated as follows:, 30 patients (26.1%) hormonally , 7 patients (6.1%) with bilateral orchiectomy, 5 patients (4.6%) with green light laser and 7 patients (6.1%) with transurethral resection of the prostate (TUR-P). 10 patients (8.6%) did not undergo any kind of therapy. In summary most of the patients with curative intent were treated with radiation therapy (26.1%), and most of the patients with palliative intent received a hormonal therapy (26.1%).

Patients with a negative biopsy ^{42 patients (50.6%)}, did not undergo further treatment, while 29 patients (34.9%) underwent TUR-P, 7 patients (8.4%) green light laser treatment, and 5 patients (6.1%) underwent prostatectomy (Data not listed in table 1).

The diagnosis and treatment of PCa in elderly patients is frequently discussed. Published data suggest that men aged over 75 should not be routinely screened for PCa 19202122. Therefore, less than 50% of urologists routinely perform PSA tests in healthy men over the age of 75 years23. This might be due to the fact that they believe either most of these men will have cancer of a lower grade and stage with minimal clinical impact or that they have high grade PCa and would suffer from treatment problems due to their increased age. Nevertheless, Mistry et al. analysed 1446 needle biopsies of the prostate in men aged 75 or older, and found that 53% were positive for PCa, of which 78% would be defined as clinically significant cancer11. They argued that the potential benefit of identifying patients with aggressive PCa even older than 75 years is of great importance. They concluded that the treatment, once the PCa is diagnosed, is dependent on the patients life expectancy, preference and general condition11. These results were similar to our own. As shown, PCa was detected in =115 of patients (59%), with 84.3% of them being defined as clinically significant (p<0.05) and 60.8% (p<0.05) as high-grade PCa. Possibly the situation is different, even if the patients were examined before the age of 75 years and the cancer is possibly detected earlier. Most of the institutions do not have information about prior examinations of the patients and therefore finding of a characteristic marker is essential.

In our case the patients received different treatments, shown in table 1, indicating that most of the patients were under therapy or at least under control.

Furthermore, it is important to consider that men who are 75 years old today are different from the 75-year-olds alive half a century ago : they are physically younger, and, in many cases, still sexually active11. Furthermore, diagnosis of PCa does not automatically mean invasive therapy. Large retrospective studies have shown similar 10-year survival rates between watchful waiting and radical prostatectomy in patients with well to moderately differentiated PCa19202122]. Therefore, according to our data, while the age of diagnosis is unimportant, the early diagnosis PCas is of great importance. Indeed, recent studies have demonstrated that in patients with poorly differentiated PCa, potentially curative therapy can result in life expectancy and quality adjusted life expectancy gains in patients diagnosed up to age 80 years 23.

In a recent study, we evaluated the surgical, the oncologic and the functional outcome in men ≥75 years undergoing robot-assisted laparoscopic radical prostatectomy (RARP)24. RARP has become profoundly popular among urologists for the treatment of localized PCa as it is a well-tolerated, safe, and efficacious intervention for the management of localized PCa1314.

We identified 45 patients and evaluated various parameters including: minor and major postoperative complications, postoperative Gleason score, pathological stage, positive-margin status, continence and potency in 12 months, disease-specific mortality, and presence of biochemical progression at the follow-up period. Major complications were noted in 2.2% of cases. Organ-confined disease was noted in 68.8%, extra prostatic extension in 31.2%, and a positive surgical margin status was encountered in 11.1% of cases. At 12 months, 86.9% of patients were continent and 39.6% were potent. After a median follow-up of 17.2 months no disease-specific mortality was evident and 95.5% were free of biochemical progression. We demonstrated that RARP in patients ≥75 years of age is a safe surgical procedure with limited complications, excellent oncologic and continence outcome as well as acceptable potency. There are certain limitations that should be addressed regarding our study. The first one is that the retrospective and non-controlled design of our work limits our ability to generalize our findings. The second one is that although after diagnosis was made 56 patients underwent therapy with a curative intent (48.6%), 30 patients underwent radiation therapy (26.1%), and 26 RPE (22.5%). As yet, we have no long term follow-up data on these men to evaluate the impact of PCa and its treatment on the quality and longevity of their lives. However, patients with high grade PCa suffer more than those with lower grade, since the tumor is more aggressive and they have metastases. It could be shown that elderly patients with high grade PCa receiving curative therapy had better outcomes and a higher life quality25

Nevertheless, in a further effort to improve personalized treatment,

we show in this study the importance of screening of patients over the age of 75 years with our defined markers.