Well...,

You may not need to rush to a decision.

Thank your urologist for the input, now consider seeing a radiologist and medical oncologist, preferably ones who specialize in prostate cancer.

At that PSA, no surprise the PET/CT came back negative.

If possible, ask for one of the PSMA scans. I had the Plarify in March 2023, it showed a single pelvic lymph node. Based on that and my clinical history we did SBRT and 12 months of Orgovyx for micro-metastatic disease too small to be seen by imaging but knowing it was there, somewhere! I just came off treatment on Thursday after discussion based on my clinical data with my oncologist and radiologist, I am under no illusions of a "cure (don't get me wrong, I'd take it!)" but looking for three to five years progression free period, then we'll see what's next.

One factor in your decision is your current state of health and life expectancy. I mean, some studies will say it may be eight years until metastases show up, you're 83...of course, that's statistics, so do you want to chance that you're in the "average!?"

As to the incontinence, radiation treatments have come a long way...I've had three rounds:

March 2016 - SRT 39 IMRT 70.3 Gya to the prostate bed only.
July 2017 - WPLN 25 IMRT 45 Gya
April 2023 - SBRT 5 x 8 Gya

Not a single side effect, a tribute to the training, education and experience of my radiological team *same ones each time) and the technological advances in the planning and delivery software and hardware.

If you treat based solely on PSA you have options:

SRT to the prostate bed only (as your urologist suggests)
SRT to the prostate bed and short term ADT, say six months
SRT to the prostate bed, extend the treatment to the PLN systems, the whole PLN
SRT to the prostate bed, extend the treatment to the PLN systems, the whole PLN and short term ADT.

The answer lies in how aggressive you want to be. As to the SEs, not dismissing.

The PSMA PET may inform your treatment decision (does not necessarily change your treatment options), providing a radiologist a target(s) to radiate vice bindly treating the prostate bed (think smart vs dumb bombs). As to the ADT, hey six months and is you use Orgovyx vice say Lupron (depending on your doctor, insurance), coming off it is faster than Luron, or at least I"m about to find out!

Give your time to BCR, age (not trying to say old..!), not sure your medical team would consider doublet or triplet therapy by adding an ARI such as Xtandi, or including chemotherapy, seems too aggressive.

Another piece of the clinical data puzzle would be one or two more PSA tests which could provide PSADT and PSAV, if PSADT:

> 12 months - option to just "monitor"
6-12 months, kind of like GS 3+4, what to do.
< 6 months - decision to treat or not just made for you.

Treatments are generally a risk-benefit decision, combining clinical data, side effects...and your personal priorities.

Kevin