Treatment Decision - Radical Prostatectomy versus Radiation Therapy

Kudos to your surgeon for his honesty - never heard of one who didn’t think he was infallible!
IMHO, as others have pointed out, you may choose surgery snd still wind up with ADT and some form of radiation. To get ‘clean’ margins your surgeon has intimated that you could wind up incontinent. Not a good starting point.
I don’t feel that your decision is based on whether decipher score is low or high - ALL treatment modalities have similar outcomes so it really comes down to which treatment will cause the least amount of harm.
I think the idea of ‘cutting it out’ is most prevalent in our minds (mine, at least) but the newer radiation techniques are simply outstanding.
Best of luck to you in your decision - and NEVER look back and second guess yourself - it’s a total waste of time…

Doug you have some great experiences here from the guys I see . Both options look good . Its always worth consulting with each Dr's again ( the RO , and Urologist ) . tel them of your concerns . You are young and healthy so both options look like a 'go' . Keep the health routine up , as it helps with recovery ! I am 61 now G 3+4 and PSA of 4.5 when I got surgery . Surgery left a trace PSA , that was rising very slowly up to PSA 0.14 , so 2 years ago I got External Beam Radiation ( EBRT) . So at 0.14 I got only 22 sessions of radiation . At first the radiation didnt do much as after radiation I was at 0.11 for the longest time , then after 10-15 months it started down to 0.076, then 0.052 , now 0.041 .... This is without any ADT or drugs . I feel fine , Hike everyday 8-15 km's with the dogs , Suana afterwards , and enjoy life . ED was an issue right after operation , but after 3 years its 80% back . Radiation of 22 sessions gave me a jumpy bladder and Jumpy colon for 4-5 months , but that resolved too . My father died from PC when he was 67 , diagnosed at 60 , and that was 28 years ago - so many things have changed since then ! Different world . He was an engineer too - Chemical and he hated Dr's . Thats one reason he was diagnosed late I think , he never went to Dr's , but had to prior to one overseas trip - thats when they found it . It must have been there for a while . I cant remember what his PSA was , but I was his caregiver and man !!! , it was tough on me as a young man ! Let us know how you progress . Keep a book of all conversations with Dr's and all your lab and images , et al . God Bless Sir ! James from Vancouver Island .

@vancouverislandhiker
What a great post. It is so uplifting to read. I did not have surgery just radiation. The information you provided of your journey is very valuable and uplifting.

I have found over time from the posts that not catching all the cancer cells in the removal of prostate is something regrettfully I read over and over. Regardless of whether you chose surgery or radiation I think the PSMA test should be standard to help rule out if the cancer has spread outside the prostate.

I echo your comment on exercise. I did get some fatique but ignored it and kept up my exercise routine with exception of bike riding. It helped me physcially but even more mentally dealing with axniety and stress.

You are being treated at a Center of Excellence so that's a great start. I too am a retired engineer and was diagnosed at 60. I chose surgery over the radiation for one main reason. It's a more difficult operation to remove prostate after radiation if the cancer returns. However, with that being said I did not have your complications with regards to possible incontinence. I also had nerve sparing surgery. My Gleason was 4 +3 not 3 +4 so that's in your favor. I've had no complications from my surgery, but everyone is different. It sounds like you're an avid cyclist and are not overweight which should make Robotic surgery easier. I wish I could tell you which route to go but I can't because I just don't know. You may want to ask for another scan to determine if you do truly have EPE or not. Inconclusive is not acceptable to me and probably not to you being an engineer. Good luck in your decision and as someone else responded don't look back and second guess yourself. That was excellent advice which I need to follow myself in all things!

I'm an avid cyclist and found bike riding, even three months after radiation, is still somewhat uncomfortable. I bought bicycling underwear AND wear bicycling shorts. This combo has helped tremendously and I can cycle again without discomfort. I've also been sticking to paved biking trails and avoiding dirt trails for now but it's really been good for my spirit to get out on the bike now that fall is here. If you're not biking because of discomfort, look into the underwear it might do the trick for you.

JC Sir , thanks for your kindness . You made my day ! Yes when rotates are removed cells stick to the bladder at times , and that produces PSA , often from non cancerous cells too ! Hence usually the Salvage radiation to clean up cells . Although my dad had PC , I thought I would dodge the bullet , but no luck that way . What I do have is all this fabulous Cancer technology around me .

Yes , PSA should a standard for all men . 100% . Here is Canada the government is trying to make it "optional unless displaying urological issues " , to save money . We all know this is wrong ! We have our troubles at times in Canada ! HA!!

I agree , exercise and fresh air is important to healing body and mind . I take a sauna after too ! Wonderful ! I am hiking with my best friends ( my dogs) up Bevan Coal Mountain today ...me and the dogs love it - im sure this is how we bonded! My wife ( wonderful women ) always wants to come too , she even wants to carry the large pack sac ( all 105 lbs of her ) . I tell you she is a small lady with a huge heart and drive ! I was truly blessed to me such a women . JC , keep in touch . May God follow you ! James on Vancouver Island .

Doug,
I just faced the same decision. I am almost 70, in good health except for periodic AFIB, and working full time as a technology consultant working mostly from home. After consulting with several other doctors I also went to Mayo Phoenix and they had me talk to focal, radiation and surgery specialists to help me make my own decision.

I believe the "right" decision may be different for others but mine was easy. My cancer was in two many separate locations in the prostate for focal. I really liked the radiation specialist but he told me my age and AFIB dictated radiation rather than surgery. The surgeon felt age and AFIB were not a significant issue. Things I considered (that the non-Mayo doctors never told me):
1) Once you have radiation you will not heal well which can lead serious complications if radiation does not kill all the cancer. (which does happen!)
2) Once you have radiation if you later have urinary problems (such as constant urges and low bladder capacity) any surgery to correct is HIGH risk.
3) The radiation path is a much longer journey than Robotic Proctectomy and includes multiple surgeries and surgery recovery period vs a single but more complex surgery.

Others might be different but for me radiation meant 1) a surgery to "scrape" the prostate to improve urination, 2) 2 to 3 months recovery from surgery, 3) Minor surgery to place markers and hydrogel spacer to block radiation from my colon/rectum. 3) 28 days of radiation treatment, and a single Hormone shot. 4) minor surgeries to remove hydrogel spacer once they were sure no more radiation is required.

If I was younger and more concerned about short-medium sexual function I might have taken a different path but for me I picked surgery which will only require a single recover period who many say is 2-3 weeks but my doctor will request 4-6 weeks from my employer.

Hope this is helpful . . wish you the best on selecting and making your journey.

Wow, that's quite the journey. My prostate radiation was a lot simpler, and involved no surgery:

1. One visit to get an MRI and add tiny alignment tattoos.

2. 20 short visits for the actual SBRT radiation therapy (quick and painless, except for needing a full bladder).

3. Ring the bell.

There was no discomfort at the time, but I exhibited some side-effects a year later because the radiation did minor damage to the bottom of my bladder: I got a high radiation dose (60 gy) because we wanted to treat my stage-4 cancer as aggressively as possible, including attacking the "mother ship".

I did have surgery to remove most of the lesion on my spine (followed by post-op SBRT there), but that was a separate thing, and had to do with spinal-cord compression.

Your #1 Never heard of it not healing well. I have had two different types of radiation. I never had any issues with healing, didn’t even realize I had to heal, never told there was a healing process after radiation. The first time I had radiation I had 35 sessions over seven weeks, never had any side effects of any sort. No surgery before or after. With actual RP surgery, you can also have cells left that can cause problems in the future.

#2 not heard of this being an issue. The bladder shouldn’t be touched/affected by radiation. True that a sling may not be successful after radiation. There are other procedures.

#3. I’m not sure what you mean by surgery. Sure hydrogel includes a procedure, it is done with a needle, not surgery. Removing the hydrogel spaceoar happens naturally, it is absorbed by the body and passed out through urine, again, no surgery involved. And again the markers are placed with a needle not surgery. In my case, they just put tattoos on my stomach.

Surgery almost always results in not being able to get an erection. That’s one good reason to get radiation. There are also new procedures that don’t use radiation and aren’t surgery.

Must admit, never heard of anybody else getting their prostate scraped because of urological problems, that is extremely unusual. Not sure that even makes sense, sure the urethra goes through the prostate, but you wouldn’t scrape the prostate, do you mean you have to have a TURP?

I have attended 2 hour weekly advanced prostate cancer meetings online for five years. Never heard of anybody having a scraping the prostate procedure done.

I’m not sure where you get all this information that is not accurate.

More data this morning to throw into the mix. RO order a biopsy based Decipher Genomic Classifier test in support of potential participation in a clinical trial. Results indicated a Decipher Score of 0.88 which puts me in the high risk group for aggressive tumor biology. Everytime I turn around I seem to get more news that pushes the risk higher and higher. This is one crazy disease. Even the treatment decision process sucks the energy out of you.

Waiting for my RO and Surgeon to weigh back in on how this might impact options or standard-of-care going forward.