PSMA negative, Biopsy positive

That’s just the opposite of what my PSMA was like. I had to empty my bladder on arrival and then drink 16 oz of water and wait 45 mins before the scan could begin. Weird right?

I am 66, had two lesions found in my MRI that after targeted biopsy showed no cancer. At the time PSA 7.0. Two other needle biopsy showed 6+6. Monitored for 6 months. Had a second biopsy December of 2024, 16 samples, with two showing 4+3, intermediate unfavorable. PSA 8.3. The two samples had only < 5% and < 20% cancer, and both were in the same area. My urologist recommends surgery. I have a PSMA PET scan scheduled this week, although after reading comments I am not sure the test will provide too much useful information. With only 2 samples out of 31 showing cancer, both in the same location, and low percentages of cancer in the samples, is this truly unfavorable and required either removal or radiation?

I'd be inclined to follow your urologist's rec.
His concern is that you now have a high risk Gleason score of 4+3. The PSMA can detect prostate cancer at your PSA level fairly well so my guess is the uro wants to see how much there may be elsewhere. That'll give a road map to the lhmp node lesions he'll remove. Chances are he'll remove nearby ones not registering lit PSMA on the likelihood they're harboring micro metasis.
You might talk w him about using radiotherapy such as SBRT to go after the problem. It too can go after nearby lymph nodes not registering PSMA.
One benefit to the surgical removal is that they'll biopsy the lymph nodes and thereby get a better grasp of your pc's aggressiveness, if that hasn't already been done w tissue from your prostatectomy. Also the removal may suggest a pattern of potential metasis.
The surgical removal of lymph nodes is still considered a Gold Standard in ascertaining BCR lymph cancer potential.
Good luck!

I just realized he's recommending a prostatectomy, a lymph node dissection after a prostatectomy
With what you've described as your condition, you might want to get the opinion of radio oncologists. They may suggest PSMA directed SBRT or other nonsurgical treatments. If your prostate cancer is confined to the prostate, which seems likely given your biopsies , it may be a good outcome w either approach. I've read the long term oncological results overall are the same for either procedure.
Good luck!!

More clarification
I meant to say "just realized he's recommending a prostatectomy, NOT a lymph node dissection after a prostatectomy."

While PSMA can detect cancer at much lower levels than previous systems, it still can't detect all of it- so called micrometasis. So it seems the first uro thinks he has enuff info to proceed and the second thinks otherwise..
But they may both plan to do a final PSMA before surgery to get a better lay of the land to help direct the surgery.
I'd clarify their inent here.

Thanks for the input. I plan to meet with a radiologist and discuss radiation treatments options. So what I am hearing is that the unfavorable label is determined by the Gleason score regardless of the number of needle samples with cancer, and regardless if the cancer is confined to one location in the prostate. With the PSMA Pet scan, I am hoping to see the true amount of cancer in the prostate, beyond the two samples that are confirmed. Also i'm was told it is recommended to decide an action to address the cancer within 6 months of receiving the biopsy results. Is that what others have been told with similar circumstances?

In general, the sooner the better once you've decided to act. Another issue to consider weighing the two procedures, is the potential impact on your sex life. Here the sparing of your two erectile nerve bundles thar are attached to the prostate come into play. In my prostatectomy the doc spared one- the other was too close to the cancer to risk sparing. The docs may have some info as to which procedure may most likely spare one or both. The value of the surgery is they can acually eyeball the situation to make the determinstion. In my case, sparing one was more than sufficient.
Again
Good luck!!!

You can do a lot of learning before you make your decision. All the comments here are excellent and even though there’s no great rush to get this done in a month Gleason 4+3 unfavorable needs to be addressed.
PSMA, unfortunately, does not show micrometastasis so even though nothing lights up on the scan it doesn’t mean your nodes are clear.
Your chances of success/failure with either surgery or radiation is the same. Surgery does, however, give you a second chance down the road if the cancer recurs. You can then do radiation with or without ADT to attempt a cure or a long term band aid to fix the problem.

I'm the OP. Wishing you all the best. My husband, 73, is doing well 1.5 years since his RP. In case you missed it above, he got a second opinion on the PSMA from a nuclear med specialist. The cancer within the prostate did light up and showed no spread. His surgeon accepted this result and surgery + recuperation went well - after surgery he was downgraded from 4+4 to 4+3.

The process and decisions are very stressful but he is happy he chose surgery, very minimal discomfort and side effects. Because of his Gleason score, he did not have the luxury of waiting 6 months. He had the surgery 3 months after diagnosis. Good luck to you!