Brachytherapy or Prostatectomy? How did you choose?

I may have misled people into thinking Pluvicto was only available overseas for rich folks. My intention was to say it is available overseas for those who do not meet the criteria for insurance payment, The requirement for prior chemo was lifted for castration resistance this Spring. I assume that it will devolve down to hormone sensitive ...etc. In New Delhi a very modern hospital is offering Pluvicto for USD 47K for the series. In principle the cancer within the capsule without metastases should be as sensitive to ligand radiotherapy if not more so?

With regard to an additive benefit of Nubeqa to ADT prior
to radiotherapy I cannot find the notice. There is however
a benefit apparently for a planned prostatectomy (RP).

Bayer just did make an announcement that the FDA had approved 03 June that Nubeqa has been approved for hormone sensitive metastatic disease.
https://www.bayer.com/en/us/news-stories/metastatic-castration-sensitive-prostate-cancer

Instead of starting a new discussion, I hope it's okay to piggyback on this one since my circumstance is similar, just not restricted to brachy as the radiation format.
I just received biopsy results and spoke to my urologist three days ago, who recommends either surgery or radiation. I'm a bit agog in deciding which to favor.
I'm 71, in pretty good shape and health apart from dealing with chronic fatigue since my first(!) Covid-19 infection about a year ago (AKA Long Covid).

This spring, after a blood test showing 7.2 ng/mL level of PSH, I was referred to a urologist, who found a nodule, and referred me to imaging, for a contrast MRI.
It revealed a .5ml lesion abutting the capsule, but apparently fully contained therein.
I subsequently underwent a biopsy, and here are the results:
(They are all Adenocarcinoma)
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C: R3 right lateral mid: Gleason pattern 3 + 5 (5%) =8, grade group 4, 5.5 mm in 13.5 mm core, 40% of tissue.

D: R4 right medial mid: Gleason pattern 3+3=6, grade group 1, discontinuous 0.4 mm and 0.3 mm foci in 14 mm core, 5% of tissue.

I: L3 left lateral mid: Gleason pattern 3 + 4 (20%) =7, grade group 2, 2 mm in 10 mm core, 20% of tissue.

K: L5 left apex lateral: Gleason pattern 3 + 4 (20%) =7, grade group 2, discontinuous 0.4 mm and 0.2 mm foci in 9 mm core, 5% of tissue.
-Perineural invasion present.

M: Target 1,:, Gleason pattern 3 + 5 (5%) =8, grade group 4, involving 4 of 5 cores, 11 mm in 43 mm core, 25% of tissue.
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I have to admit I'm a bit confused about the final "M: Target 1" as I'm uncertain just where that was from, or if it's a generalization of the bunch. Forgot to ask my urologist about that.
He seemed to discount the Perineural invasion as insignificant.
He did say that the cancer does appear to be contained just within the organ, but that it is somewhat aggressive, and needs to be dealt with "soon", but he was agnostic about whether surgery or radiation would be best. I asked about focal radiation, but apparently the cancer is a bit too dispersed for that to be effective. He also discounted brachytherapy as appropriate.

I'm dealing with the local University of California health system here, which I understand is well-regarded, and he has referred me to a surgeon there (turns out to be the same one who did the biopsy, coincidentally), as well as their hospital in La Jolla that is equipped for radiation therapy.

I'm nervous about the possibly greater chances of urinary and ED problems (I have a wife) with surgery, but the higher chance of bowel problems with radiation certainly gives me pause, along with its side effect of (more, in my case) fatigue.
I think I'm leaning towards the surgery option--they do have the amazing DaVinci (or was it Cuisinart..?) robotic thingie--and the finality of it appeals, but, again, I'm uncertain, and would love to hear from some of you knowledgeable and experienced fellows for your perspectives.
Thanks so much!

Reply To: @sandguy

A target would normally be where an MRI showed that there was a nodule.

It would mean that they took five cores of that area and that Four of them had some (25%) cancer. Only 5% Gleason 5 however. Other spot had higher 40% cancer but again only 5% Gleason 5.

This does sound quite treatable. Surgery does have a pretty good chance of causing ED. If they can spare the nerves, then it makes it more likely would be able to have erection. It may take a while, Though some people recover quickly.

I was just at a seminar a few days ago, where they talked about urinary incontinence after surgery and they said it could take up to a year in some cases for full recovery. If it’s not recovered in a year, he said it is not going to come back and you need something like the AUS. I know in my case I really didn’t have any incontinence issues after surgery. The results vary considerably, if you do a search on this forum for incontinence you should find many discussions and many different results. Doing kegels before surgery and then after can really help with incontinence.

If you decide on radiation and have a spacer put in to protect the rectum from damage. Some doctors Don’t like it. There are three different brands SpaceOAR, Barrigel, or BioProtect.

As far as whether you should have surgery or radiation, The results are about the same. Some people have to have radiation after surgery because it reoccurs . You could get a Decipher test to see if there is a high likelihood of reoccurrence. Ask your doctor about it.

It’s really a roll of the dice and your personal preference. Just to be clear, there is nothing FINAL about surgery - roughly 30% require retreatment and the daVinci robot is amazing - until it’s used on YOU. A little better than open surgery in very skilled hands but just as invasive. If the surgeon manages to get every last cell, you’re cured…
Radiation for a 71 yr old is a pretty good bet as well. Side effects vary from none to pretty intense, bladder and bowel-wise. So somewhere in the middle is very tolerable.
With a Gleason8 abutting the capsule I am surprised there’s no mention of ADT with radiation (either SBRT or IMRT) since an 8 makes your cancer aggressive even without a Decipher score.
Although you need to act somewhat quickly on this ( like not this week, but not Christmas either!) you need to get more info; I would get an opinion from a radiology oncologist (or two) - someone who does actual treatment, not your urologist telling you about it.
In either case you have a good chance for successful treatment. Best,
Phil

I had few if any side effects from Brachytherapy. ADT on the other hand was pure HELL.