With Gleason 3+4 virtually all the various treatment modalities are applicable including, Focal (Cryo, Laser, Ultrasound, Electricity etc.), RP (robotic), external beam radiation like IMRT or SBRT (CT-Guided or MR-Guided, Photon or Proton), LDR brachy, and of course surveillance.

The issues with Focal are: not a lot of long term outcome data available compared to other modalities but the biggest issue is that there is a tendency for radiologists to be lazy and only report the first sizable lesion they see and stop looking for others. Focal requires that all the lesions are identified. So it is essential that you have an expert radiologist who is familiar with focal requirements to provide a second opinion of your MRI images. You're under general anesthesia so it seems like the procedure only took a minute. Recovery takes about a week and requires a catheter for much of that time. Focal has the best side-effects profile.

The issue with RP is that it is extremely invasive with a high potential for life-long side-effects. Providers including radiation oncologists will push younger men in this direction saying that once you have radiation (IMRT or SBRT) you have no more options for treatment if there is a relapse whereas with a relapse after RP you can get radiation. While technically that is true the point being missed here is that the prostate does much more than just create seminal fluid and provide an income for urologists. It provides the framework for holding the urethra, internal and external sphincters, and the neurovascular bundles. When you take it out and then apply IMRT or SBRT to the region you are hitting both sphincters, the bladder, and the neurovascular bundles (if they were able to be saved in the RP procedure). Then you may end up requiring a permanent urinary diversion (pissing in a bag). They also don't typically tell you that you will lose an inch (more or less) of your flaccid penis length and many men can't afford to lose that much real estate. Perhaps they should lead with that bit of information. Recovery takes several weeks and full urinary control and sexual functionality could take as long as 2 years if ever.

It has been shown in a recent study (2025) as pointed out by Dr. Mark Sholtz of PCRI that external beam radiation Photon or Proton either IMRT (low dose) about 20 sessions or SBRT (high dose in 5 sessions) does not provide adequate dosing to achieve the curative results that we would expect. Recovery time is quick and usually a catheter is not required. The long term side-effects profile is only slightly better than RP.

Mark Sholtz favors LDR Brachy and this is probably why:

- a single session that takes about an hour and you're done.

- you're under general anesthesia so it seems like the procedure only took a minute

- recovery time is virtually immediate (you can leave the recovery room and immediately go out for dinner and drinks)

- usually a catheter after the procedure is not required.

- the permanent seeds provide a sufficient dose to achieve the best curative results of any treatment modality as evidenced by the ongoing study of 129,000 men who underwent all the different modalities of treatment. It measures their outcome by modality. You can look this up at prostatecancerfree.org

- Because Brachy treats the prostate from the inside out with little overspray to surrounding tissues RP, Focal, and even radiation can be utilized later in the case of a recurrence however recurrences are extremely rare. The side-effects profile is only slightly worse than Focal but better than RP or external beam.

In your case, if you have some 4+3, I would imagine that a radiation oncologist (RO) who offers Brachy would suggest the following line of treatment: permanent seed brachy followed by maybe 10 sessions of IMRT followed by 6 months of ADT. However, it likely wouldn't be unreasonable to do Brachy and then some time with active surveillance to see how things are looking. In my opinion, the worst thing you could ever do is radical prostatecomy (RP). I had LDR brachy and it was extremely uneventful. I liken the experience to going to a spa for a couple of hours. No pain or discomfort afterwards. Immediate recovery. Only a slightly slower stream for a few weeks. I can't really understand why, when LDR brachy is available, people would bother with focal especially when focal isn't covered by all insurance companies and not at all in Canada. I would be happy to tell you my experience. Feel free to PM me.