44yr PSA180 Gleason9 non-metastatic. Surgery or Treatment?

Great to hear your testosterone is going down with Firmagon. That’s what the people at the online Ancan.Org Mutation meeting said would help, It appears to definitely work.

A PSMA pet scan would probably cost you $4000 to $6,000 or more in the states. Much cheaper to have it done in Europe.

Really interested in hearing what your second PSMA PET scan shows.

The somatic genetic test is really a good idea to get so it’s good to hear they’re doing it. It can actually show genetic issues in your metastasis that are different from the genetic issues in your hereditary test. I know people that have it show BRCA2 and they’ve been able to take PARP inhibitors as a result.

Alright folks, fresh off the press. The results of the second PSMA are in and somewhat encouraging:
LYMPH NODES
Morphologically conspicuous lymph nodes:
A previously pathologically enlarged lymph node on the left (parailiacal) has decreased in size to 10 mm (previously 14 mm).
No other morphologically suspicious lymph nodes.

SKELETON
No bone lesions typical of metastases.

CHEST
Size‑stable, individual, nonspecific round nodules, e.g.:
A perifissural nodule in the middle lobe (7 mm)
A subpleural nodule in the left upper lobe (3 mm)
No infiltrate.
No effusion.

ABDOMEN
No focal liver lesions (as far as can be assessed without contrast).
No adrenal masses.
Uncomplicated diverticulosis.
Pelvic phleboliths.
An accessory left renal vein running behind the vena cava.
Nonspecific small areas of density in the subcutaneous fat of the lower abdominal wall on both sides, most likely post‑injection.

PET MEASUREMENTS (SUVmax) AND PSMA‑RADS
Prostate (left side)
Before (10.09.25): 36.4
Now (07.01.26): 19.4

PSMA‑RADS: 5 (highly likely prostate cancer, but much lower activity now)

Lymph nodes
Location / Before / Now / PSMA‑RADS / Meaning
Right parailiacal / 5.9 / Not detectable / – / Completely resolved
Left parailiacal (external region) / 114.8 / 31.6 / 5 / less active
Left parailiacal (internal region) / 9.8 / 3.5 / 3A / Now borderline/uncertain

Normal tracer uptake
Normal uptake in salivary glands, abdominal organs, nerve ganglia, kidneys, and urinary tract.

SUMMARY OF THE PET/CT
Compared to 09/2025, oncological improvement under ADT:
Decreasing PSMA expression in the primary tumor and left parailiacal lymph node metastases.
The right parailiacal lymph node metastasis is no longer detectable.
No new metastases.

As I said, stay positive be strong.

These results show that the ADT and ARPI drugs are keeping your cancer suppressed which results in metastasis shrinking in size and not spreading any further.

Great news.

Just got back from my Urologist. Had another shot of Degarelix (80mg).
He is pleased with the response of my body to the Degarelix initial shot and now we are down to the straight line: RARP.

Option 1:
Head to a private clinic, in north Germany, about 2 hours flight, where they MAY be able to do SOME nerve sparring. This option involves a $2500 out of pocket for the surgery and care afterwards, plus the costs of the trip. So about $4K out of pocket.
Here I will get RARP with a Da Vinci system. The post-OP treatment (RT and ADT) will however be done in my city at the local hospital urology clinic.

Option 2:
Get the RARP at the local hospital. Also with a Da Vinci system. Here they will not attempt to do a nerve-sparring procedure. The procedure will be covered by my insurance and I am about 15 minutes drive from home. The hospital stay is expected to be 3-4 days. Post-OP treatment (RT and ADT) will also be done here.

Some food for thought over the weekend and then it is decision time.

To all a good weekend.

Be positive and stay strong.

@dinu
It’s really too bad you’ve had to come out of Pocket for the PET scan and now considering it for the surgery.

There is a big difference between nerve sparing, and non-nerve sparing. You will probably never get an erection again, on your own, if you don’t get the nerves spared. You could get an implant put in, which will give you an erection and works quite well people say. The other option is using Injections of bimix or Trimix, Which work for almost everyone, but would be no fun for somebody as young as you to have to do it for so long. The thing is, you are pretty young. I would imagine that getting an erection for the rest of your life, or for at least the next 15 or 20 years would be very important. You could check out the cost of getting the implant that would resolve the problem and then you can get a cheaper surgery. The implant is covered by insurance here in the USA.

@dinu

Congratulations on the results thus far.

Appreciating that economics are large factor in any decision, I can only offer that in terms of prostatectomy surgical expertise, there is no real comparison between the surgical team at Martini Klinik and Heidelberg, and I intend this comment to be respectful to the expertise at Heidelberg which is comparable to any center of excellence in the US.

Why do I believe this?

First the statistics. Across and average of 2900 patients that receive prostatectomies at Martini Klinik every year, including patients with all Gleason levels and ages greater than 75 years old, their average for full continence is 90.3% within 12 months and this statistic is only below 95% because they treat some of the most challenging surgical cases worldwide, their post op potency rate is 81.0% within 18 months and this is only lower due to many older patients they treat. My experience with patients that have been treated at Martini Klinik, including a recent 76 year old, is they were fully continent immediately and regained full potency with 9 months ( the recent 76 year old amazingly was full continent and potent immediately). Obviously not all patients have these results.

No many surgeons will show these statistics. The top three surgeons speak at the major US conferences on their latest surgical techniques to improve continence and potency. The top surgeon is considered to be the world expert on the single “arm” DaVinci, which has been demonstrated to significantly reduce recovery time.

Many of the techniques they use are challenging for a surgeon, unless you have the skill and the learning cycles they demand of their team and this is the reason that many of the top prostatectomy surgeons in the US have visited the Martini Klinik.

For those that choose surgery, I always recommend to get the best surgeon that can show their patients post op statistics on continence and potency. While Martini Klinik is recognized worldwide for their expertise, measurement processes, and openness with patients, you can also find surgeons in the US, Asia, and Europe who have the expertise and results, but not most.

Because of some of the European based PCa support forums in which I also participate, I may have more exposure to patients that have been treated at Martini Klinik and others centers within Europe, but the Mayo Connect forum also includes some patients that have been treated at Martini Klinik. As well as at least one that have been treated at Heidelberg.

My personal experience with some surgeons within Europe is that they attempt to understate the expertise at Martini Klinik as being “a factory.” After having toured Martini Klinik a few times, participated in many conferences that included their surgeons, and communicated with many, many patients across the world who were treated at Martini Klinik, my response to these surgeons is always that if Martini Klinik is a factory, my opinion is that it is the most finely tuned, innovative, and technology leading factory in the world:-)

Lastly, as well as I view Martini Klinik for prostatectomies, my opinion is that there are better European and Germnay centers for radiation therapies and I believe there are better centers for GU oncology expertise, which includes Heidelberg.

@dinu Sorry to ask this. Do you use private insurance or statutory insurance? With PSMA scan, you may need to get pre-authorization with statutory insurance. If you use private insurance, be sure to check with them too. Each hospital that offers this PSMA scan seem to have different price. the newest tracer PSMA scan is at Saarland University Hospital in Homburg (near Ramstein). Some of the German patients got their PSMA scan there and discussed about it. My husband got PSMA scan at University Hospital Tuebingen on last Wednesday.

@dinu

For some reason, I missed this message. I wonder what you decided to do.

Good to hear the shot is working. Did your testosterone drop way down?

At your age, the nerve sparing procedure is definitely more desirable.

Was there a problem with the location of the tumors that makes nerve sparing iffy? Is the doctor real experienced in doing nerve Sparing at the option one hospital?

What happened with the surgery?

@prettypass2000
So the first PSMA scan was covered by the German insurance (TK) after the urologist at the Uni Klinik Heidelberg requested it and my local urologist (not the one at the SLK Gesundbrunnen) wrote me an Überweisung. I got the PSMA scan at Uni Klinik Heidelberg as they were able to offer a appointment in a 2 week window versus the SLK in Heilbronn, where i had to wait 1.5 months for the next open spot.
The second PSMA scan I did again at Uni Klink Heidelberg. This time it was not covered by the insurance, and both Heilbronn and Heidelberg had the same cost (1600 Euros). I chose Heidelberg since they already had the data from my previous scan and they were able to include in the report a comparison between the first and second scan. Also, Heidelberg was able to give me the appointment a lot faster.
For this one I paid out of pocket. Since I am a Vet and the cancer is service related to my time in the Navy, I will be reimbursed by VA.
If I may ask, is your husband associated with the military? Is he a Vet as well?

@jeffmarc
Hi Jeff, the testosterone is at 0.49nmol/l.
I am going for the RARP, with nerve-sparing at Martini Klinik in Hamburg. I have a pre-surgery consultation this coming Friday and after that i will schedule my surgery depending on their available slots.
I am not sure if the location was an issue or if the other surgeons that spoke with did not want to bother/risk not taking everything out.
The Martini-Klinik has a procedure where they freeze the nerves once they take the prostate out, they the do a live biopsy/slicing of the prostate and decide on the spot if the prostate tissue that was in contact with the nerves was affected by the cancer cells or not and if they need to cut the nerves as well and how much.
So the surgery will probably be around March-April time frame.