Radical Prostatectomy vs. Radiation therapy?

You can work through radiation treatment much easier than working through surgery and its recovery time. In your case, one issue that makes radiation a bit tougher is that with your high 0.96 Decipher your doctor would likely recommend ADT and that makes you tired from time to time. I chose radiation with a 3+4 case and 0.81 Decipher and am very glad I did. See my bio for more info.

@wwsmith One of the precautions we worked with during radiation treatments - though this rarely is as much a problem with proton as it is with photon - is that of avoiding hitting the penile bulb with radiation.

Data show that late ED may be avoided by minimizing radiation hitting the penile bulb —> https://www.icr.ac.uk/about-us/icr-news/detail/avoiding-penile-bulb-with-radiotherapy-could-save-men-with-prostate-cancer-from-harmful-side-effects

@wwsmith
Erectile dysfunction (ED) is a common, often delayed side effect of IMRT for prostate cancer, with studies suggesting that 30% to 60% of men may experience some degree of erection problems within two to five years after treatment. Unlike surgery, radiation causes gradual vascular and nerve damage over time.
Johns Hopkins Medicine

Yes, I have seen reports like that before but fortunately, I haven't seen much actual complaints like that from RT guys on the forums. That is in contrast to the large number of guys we see complaining about ED and sexual function after an RP.

@wwsmith Agree- there’s no question in my mind that surgery can be devastating to your sex life; I am a walking example of it.
However, all surgeries are not the same, right? In my case I had an extensive amount of G4+3 which spread so far laterally that it caused a ‘tiny’ (Haha!) break in the capsule.
So of course I am impotent - I told the surgeon to cut until it was gone and not worry about my future as a pornstar.
But not all men have cancer that extensive and many - probably not on this forum - do recover fully.
It’s the old saying that ‘we’re all different’…so much so that I sometimes wonder how any of us can offer advice to a newbie since we really have no idea how they’ll react to anything we ‘recommend’. It’s such a damn crapshoot!!
Phil

There are a lot of highly informed and knowledgeable participants on this site that helped me sort through the options. Heavy Phil and Jeff Marci (who must be a doc in his former life) and others were very helpful. Watch their posts. At your age... find what works for you and get treated. Long race ahead. Putting things off is never a good idea especially with health issues.

My circumstances are very similar. Age 64 - 6 lesions (4 = gleason 6 / 2 = gleason 7 with cribriform). Decipher = .72. My oncologist / surgeon is Joseph Wagner - 4k successful surgeries -- high demand surgeon from around the country and beyond, he was a very early adapter to minimally invasive surgery, HHC Tallwood affiliated with MSK. He advised: SBRT/Surgery were 'equipoise'. I opted for SBRT RE: faster recover, lower odds of incontinence and best shot at lower intimacy issues. David Byun, radiologist (Weil/MSK) did the SBRT and I was on 120 days of orgovyx. The radiation side effects were tolerable, the orgovyx as well. Both had side effects that were manageable (urgency, low libido, some mild discomfort voiding, hot flashes, fatigue). Fatigue was the biggest side effect and exercise was the cure. Cribriform was frankly my biggest concern combined with a high decipher. Joseph Wagner is a superstar renowned surgeon and he was very candid. Cribriform is 'tough' and neither treatment is a guarantee. He leaned in on the radiation as we talked and explained how effective and quickly advancing the treatment has become. He explained that there are fast evolving and better options if recurrence comes along with radiation (and salvage if deemed necessary), lower side effects (even vs nerve sparing surgery which would be the plan), and highly precise applications.

The treatment was 100% tolerable and my psa is now undetectable. I feel fine (all done as December (SBRT) and orgovyx (ended ~30 days ago). Exercise, exercise, exercise - good for the treatment, good for the voices in your head. I left the work force upon diagnosis at age 61 (all gleason 6 - 4 tumors then). Work was very important - I travelled continually managing things for large publishers across North America and Europe - a great gig. But life is a different four letter word than work. It was a tough choice and a great decision. I was stunned by my diagnosis and nearly as much so as how quickly I adapted to 'retirement'. Life first... We planned to hang it up at 63 so things were in order... But the cancer diagnosis was not in 'the plan'. Good luck with your treatment - you work(ed) hard, you will find the way forward.

@heavyphil
Indeed. We don't know what we don't know. 'We're all different' really hits the mark... one applicable treatment for the same set of circumstances, or very similar, I don't think exists. Lots of similarities and a bare few exactly the same. I suspect you are right that many of the men with lower grade circumstances are not on this forum. I wasn't on here until my gleason 6's showed up as 7's with cribriform. (What the hell is cribriform? ....and I found you guys). Great posts Phil... you and Jeff Marci among others - really helpful.

@wwsmith "You can work through radiation treatment much easier than working through surgery and its recovery time."

What recovery time?

Maybe that's true of conventional prostatectomy, but I don't understand that statement when a robot-assisted laparoscopic surgery is done by an experienced surgeon. I walked out of the hospital the next as though nothing had happened & resumed normal activities immediately. There was no pain or incontinence.

I don't think that is at all unusual.

And, one overnight visit to a hospital is a lot more convenient than 20-40 radiation visits.

@readandlearn After reading many others' experience on recovery from RALP I have never heard of anyone being fully continent the day after surgery. Also, I am sure that you had weight limits imposed for awhile on what you could lift. No doubt, there is probably a lot of variation on side effects after RALP surgery, but just reading through many case examples on this forum shows lots more side effects after RALP than what you say that you experienced.

@wwsmith
I agree and both my surgeon / oncologist, Joseph Wagner, and radiologist, David Byan advised the same - faster recover with radiation. This was confirmed by 4 physicians providing second opinions - surgeons and radiologists at Yale Smilow and MSK confirmed the same. The surgery is definitely safe and routine. The risk of incontinence and intimacy issues is present in both treatments. SBRT was 5 sessions for me. Mild side effects. I have cribriform and each doctor confirmed that both treatments were equal.