Info is in, now decision time. Thoughts welcome.

I’ll add my experience - I have a sort of similar profile: 59, three lesions (3+3, 3+4, 3+5, so treatment tailored to that last one), but no metastasis detected, no cribiform.

I was given two options - surgery or hormones/radiation, and immediately (like, within seconds) chose surgery, though my oncologist did make me go home and think about it, but it was surgery all the way for me. I didn’t care for the long list of definite, probable, and possible side effects associated with the hormone/radiation route, nor the amount of time it would have taken (3-1/2 years!).

My surgery was done at a centers of excellence cancer center and was partial nerve-sparing (the nerves on my left side were removed, along with some lymph nodes). Pathology revealed no cancer in either, and no positive margins, and my tumor was classed as pT3a N0.

My care team was very clear with me on the side effects and did discuss them with me, especially the “Big 3” - incontinence, ED, and dry orgasms.

It’s been four months and just a few days since my surgery. ED, check. Incontinence, check.

Incontinence is by far the bigger concern for me right now. Out of the gate, it was a constant bladder-emptying experience - sometimes a drip, sometimes a gentle stream, sometimes a raging river.

That has lessened, I use the bathroom the traditional way several times a day now, I don’t have those flood-like releases in my pants any more…but I still leak quite a bit. I don’t leak much overnight anymore, and where I was getting up 5-6 times a night after surgery to empty my bladder, now it’s 2-3 times. I’m also working with a pelvic floor physical therapist to help with that. I’m hoping for more improvement over time.

ED…I was getting phantom erections right after surgery, and nowadays, I do occasionally get very slight stiffening - hard to quantify, but not much, like maybe anywhere from 5-25% of an erection. That’s just sitting around on its own, without me trying.

I do use a pump every day (5 “erections” over 15 minutes) and take low-dose Viagra. Both are just to keep the blood flowing and to keep the penis healthy during recovery.

While I’ve been cleared to take more Viagra or use a tension ring with the pump and attempt sex, both my wife and I prefer to get a better handle on the incontinence before we attempt that.

However…even with a limp fellow down there, it is possible to masturbate, and some experts say that can serve a purpose to sort of “remind” my remaining nerves what they’re there for. It can take a while to achieve orgasm, just because it’s a little more difficult to stimulate the sensitive tip, so it takes longer, and be warned…that first dry orgasm, for me anyway, was very strange. The feeling was more or less the same, but it sort of messes with one’s brain when there’s that feeling of release…but there’s no accompanying ejaculation.

Also, I may be one of the fortunate few, but I lost no penile length at all. My testicles, however, seem to hang a lot lower! 🤷‍♂️

If the decision is surgery, I’d say start doing those kegels now, following the advice of your care team. Go ahead and do the advance work of tracking down a pelvic floor physical therapist, so you have that at the ready, should you need it. Those folks are few and far between and their schedules can fill up fast.

If I had it to do over again, I’d make the same decision regarding treatment. While the incontinence is annoying and the ED isn’t the happiest thing to deal with, I still feel that it was a better choice for me than the hormones and radiation.

Good luck going forward. There’s absolutely life after treatment!

I choose surgery and I was 64, 70 now best decision I made is to get that out of my body. My numbers have 0.00 ever since. The Doctor jokingly told me I would of something else. Good luck in the future.

Only had one thought as I read your OP. Take the time you need to learn as much as you possibly can about PCa BEFORE you make your decision. There is a lot of, "I wish my doctor told me that." Thing is all that stuff is available with minimal research. Taking the time to learn will make you feel much better about your decision. The added benefit is that it teaches you what questions to ask when your Dr. says something (or doesn't say something). Best wishes!

I had surgery 5 weeks ago today. The pathology report did not differ from the biopsy:
Gleason 4+3, PIRAD 4 on the MRI, no ECE, negative margins, negative lymph nodes (11), vesicles, etc. The surgery was nerve-sparing on one side, partial on the other. I have been completely dry since removal of the catheter. I consider myself lucky, but there was work involved.
The things that made a big difference:
1) Do yourself a favor and buy the book "Guide to Surviving Prostate Cancer," by Patrick Walsh and Edward Schaeffer. It has become my bible, before and after surgery. Tons of info and resources. It helped me make my decisions, and every decision is personal. Schaeffer has a bunch of great videos on YouTube.
2) That book suggests a high-volume, preferably academic/research hospital and a surgeon who does this exclusively. I drove over 2 hours to have mine at UW Medicine in Seattle. Totally worth it in every way. Find a good surgeon at a good facility and the book will help with that.
3) My surgeon ordered pelvic floor prehab so I was doing various exercises religiously for 2 months leading up to surgery. It made a huge difference. I start rehab tomorrow for sexual function, which to be honest I haven't given much thought to yet, focusing on healing. I cannot tolerate even very low doses of the ED meds (migraine) so medical-grade vacuum erection device (a penis pump, but not the cheap, sex toy type) is going to be on order. This is good for ED and also for tissue repair, scarring, and shrinkage.
4) I was proactive about anesthesia. I requested and received TIVA (total intravenous anesthesia - propofol) rather than any kind of gas, and also requested a scopolamine patch. Woke up feeling not in the least nauseated so that was all great! They did use morphine and fentanyl during surgery so I was a little loopy and out of it for a little while, but felt pretty great! Was drinking and eating (vegetarian) in short order.
5) Since I was long distance, they kept me overnight in the hospital. Lots of patients go home the same day and I can't see how! The overnight was so helpful with nurses, heparin to prevent blood clots, pain IV, walks around the ward, etc.

These were the big ones. I have had no complications at all. No infection, no blood clotting, took no pain meds other than Tylenol rarely. The worst part of recovery was probably the week after the catheter came out (which was also nothing to fear or worry about) and getting the plumbing working again. It was painful for a bit, felt like a UTI and I was up every half hour at night that week so had to regulate sleep throughout the day. I am retired (70 years old) and live alone so I have the luxury of quiet and not needing to be anywhere or do anything. My kids checked in on me. Allowing yourself a good recovery and taking it easy for a few weeks is the best gift you can give yourself.

I am happy with my decision. My first PSA test was today, again, at 5 weeks, and it came back at .19. That worries me a little but the doctor tells me it's on track at 5 weeks, that it takes a while for PSA to flush out (American Cancer Society and others recommend 6-8 weeks for the first test) and I will have the next test in 7 weeks. Fingers crossed! I may have forgotten important things, and if anything comes to mind I will add to this. I hope it helps. I am happy to answer any questions too, if any. Thanks to you all for sharing and may things go your way.

Hi,
I would go with the one incision newer surgery which lessens the amount of ED and urine leakage and nerve damage. Find the best surgeon+best facilities=the best results, even if you have to travel a distance. I feel a good process like heavy phil said, surgery first, radiation second + ADT if needed.
Dave 3+4

RARP Oct 25. Family history was the influencing factor. PCa got my father and grandfather, so it wasn't a hard decision at the time. Eight months out, have resumed all normal activities... save for sex. At 64 and in otherwise excellent health, I downplayed the potential trauma of incontinence and ED. The incontinence has been manageable. Decent control, but still leak and dribble some with physical exertion, and alcohol to excess results in what can best be described as seeping. ED is the depressing part. Post op erections were fine, but no orgasm. I grossly underestimated the psychological effect. Everybody is different, and my advice is to thoroughly evaluate the value of ejaculation. I'm hoping in 10 years we'll look back and laugh about it. Currently, experimenting with meds (cialis, viagra, gabergoline, etc) is search of the magic potion.

@jnlracer18
Hi in october 2025 What is been psa before pet?

I pretty much agree with your own assessment. I'm 67, had a 3+4 and a 3+3, contained, and a high decipher score. I opted for removal. Got nerve sparing RALP, and now, 3.5 months out, I'm mostly continent(one light pad a day-often no leaks for the entire day), and my erections are approaching 50% of what they were. Overall, I'm happy with my decision as the cancer is out.
Best of luck on your journey.

I was 65y/o when I had that decision to make in 2020 - PSA 7.976, PIRADS 5, localized, Gleason 7(4+3).

My urologist (a surgeon) recommended prostatectomy; I also looked into SBRT (Cyberknife & TruBeam), brachytherapy (LDR & HDR), as well as IMRT (photon) and proton. Each specialist indicated that their protocols would successfully treat my disease. I chose proton.

Urologist could not give me any level of confidence of after-effects. His comment was “50/50 chance; We’ll know for sure once we get in there.” That wasn’t good enough for me.

For localized prostate cancer, data show that recurrence rates are statistically equivalent. The treatment decision comes down to side/after-effects you’re willing to deal with.

Regarding Hormone therapy - it isn’t a big deal - if you engage in a robust resistance-training exercise

With radiation, you’ll have few side/after-effects if they don’t overshoot the prostate and hit nearby otherwise healthy organs and tissues and you take precautions. What radiation doesn’t hit, it doesn’t hurt.

When you say that “…radiation is off the table or more complicated because I already had it.” - what do you mean?

There are other biomarker tests you can get to help you determine if something more serious is lurking unseen. (For what other disease, illness, or injury do we amputate first, and then figure out later if we actually should have?)