Deciding: Surgery vs. Radiotherapy 64yr old Gleason 3+4

I am very happy with my surgical results. You can see my posts under my profile. I recommend that within your decision making regarding surgery that you see that not all Robotic Assisted Laparoscopic Prostatectomy (RALP)’s are the same. It seems all discussions are just RALP and no difference’s in the procedure are discussed but their are significant differences in the procedure. Please research the cutting (RALP) of the Puboprostatic ligament to the bladder and the non cutting (RS-RALP) of the ligament. There is a newer surgical technique known as Retzius Sparing (RS) - RALP. The studies reviewing RS-RALP have shown results regarding improved continence and less ED.

Data comparing surgery vs radiation for localized prostate cancer indicate success rates to be statistically equivalent: (https://www.nejm.org/doi/full/10.1056/NEJMoa2214122).

It all comes down to side-effects and quality-of-life desired (or as that paper concludes, “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”).

At 65y, diagnosed with 7(3+4), both successful treatment and quality-of-life were of equal priority to me (and I wanted more options if I had a recurrence) so, I chose to have 28 fractions of proton radiation. (As it turned out, a second opinion on the biopsy upgraded the Gleason to 7(4+3). Accommodating that change simply required adding 6 months of ADT. That was 5+ years ago. Today, it’s ad if nothing ever happened.)

You have to decide about your own priorities and come to a treatment decision that is right for you.

What percent was "4"? How many 3+4 cores? Any notes on aggressive features such as large Cribriform? What is your PSA and how fast is it doubling? Did you have a Decipher or other test to estimate how aggressive the cancer is? If in USA what does your insurance cover? Will you get better coverage (if you want Proton) from Medicare in a few months? If sexually active it will never be the same after treatment with either RP or RT.

I was presented with the similar treatments for my PCa - originally scored as 3+5, intermediate unfavorable. I had the options of surgery (standard RALP, because I wasn’t a good candidate for RS-RALP), or hormone-and-radiation therapy. 59 when I was diagnosed and had surgery, 60 now.

I chose surgery (partial nerve-sparing) based on what I saw as far fewer major side effects and the length of treatment - surgery, they pluck it out and then I was on my way to recovery, but the other treatment plan was 3-1/2 years, and then the ongoing recovery from that. As the outcomes were statistically the same, I went with the surgery, and had that done in January.

Do I like the side effects (incontinence and ED)? No, but I sure do like that the treatment is over, and now all I focus on is recovery, which at this point consists of pelvic floor exercises twice a day and avoiding all bladder irritants (caffeine, alcohol, spicy foods), and penile rehab (daily low-dose Viagra, daily vacuum erection device session, and a weekly full-dose Viagra and attempt to achieve an erection, just to gauge progress).

My incontinence is much improved (I’m on track to have an entire week of daily leaks of <100ml, that’ll be a first), and I’m occasionally feeling little indications of signs of life with my erections, but nothing even close for penetration. That can take years, though, to recover (if it does recover).

BTW, after surgery, pathology downgraded my cancer to a 3+4, intermediate favorable, though they did find cribiform glands, and technically, the cancer had begun to escape the cap, but it doesn’t appear to have spread so far. All the tissue and bits and pieces they took out of me came back negative, and I’ve had two clean PSA checks since then.

Good luck with your decision.

It sounds like TurtBean was informed by his surgeon that his surgery was going to be partial nerve sparing in advance or learned after surgery that the surgeon was only able to do partial. Many patients are not advised up front other than that their surgeon does nerve sparing.

Regarding nerve sparing, definitely be aware that may or may not be possible depending on the severity of your cancer spread and the cancer being out of the capsule. There are two nerve bundles, one on each side. Again depending on circumstances a skilled surgeon can avoid and save the bundles 100% or sometimes 50% or more. He might save both sides 100%, one side 100%, one side 50%, one side 100%, one side 0%, 50% each side, none at all. This is all depending. What is important is just because you hear the Surgeon say “I will do nerve sparing”, you need to ask to what extent or percent he expects to save of the bundles from his review of your MRI and biopsies. He generally has an idea based on the MRI and biopsy. Don’t just believe by his statement regarding the surgery you are in the clear and then be terribly disappointed afterwards with the results. It is better to know upfront what can be possibly saved. This depends if the tumor is deep in prostate or was on just one side or tumors on each side. The point is that there are limits due to the extent of your cancer in what surgeon’s are able to do regarding this and be prepared regarding nerve sparing and your expectations when you hear they will do nerve sparing. Some patients hear nerve sparing and just believe that keeps them from ED issues.

I was also a 3+4. I had my biopsy 16 years ago and they Had two options, radiation or surgery. My father had radiation and died of prostate cancer so I picked surgery. Back then, they didn’t have nerve sparing. After surgery, it turned out my Gleeson score was really 4+3. It is not uncommon for them to find this since the biopsy only gets about 1% of the prostate. I have run into people that were 3+4, that end up being 4+5 after surgery. If you have radiation, you never know. In my case, they kept the catheter in for two weeks and when they took it out, I was completely continent. I did have ED however.

Nowadays, they have much better options like Retzius sparing surgery with nerve sparing, Where you can almost definitely be continent and not have ED. One thing they don’t mention about radiation is that after a while most of the people that had radiation lose the ability to get an erection because they burned up the nerves. They don’t spare them during radiation.

@wheel1 Wrote a lot about this in his original message. Here’s a link to it so you have an idea what the new types of surgery can do for you. There’s a whole series of conversations following this link
https://connect.mayoclinic.org/discussion/newer-surgery-technique/

tmla, there is a five fraction (treatment) sbrt that you might check out before you decide. https://pmc.ncbi.nlm.nih.gov/articles/PMC4740633/

@tm1a
I had 3+4 with a 10.2 psa. I had 5 treatments with a real time, built in MRI guided radiation machine called the Mridian but the Elekta Unity is similar. I had spaceoar put in 2 weeks or so before the treatment and was done in February of 2023. I was happy with the results. So far so good as PSA has stayed down and quality of life has been good.

As for advice, there’s plenty; we each have our own particular story to tell, what we’ve learned, did and wished we’d never done.
YOU have a lot of homework to do specific to your own case and needs; and importantly, what side effects are MOST important to you, because you’re having them no matter what treatment you choose.
Rarely does a man come away completely unscathed, but it does sometimes happen.
To me, the single most important thing was to be able to treat it again if it came back; but my cancer -high volume Gleason 4+3 -was much worse than yours, so maybe this is not an issue for you.
Just know that there are NO definitive answers out there, even from the Drs…a lot of possible, maybe, perhaps and we’ll see.
Do what you are most comfortable with and what makes the most sense - to YOU. Best,
Phil

@wheel1 mentioned nerve-sparing. Here’s how that happened for me:

Day of surgery, probably 15 minutes before I was wheeled down, the attending surgeon came in to do the usual pep talk surgeons do.

Then he popped out with, “Ok, you have a decision to make. We think your cancer has escaped the cap, on the left side. Characteristics of your cancer tell us there’s a 70% chance your nerves on that side are positive. We can take them out when we remove your prostate, or we can leave them. If we take them out, that will likely affect your ability to have an erection, but you’ll still have your nerves on the right side. If we leave them and they’re found to be cancerous later, we’ll have to treat that at that time.”

Since my biopsy and PET scan had been done months earlier, I wasn’t sure why I was hearing about it 15 minutes before surgery, but the truth is, that wouldn’t have changed my decision at all, so it was a wash, really, and probably saved me a few months of thinking about it.

Like with my decision with surgery, my answer was almost immediate: I looked at my wife, she looked at me, we both looked at the doc, and in unison said, “Take ‘em out!”

Good news was that after being sent to the lab, they came back negative, but it wasn’t like he could put them back at that point. 😉