Had Radical Prostatectomy last week: What are next steps?

There are two possibilities...adjuvant or salvage radiation therapy (ART or SRT)...

SRT - You could actively monitor your PSA every three months and see your urologist during the first year which is standard of care. If you use a standard PSA test, one that only measures to a single decimal point then the definition of BCR is when your PSA becomes detectable with a reading of .2 tor higher then a subsequent reading of .3 or higher, usually 90 days apart. If you use an ultrasensitive PSA tests which measure to two to three decimals, well there is no general agreement on what constitutes BCR. Either way, if your PSA becomes detectable and based on you and your medical team's criteria for any decision to treat, for example, when PSA hits .3 or higher, you have another decision to make, do you image, with what and at what PSA. The dilemma is the higher your PSA, the greater the probability of locating the recurrence but the higher your PSA the greater the chances are that treatment for BCR may not "cure" you. Most treatment decisions for SRT after BCR are doublet or triplet therapy, ADT for a specific period combined with radiation. some advocate triplet therapy by either adding a 2nd ADT agent or chemotherapy. If you elect to radiate the prostate bed I would strongly consider imaging to locate any recurrence and including the PLNs in the radiation treatment plans.

ART - Your other choice is to with that margin result in the pathology report is you and your medical team decide there is likely micro-metastatic disease outside the prostate and do adjuvant radiation therapy. In that scenario, it's a pre-emptive strike and imaging is not likely in play since you're treating at very low PSA levels. Still, doublet or triplet therapy is in play as are the PLNs in the radiation treatment plan.

Discuss with your medical team, wait until we have further clinical data and if necessary, do SRT, or assume there is micro-metastatic disease that has spread outside the prostate and do adjuvant radiation therapy.

While you don't want to "over treat," neither do you want to "under treat" when your disease is low burden and may be vulnerable to combination therapy which can provide a cure or durable and long term remissions.

Here's my clinical history. After surgery failed I did SRT. At the time, the SOC was radiation treatment to the prostate bed only. There was data emerging (some from Mayo) that indicated more often than not the failure of SRT was a result of not including the PLNs in the treatment plan where there was micro-metastatic disease. When I talked with my radiologist about adding six months of ADT and including the PLNs, she dismissed it saying there was not "long term data...!" 90 days after completing SRT to the prostate bed only, my PSA was still climbing with the result of still having to do ADT, chemotherapy and radiation to the PLNs. Last time I let my medical team talk me out of a treatment decision! To be fair to my radiologist, she admitted that she had been wrong and with subsequent patients of hers, she talked to them about do doublet or triplet therapy.

Now, eleven days post-RALP, and with the catheter out almost three days, I find myself fully continent, perhaps due to the Kegel PT prior to surgery. I begin more PT next week. My lab work came back completely negative, and I was placed on Cialis, 20 mg daily, to promote circulation and healing. The Cialis dose was halved as it caused my BP to plummet, making walking very difficult and driving impossible. Life is Grand!

That's great to hear Max. Congrats. I begin PT for pelvic muscles next week. 95% to full continence, still a little leakage at times. I'm glad the RALP is behind us, but if anyone is considering the surgery the recovery is not bad. Just research a surgeon who has done a lot of these. My Dr averages 3/ week for 17 years.

I’m following this discussion with great interest.

70 yo, PSA doubled in 6 months from 3.5 to 7.0 in June 2022. Diagnosed in August 2022 after biopsy showed Gleason score of 4+3. MRI with contrast showed cancer was contained in the prostate, so I opted for RALP as first treatment step - which was performed on January 10 of this week.

The surgeon told my wife he was very pleased with the surgical results, which of course sounds great at this point. Catheter comes out on the 18th. I believe 4 nodes were removed, and I should have the biopsy results from those tissues next week.

I tolerated the surgery well, and now, 4 days post-op, I’m happy with the decision to go for the DaVinci RALP. So far, life is good.

Jim

Glad to hear surgery went well. Next step is catheter removal which is no big deal. After that relax and heal up. My urologist wrote a script for me to have post surgery Physical Therapy with regards to strengthening abdominal muscles. The therapist just shows you how to do Kegel exercises properly. However, you have to wait to start this until 7 weeks after surgery. I'm 60 years old and had surgery Aug 4 2022. No issues at all with incontinence. I've had 2 clear follow on PSA tests to date. Your first PSA test will be 8 weeks after surgery most likely. Relax in the fact that the tumor has been removed and you can concentrate on healing. I had to have a follow on Abdominal MRI as I had a lesion on my liver. This turned out to be a cyst or angioma of some type. No sign of cancer. These are quite common and are found incidentally when initially having MRIs performed before surgery is approved.

Perry Christopher - I appreciate your comments very much. My surgeon is a man of few words, so it’s good to hear what probably lies ahead for me from someone who’s just ahead of me. I’m looking forward to the next step !

Hi, glad your surgery went well. I had RALP a year ago. My surgery went well. However, my biopsy results showed cancer in one lymph node. I got my catheter removed one week after my surgery. I started immediately walking everyday for physical therapy. I was totally incontinent for six weeks. I watched some YouTube videos on Kegels. It took quite some the before I was continent, but it did happen! Good luck with your recover. Jerry

Jerry - thanks for your comments, and congratulations on regaining continence.

The catheter comes out on January 18, the 8th day after surgery. I’ll find out shortly what my continence experience will be. I’ve been active bicycling, walking and practicing gentle yoga for several years. Many of the yoga floor poses are similar to Kegel exercises, so I’m hoping for the best.
Jim

Hope things work out for you. I got my catheter out after my procedure...I am working on getting my bladder back to normal (?), Seems I have to urinate about every 45 minutes, hoping this is not the case for you. Annoying, but at least I have the sensation of when I need to urinate.

Thank you ! Sounds like you’re on the path to recovery - I hope you continue to make progress.
Jim