Radical prostatectomy vs external Beam and Seeds for Inter. risk PC

When I look back at myself during that decision-making process, I see someone who wanted to minimize the severity of my situation. Fortunately for me, I got excellent prognostic information from the (second) mpMRI and mpMRI guided transperineal biopsy, in a city far away by a highly qualified practitioner followed by frank advice about my situation and a good referral. That is not always the case.
So my only addition to this discussion is to look as honestly as possible at yourself and listen closely to advice that goes against what you would like to hear. After all, ultimately you want to do what is actually best for your actual situation, not what is theoretically best for what you imagine your situation to be.
Of course, you may be better at telling yourself the truth than I am :-).

For me the critical factor in deciding between surgery and radiation was the higher incidence of bowel dysfunction following radiation. The rate is fairly low and has decreased as techniques have improved, but it is still significantly higher with radiation than with surgery. Of all of the possible side effects, that was the one that I felt would be most compromising to my life style.

I have been quite fortunate in having had only a minor decrease in sexual function, which has been offset by the use of Cialis, and minimal issues with incontinence (I wear an extra light guard during the day in case of the very occasional dribble, and I need a light/medium pad when go out for a 3-6 mile run).

74 yoa here in good shape. Two 8 Gleasons and two 9’s so I graded “high risk.” Consulted with a surgeon and radiologist at Mayo and my local urologist who did the original biopsy. I chose surgery because of my scores and because all three said that if radiology didn’t work, then surgery after it would be very difficult if not impossible. I figured let’s take our best shot and leave as many options on the table as possible if something shows up later. Had MRIs, nuclear bone scan, and PET scan prior to surgery, all of which showed nothing outside of prostate. Surgeon removed 13 lymph nodes, seminal vessels, and vans. All of them were clear as were bladder margins, etc. I’m six weeks out from surgery and slowly regaining continence. I can live with a liner in my briefs better than I can cancer in my body but that’s just my thinking. May not be for everyone. You’ll have to make your own call. Prayers for you and yours as you decide and for peace and full recovery🙏

Donald, at 74 and Gleason 9 CR aggressive I also had RP and then 13 months of ADT and Erleada and my thought process was the same as yours. Now about 22 months after biopsy and surgery, good PSA and testosterone numbers. I think that you and I made the right decision, but only time will tell. I am continent getting my energy and good attitude back, still ED but I can trade a sex life for another 10 years. I hope that we all have good luck, make good decisions, have expert care and have a good long run

Thank you so much for your reply. Lots to consider. Matt

Thank you so much for your reply.
Sounds like you made a good call.
Matt

The level of cancer you have can often make the decision. I went with HDR brachytherapy because if delivered a high degree of radioactivity directly to the site for a short period of time (5-15 minutes). It is a two-visit outpatient procedure. I did not choose the seeds (LDR brachy) because they can move around. I did not choose surgery because of the increased risk of incontinence and ED and the initial downtime. The downside of HDR brachy is that it can cause your prostate to swell a bit and reduce your stream. Both brachy and surgery are the current gold standards. There are some beam options that offer very high success rates (the low 90's, just like surgery and brachy options). The new beam options, such as CyberKnife, apparently only exposes healthy tissue to radiation on the way "in". I'm 70, in good health, and was classed as "unfavorable intermediate". Gleason 3+4. I've been told that the "no surgery after radiation" rule is no longer a thing. I had my brachy in April 2023, so no long-term results. The best advice is to choose your doctor carefully. I had my work done at Mayo Rochester. An amazing place where EVERYONE does their job. You can contact your local Mayo clinic (and probably many others) and have a video chat with a surgeon and a radiology oncologist. There are other great clinics out there. Good luck.

Thanks. How long ago did you have treatment? Can you elaborate on side effects following the procedures? What were your Gleason scores? Much appreciation.

April 18 and 25, 2023. No pain during or after the process. I didn't take any pain medication. There is some tenderness after the procedure, and you won't feel like sliding down a banister or riding a bike for a while. The worst side effect is that the prostate swells a bit and can slow your stream. They put you on tamsulosin (generic Flomax) for a month or so. I stayed on it two months and doubled the dose for three days. That keeps you flowing. I have a slower stream now, especially when I am drinking lots of tea. I seem to do much better with just water. Caffeine is a bladder irritant. I had five cancerous lesions (PI-RADS 3, 4, 5) with mostly 3+4 with a couple 3+3. There is no great choice, only deciding what you are going to live with the rest of your life. I understand that, for most people the side effects can settle down after some time. I still have a slower stream (though not all that annoying) but I don't have to wear pads. With ALL procedures you will lose your prostate, which means no more ejaculate except for a bit of pre-seminal fluid (half-teaspoon) produced by the Cowper's gland. I waited a year before having anything done but my PSA started jumping (5-8-11) and a second MRI showed the big lesion was pushing against the capsule (prostate skin) with the risk of breaking out.

I received SBRT Proton beam therapy.
And one dose of Lupron.
Most noticeable effects were fatigue, some loss of muscle mass, and bowel Irritation. I am 3 months post radiation and bowel issues and fatigue subsiding. I can tell the Lupron is beginning to wear off.
Weigh 5 pounds less than when I began treatment.
Lupron side effects- some fatigue, occasional hot flashes.
Overall recovery has been pretty smooth.
Had gleason 4+3
2 identified spots, PSMA PET Showed no spread outside of Prostate.
Had the option of surgery. Happy with my choice