Choosing a simple RALP vs. a radical RALP vs. a compromise RALP?

These sound like questions you need to ask your doctor. This would be decided on a case by case basis.

@jeffmarc Understood, but urologist time is precious (and 3 hours away), and so I need to limit my discussions with him to only those ideas that haven't already been shot down here or through my research.
Don't you have a severe doctor shortage where you live?

@jercalif
I contact my oncologist With email and over the phone. Same with my urologist though I have not had to contact him often . Where I live, there are a lot of doctors since it’s a major city, But after eight years of the same oncologist, we’ve never met in person, even though she’s about 3 miles away. Every three months I have a video or telephone call with her. No need to meet in person for any kind of question.

Email your question to the doctor and see what they have to say. A close look at your specific medical records is really needed to answer this.

That’s a doctor-question, with each option you mentioned having to be very well-defined within its own context as to its ability to treat the disease while still maintaining the quality-of-life desired. Then score each option against each other and see which ranks best.

However (none of this being medical advice):
(1) If it were me, I would first try the less-invasive option of Finasteride, in hopes of shrinking the prostate and resolving/reducing the BPH issues.

That would also be beneficial for radiation treatment because there would be a smaller prostate to treat.

Depending on where the lesions are in your prostate, (based on the FLAME protocol) a boosted radiation dose can be administered where it’s needed, and less where it might not be needed (perhaps near the nerve bundles to further minimize risk of ED?). (My oldest brother recently had 28 IMRT sessions using the FLAME protocol, where at each session, three different Grays of radiation were administered, more Grays to areas of concern and less to other areas, thereby minimizing risks near areas of less concern.)

Also, if using radiation, caution should be taken to avoid radiation to the penile bulb, in order to avoid late ED issues.

(2) If it were me, I would be cautious about thinking that RALP “permanently solves” anything. If that’s what I was thinking, then I would do a bit more research on the possible side/after-effects of the procedure.

For a RALP:
> if sexual function is the priority, then a nerve-sparing procedure is preferred (with as much of both nerve bundles preserved as possible, and with minimal movement of them).
> if incontinence Is the priority, then a retzius-sparing procedure is preferred.

I would follow @jeffmarc lead with a telehealth but I would definitely do one at a center of excellence for a second opinion. The decisions you make now are too important to be restricted by the time limitations imposed by any one doctor or any one institution.

@brianjarvis Your advice sounds solid for most patients, but perhaps not for me, because, unlike most patients, my SOLE goal is avoidance of pain... I should have explained that earlier. It's like two people walking into a casino with two completely different goals...one wants to enjoy a little minor gambling and maybe win something or maybe not, the other needs $1 million to pay off the mafia loan sharks that are going to kill him, and so it makes sense for him to gamble away every penny he has, if necessary (and if he loses, then there is always suicide as an option).
Since my sole goal is avoidance of pain at all costs, I'm willing to gamble away everything that I have in an attempt to keep my pain to a minimum (and if I lose, then there is always suicide as an option).
You don't have to read the following unless you want to (obviously), but it explains how/why my thinking is going to be different from most patients:

Radical RALP + suprapubic catheter is not a panacea, but...since my SOLE goal is minimal PAIN...that means:

1.) Minimal # of biopsies w/o general anesthesia,
and
2.) Minimal # of urethral insertions w/o general anesthesia,
and
3.) Minimal chance of urinary retention.

...and it seems to me as if a radical RALP + suprapubic catheter would minimize all of the above, while simultaneously also solving my current severely enlarged prostate problem AND any well-contained current or future prostate cancer problem.
And even if I currently have prostate cancer that is NOT well contained, why wouldn't I STILL want the radical RALP + suprapubic catheter?
And even if I currently have NO prostate cancer, why wouldn't I STILL want at LEAST a SIMPLE RALP + suprapubic catheter?...although I would argue that, given my sole priority of minimal pain, a RADICAL RALP + suprapubic catheter still would make the most sense, because a biopsy can miss existing cancer, my prostate is prone to developing cancer in the future because my father had prostate cancer, and because of those two factors not removing my entire prostate now means that I likely will need repeated biopsies over the years and also likely need a 2nd RALP (radical, at that point) surgery in the future (doubling my chances of surgical complications over a single radical RALP now).

Neither loss of sexual function nor incontinence cause PAIN, and so I am 100% fine living with those problems, in exchange for the pain reduction above.

@bens1 You wrote: "The decisions you make now are too important to be restricted by the time limitations imposed by any one doctor or any one institution."... I agree with you 100% in principle, and if doctors were merely computers in white coats that were programmed to treat all patients equally, then what you are describing would be 100% do-able, but doctors are human, with human biases, egos, and a strong sense of self-preservation and even selfishness, and therefore what you are recommending is subject to those human limitations.
A computer so programmed wouldn't care if a patient sought out a second opinion, or sought out a treatment that the computer was either not competent in or perhaps even aware of, and the computer would not black-ball a patient for these things, either...preventing the patient from seeking help from other computers.
Again, I'm sorry to sound so cynical and negative, but in my experience the above is the rule, and you are extremely lucky if you can find a doctor that is the exception to that rule, such as my primary care provider.

@jercalif I can appreciate pain avoidance. Personally, I hate needles. But, in every instance I weigh the benefits of appropriate diagnosis and management against any potential risk/pain.

But, if my SOLE (and absolute) goal was avoidance of pain... yes, that would certainly limit medical care.

As I heard one doctor explain it, the only pain-free choice is watchful waiting. It’s absolutely pain-free.

If I were absolutely against the pain of a tissue biopsy, then I would request one of these liquid biopsies (some of which involve somewhat painful blood draws):

> FoundationOne®Liquid CDx; Guardant360; Caris Assure.

And there are other liquid biomarker tests:
> (blood): 4KScore; EpiSwitch PSE; Phi Prostate Health Index;
> (urine): SelectMDx; PCa3 (PC Antigen 3); MyProstateScore (MPS), ExoDx.

As for treatment, if your sole goal is to avoid/minimize pain, then the only option is radiation;
> proton
> photon

No needles; no catheter; no anesthesia; no surgery; minimal chance of urinary retention. Depending on how well is it’s done, minimal chance of serious side-effects.

My proton radiation treatments were relatively uneventful. My wife later told me that if she hadn’t known I was undergoing radiation treatments, she wouldn’t have realized it from any change in me.

If you look at the data, RALP does not solve “any well-contained current or future prostate cancer problem.” Recurrence rates of RALP for localized prostate cancer are between 30%-40% (just like with radiation).

If you currently have prostate cancer that is NOT well contained, and you still went with radical RALP + suprapubic catheter, you’d then have to go through radiation + hormone therapy anyway, so why go through both RALP and radiation? Why not just only do radiation and avoid the pain/discomfort of the RALP/catheter procedure?

Since your father had prostate cancer, have you had a genetic (germline) test to see if you’ve inherited any gene mutations related to prostate cancer? If you have not inherited any gene mutations related to prostate cancer, then your father having the disease has no impact on your prostate being prone to developing cancer in the future.

Yes, a biopsy can miss existing cancer, but there are other tests to monitor whether there is something more insidious lurking unseen.

Again, with your sole goal to minimize pain, RALP+catheter should be out of the picture.

As for needing repeated biopsies over the years, I had proton radiation treatment in 2021, and haven’t seen my urologist since. There’s no need for another biopsy. If my PSA ever gives indication of recurrence, then a PSMA PET scan is the next step (& then a treatment decision made from there), never a repeat biopsy.

If there is a confirmed recurrence following initial radiation, choice of treatment would depend on the nature of the recurrence; there are other options (either painless or painful): focal therapy (e.g., cryo), SBRT, brachytherapy, and yes even re-radiation in some cases. I personally know two guys who had their prostate recurrence re-treated with SBRT, because the recurrence was a single spot.
> surgery as salvage treatment is old-school that doesn’t consider modern treatment techniques.

I had 28 sessions of proton radiation + hormone therapy; the treatments caused no loss of sexual function, and no incontinence. The only pain I experienced were from the Eligard injections; these days there are Orgovyx pills to take instead.

If pain-free is the sole goal, radiation is the way to go.

I have saved your message and will be using it throughout this long process... Thank you.
My question was "why not" [RALP + suprapubic catheter], and you substantially answered my question... Thanks.
My reasons for proposing [RALP + suprapubic catheter] for myself were:

1.) I already have a severely enlarged prostate, and so I am basically sitting on a time bomb waiting for urinary retention to occur, and a simple RALP seems/seemed like the least painful quick fix,
and
2.) I just figured that while the surgeon is already in there doing a simple RALP, why not have him/her do a radical RALP instead and "kill two birds with one stone"?

You have to admit that, to a layman, having two input/output ports sounds a lot better than just one input/output port, and also the appeal of "just take the whole damn thing out".
But you answered my question (except without regard to my severely enlarged prostate) and so now I need to dig deeper into everything you spoke about and reevaluate the path of least resistance as far as pain is concerned.

@jercalif
If you want, no pain, then the regular catheter is the solution. I had to have one for two weeks. There was no pain involved at all.. Taking out is nothing.

You’d rather have a hole cut in your stomach to put in a tube, You don’t think there’ll be any pain and some recovery time from that, compared to just having a regular catheter.

Radiation causes the least pain no real recovery time other than maybe some irritation while peeing, I had 8 weeks of IMRT and never had that problem. Actually had absolutely no side effects at all.

You could also do SBRT radiation, Around five sessions really do the job on your prostate.

No catheter involved if you do radiation.