Deciding: Surgery or Proton Radiation + ADT

I had surgery because my father died of prostate cancer and he had radiation. Turns out I found out 10 years later I have BRCA2 so the surgery choice was the best option since the cancer came back after 3 1/2 years and I had to have salvage radiation and it came back 2 1/half years later, and I had to go on ADT.

Just so you know, the only thing that counts is the 4+3 which is what I’ve had after they did surgery. Proton radiation would be a good choice though, It might take care of everything. The question is was anything else found in your biopsy that is aggressive. It doesn’t have to leave the prostate to be aggressive.

If you get surgery, make sure your doctors try to save the nerves. That can allow you to get an erection later. Ask your doctor ahead of time because they might be able to tell you if they see anything that causes that to be a problem.

Long-term people have the same chance of progression free survival whether they had surgery or radiation. Radiation can allow you to have an erection right after radiation in most cases, But occasionally, it doesn’t work.

If your post your biopsy results, we can tell you more about whether or not surgery or radiation makes more sense.

Thanks, Jeff for the extremely helpful info. As a follow-up, what is your impression of the likelihood of long term, on-going urinary incontinence with surgery?

@daveslp
The likelihood of long-term urinary Incontinence after surgery is pretty low, 6-8% have long term moderate to severe incontinence. For myself, I had no real incontinence problems after surgery. Not leaking at all.

The bigger problem is if you have to have salvage radiation after surgery. That causes the urethra to harden And in my case and many other cases I know of, that can lead to long-term incontinence, but not immediately. In my case, incontinence started about five years after radiation and has gotten progressively worse over the last six years. Bad enough that I’m considering getting an AUS.

After surgery, most people Have the incontinence issues resolve within a year.

It's a tough decision. I was 70 last year when I was diagnosed with 3+4=7 grade 2. I'm not a medical professional and I certainly have no idea which treatment would be best for you. That said, here's my story: The MRI indicated my PCa was contained in the prostate. During the consultation I asked my very experienced CCOE surgeon what he thought my (case specific) odds were for incontinence, ED, and whether I was a good candidate for surgery. He told me for my case he thought he could spare my nerves and that my odds at 1 year after surgery of being continent was 90% and 70% for regaining sexual capability (assuming I was capable before surgery), and that I was a good candidate for surgery. I thought those odds sounded pretty good, and I was also getting some family advice pushing me towards surgery, so I went with surgery. I was immediately continent after the catheter came out (except for some minor releases as I figured out the new normal). I did experience ED but daily 5mg Cialis (plus either a higher dose of Cialis or a dose of Viagra on days I want to have sex) has helped a lot and at this point (15 months) I'm back to my pre-surgery sexual capability. Further, I've been able to resume all my pre-surgery physical activities. One thing that's actually better is that now, without my old enlarged prostate, I urinate like a 30 year old. The surgery also gave me the benefit of a pathology report on my prostate, which found both cribriform and IDC present. So I was pretty glad I choose surgery plus I do know if it comes back I want to aggressively treat it. Bottom line: picking surgery has worked out great for me, but clearly not everyone is so lucky. I do believe the experience and expertise of the surgeon is crucial to a good outcome. All that said, whatever treatment one chooses it's impossible to know how it's going to turn out, so it kind of comes down to trying to decide which treatment seems best for you and then never looking back. Best wishes.

daveslp, view this video from Amar Kishan at UCLA.

@retireditguy Thank you very much for sharing your experience and perspective!

@jeffmarc Thanks, again, Jeff. Very useful information.

I started adt April 2025 - orgavux - only significant side effect for me is major ED - finished 28 radiation treatment August 2025. My gleason was 4+4 . 1st psa test was < .01 . Radiation was a bit stressful your colon needs to be totally empty n no gas present. This can only be accomplished with gas x - 4 aday n an occasional enema. I was told of a procedure called a gel spacer that could have been used but not until I was partially thru procedure, My understanding is spacer procedure similar to biopsy it is considered surgery . That was my experience. GL

6weeks post radiation - bowl movements back to normal - still experiencing some urgency to urinate n night time I'm up 2-3 times

@garyhu Thank you for sharing your experience, Gary!