Quality of life feed back . Radiation vs.surgery 54 years old

Talk with a Radiation Oncologist.

I agree whole-heartedly with everything that has been said above. All we can tell you is about our own experiences. Even research studies cannot tell you the answer because they only give you statistical averages and your personal experience may be different.

I have just been reviewing my personal experience as a doctor. Back in 2010 when I was 60 I checked a screening PSA. It was 4.64. I took a course of ciprofloxacin antibiotics and rechecked PSA with free PSA. Some of the circulating PSA is bound to proteins but it is the unbound fraction that is more important. It came back at PSA=3.7 with 19% free. Statistics showed that at 60 years old I had 24% chance of developing prostate cancer.
I believe the best way to determine whether cancer is present is by biopsy, but that has its own risks of complications. The next day I asked my urology colleague if I could have a biopsy. It was done 3 days later and as I received an urgent text from by brother in Christchurch during the huge Christchurch earthquake I was distracted and didn't feel a thing during or after the biopsy with multiple samples.

Mayo Clinic reviewed the biopsy and gave it Gleeson 3+3 which is considered positive for cancer. My father had already been diagnosed with prostate cancer and shortly afterwards it became metastatic and he died of it later, in 2014 at age 94.

Now MRI imaging may be used rather than going straight to biopsy, but I wonder how reliable it is, when you really want a pretty definite conclusion. I think biopsy is necessary to be sure.

As others have said, my reaction was, "I don't want to take 24% chance on this, I just want it out of there." I researched the options. At that time (2010) the risk of adverse side-effects of radiation and surgery were not significantly different, although there was a trend towards better results with surgery (not considered statistically different). If you have radiation and the cancer returns you cannot have full-dose radiation again. I just had a better gut feeling about a surgical approach. I had a limited robotic prostatectomy at Vanderbilt by the head of Urology Prof. Jay Smith who had done 2000 robotic procedures at that time (since retired like me).

After surgery the pathology showed 10% of the prostate contained cancer with a final diagnosis of T2a. They did not think it necessary to remove any lymph nodes.

This week I watched a video of a complete robotic prostatectomy procedure in Italy. What a long drawn out complicated procedure! It took one hour 46 minutes of continuous resection, not including initial setup. They used 6 ports through the abdomen and had tiny scissors that could also cauterize by passing AC current through them, with a grounding pad attached to the patient's skin. This is the same as the Bovie scalpel they have used to minimize bleeding for many decades. They also used a small clamp in the left hand and it could be used for bipolar cauterization where current is passed from one half of the clamp, through to the other half of the clamp. Larger vessels were clamped with plastic clips.

The risk of adverse side-effects such as incontinence and impotence were reported to be low after robotic prostatectomy, but the criteria used for deciding what were significant side-effects were not well defined and varied between studies making it difficult to compare. I was a bit surprised that I ended up in the 10% who had all the problems, except that after 15 years my PSA is still unmeasurable. So I have to be thankful for this great outcome.

As I have said elsewhere, I have had 5 surgeries for incontinence with the third artificial urinary sphincter placed 3 weeks ago. I have great hopes that it will work better this time!

As others have said, their experiences...

Same for me....

I was diagnosed in January 2014 at the age of 57. Options at that time were binary:

Surgery
Brachytherapy

Imaging options weren't even binary, MRI/CT

So, I chose surgery.

It went "well..."

Within several weeks I was back to "normal."

I had no incontinence, I was doing light exercise, travelled...gradually I increased my resistance training and other levels of physical activity, playing basketball, riding my bike, skiing, hiking, swimming,

Within 12 months I had regained erectile function using a daily 5mg Cialis albeit with the normal changes - no semen, greater physical and mental stimulation to achieve an erection...

So, am I an outlier, likely. There are "horror stories" on this forum and others. It's like statistics and the Bell Curve, where will your outcome fall...?

I did have a skilled surgeon, my surgery was nerve sparing...

Men diagnosed today may have more informed choices based on newer imaging capabilities such as the PSMA ones, MPRIs. The choice of systemic treatments has expanded too for De Novo PCa as have the tools in the hands of radiologists.

If you have not read through guidelines such as the NCCN and AUA, may be useful, they are the science and can serve as a starting point in discussions about treatment with your medical team which as others have indicated, should be multi-disciplinary and include consults with a radiologist and oncologist with experience and expertise in PCa.
https://www.nccn.org/guidelines/guidelines-detail?category=1%26id=1459
https://www.auanet.org/guidelines-and-quality/guidelines/oncology-guidelines/prostate-cancer
There are nomograms such as the MSCKCC to "predict" outcomes - https://www.mskcc.org/nomograms/prostate

There is a new "kid on the block..." - https://www.urotoday.com/center-of-excellence/imaging-center/video-lectures/video/mediaitem/5020-study-evaluates-psma-pet-based-nomograms-for-prostate-cancer-prognosis-kambiz-rahbar.html?utm_source=newsletter_14494&utm_medium=email&utm_campaign=using-psma-pet-imaging-to-guide-patient-care-decision-making

Kevin