Surgery or Radiation for Intermediate Prostate Cancer?

RALP=robotic [assisted] laproscopic prostatectomy. While it is now the most common approach, statistically there is no different in the outcomes (by comparably experienced surgeons) between RALP and "open" (i.e. traditional) prostatectomies.
I encountered the referenced urologist by volunteering for a clinical trial. I did not qualify for the clinical trial when a repeat mpMRI on better equipment with better pathologists found an additional nodule and the transperineal MRI-guided biopsy then found 4+3 pathology in that nodule. The clinical trial was for a new form of ablation (killing cells in situ), but the guidelines limited participants to 3+3 or 3+4 pathology.
The post-surgery pathology found cancer at the margin ("positive margins") which indicated to me after the fact that if anything I was too late on the surgery, not too early :-). So far no indicators of further growth though....

Yes, you're right that there's a lot of debate about how/whether to treat low-grade, early-stage prostate cancer.

There are many of us with high-grade and/or advanced prostate cancer here in the forum, but I don't think we're representative; it's just that people with more-dangerous cancer are more likely to seek out information and discussion groups. My radiation oncologist told me that about 5% of prostate cancers (1 in 20) are like mine: fast moving, strike people young, and often aren't discovered until they've already metastasised.

Obviously, for people in my situation, there's no choice: treat it aggressively, or die in a few years (or less; Canada's former Leader of the Opposition, Jack Layton, was diagnosed with advanced PCa in 2010 around age 60 and died in 2011). For people with very low-grade PCa, the choice is either active surveillance or (to be on the safe side), a few months of ADT, which will have no permanent impact once it wears off.

The tough decisions lie in the middle: what if your Gleason score is high, but the cancer doesn't appear to have escaped the prostate? Do you make a life-altering change like removing or radiating the prostate? There's no *wrong* choice, just the choice that works for you.

While I wish we'd caught mine at that early stage, I still don't envy you the decisions you have to make.

I had an RP at ucla in 2014
Psa was 10 Gleason 3+4
Non muscle invasive
Psa undetectable for 8 years
Slow rise to 3.6
5 SBRT took psa to .6 3pelvic lymph nodes
Resolved 2 shrank 1
Slight rise to .8 Psma showed 1 New small lymph node issue which ucla said was not practical
To do SBRT on
Started on Orgovyx and xtandi. 4 months later psa undectable
Fatigue, libido and blood sugar issues

My personal experience was SBRT (5 high intensity sessions of radiation) with six months of ADT (two months before, and four months after) which was explained to me as helping radiation to kill the cancer. I bleed somewhat easily and didn't want to risk surgery.

It was also explained to me that, with surgery, your side effects are up front and generally improve over time, but not always. With radiation, your side effects generally start later, but not always. For me, ADT had more side effects than radiation, and those have been more mental side effects than physical, though not everyone gets every side effect listed.

Radiation has less chance of urinary incontinence, but a slightly increased chance of bowel issues. If done without ADT, there's also a "honeymoon period" where ED is minimal. After about two years, though, the data I researched shows that the ED levels are the same for both courses of action. The disadvantage of radiation is it takes longer to know if it worked. With surgery, your PSA drop will be fast and should be to "undetectable" since you'll no longer have a prostate making PSA. Radiation has a slight chance

If you work in an office you'll need time off if you have surgery and may need a reduced workload because of fatigue from radiation. If you do manual labor, you will need more time off for surgery.

Whichever you choose, try to get yourself in the best shape possible before treatment to help speed your recovery.

[Edit: P.S. I forgot to mention that, generally, both surgery and radiation have equal chances of putting you into remission if you are Stage 2 or less. You should talk to a surgeon, a radiation oncologist and a medical oncologist before making your decision. Some options are better for some people based on extenuating circumstances.]

This isn't Spino, but RALP is Robot Assisted Laparoscopic Prostatectomy. I had this surgery in August of 22. Gleason 4 + 3. Surgery was not painful. No incontinence issues. Erections not quite the same but feeling is the same. I had nerve sparing surgery. If you opt for RALP I suggest you find a surgeon who has performed a thousand of these. My Urologist who also was my surgeon performed several per week for the last 20 years. Thankfully, my PSA has been under 0.1 since. My Urologist didn't recommend follow on Radiation or ADT after surgery. I went back to work after 8 weeks. I'd also ask your Urologist for a prescription for Pelvic Physical therapy. The therapist will instruct you how to perform proper Kegels to prevent or eliminate incontinence.

@perrychristopher
Thanks for all of this great input. You are still working, so I am guessing you are in your 60s?. I will soon be 69, not working full time, very active (bike, walk, golf, ski, kayak, play the drums semi professionally) and in pretty good physical shape. When did you start the Pelvic Physical Therapy? I have yet to meet with a surgeon, but that is scheduled for next week at Mass General Cancer Center. Do you have any other questions for the surgeon that I should put on my "Must Ask" list?

@ljbboston -- I know you asked @perrychristopher, but thought I'd weigh with as well to your question. I'm no expert, but from what I read and heard from my doctor, Pelvic Physical Therapy is essentially just exercises (ie. Kegals) to strengthen the muscles that play a role in controlling urination. If you do choose RALP, then Kegals are very important as they will strengthen the muscles that remain after RALP. As with pretty much any muscle, starting early is better, so I was advised to start them before surgery since I had time. Then continue after the catheter came out. There's some excellent videos on the web. I particularly liked some by Michelle Kenway; she has several on youtube. They're easy to find. I'm not suggesting you shouldn't see a therapist, but rather the videos will give you a chance to see what they're like. Frankly, I ended up just using the videos as it seemed pretty straightforward to me and I felt like I was doing them right. But if I'd had any questions or concerns or incontinence, then I'd have definitely seen a therapist. As I said, I'm not a medical expert, but just wanted to share my experience with you.

I retired in February 2022. It had nothing to do with the PCa though. Forty years was enough for me, lol. I started the PT about 7 weeks after the surgery. They won't let you start before that as you need time to heal. I have seen others on this site say they had PT before surgery which seems like a good idea. My surgeon wanted me to talk to an Oncologist before I made my decision between surgery or radiation. I decided on surgery as I was 60 at time of diagnosis and also wanted to have the option of radiation if the PCa ever comes back. As far as other questions to ask other than his number of surgeries he's performed...... I'd ask based on size and location of tumor what are chances of incontinence after surgery. Also, what is he removing. Will it be nerve sparing surgery in his opinion. Also, my surgeon never ran a Decipher test on my biopsy sample or removed tumor. The Decipher test tells you how aggressive the cancer may be. You could ask him about the benefits of performing this if he hasn't ran it yet on the biopsy you had. It's a lot to handle but you'll get through it. Good luck with whatever decision you make. We are lucky in the sense there are so many treatments for PCa.

@ljbboston -- I agree with everything @perrychristopher said. Here's a couple more things to consider with your meeting with the surgeon: 1. have a written list of questions, 2. bring someone to take notes of what he says as you'll be in information overload and may miss something he says, 3. in addition to chances of incontinence, also ask about chances of ED, 4. with nerve sparing RALP, there's sparing both nerve bundles or just one nerve bundle, so ask which he'll be doing, 5. I had my RALP at a teaching hospital, so I asked if he was going to actually be doing the surgery, 6. I specifically asked if I was a good candidate for surgery. Best wishes going forward figuring out which treatment is best for you.

All good points. Thanks for adding them.