Vesicourethral Anastomosis and BCR

I’m not sure where you get the idea that reconnection of the urethra has anything to do with having recurrence in prostate cancer. I had a prostatectomy in 2010 and 3 1/2 years later my PSA started rising. At no time was the connection between the urethra after surgery had anything to do with the reoccurrence. I had salvage radiation and it did allow my PSA to be undetectable for 2 1/2 years at which point it started rising. I have BRCA2 so that is one of the reasons it keeps coming back. I’ve heard from dozens of people that have had reoccurrences and never heard anything related to the urethra connection.

What makes you think there is any connection Between the urethra Connection and reoccurrence.

I have attended that weekly advanced prostate cancer meetings for over four years and have never heard anybody refer to this as a possible issue. Reoccurrence occurs because Something got out during surgery or even before it and mini metastasis started growing. They do salvage radiation at .2 PSA because that is the point at which the chance for the best Long-term survival is optimized.

While your PSA is .09 Even more important isn’t the doubling rate. How quickly has it reached .09? Has it been doubling noticeably and quickly. What should be more important to you is when you should have salvage radiation as an option.

From Ascopubs about what PSA to do salvage radiation.
≤0.2 ng/mL:
Starting at this level maximizes disease control and long-term survival. Patients treated at PSA < 0.2 ng/mL achieve higher rates of undetectable post-SRT PSA (56-70%) and improved 5-year progression-free survival (62.7-75%).
Delaying SRT beyond PSA ≥0.25 ng/mL increases mortality risk by ~50%.

0.2–0.5 ng/mL:
Still effective, particularly for patients with low-risk features (e.g., Gleason ≤7, slow PSA doubling time). The Journal of Clinical Oncology recommends SRT before PSA exceeds 0.25 ng/mL to preserve curative potential.

0.5–1.0 ng/mL:
Salvage radiation remains beneficial but may require combining with androgen deprivation therapy (ADT) for higher-risk cases.

Jeff, on a side note, I love reading your replies on this forum, they are very helpful. Thanks for taking the time. Don't want to highjack the thread but i'm still < .1 at 23 months post surgery and pray it continues. Any topic regarding BCR peaks my interest. Do you think that sometimes the biopsy can pull cells out along the needle track and they settle in the prostate bed?
Chili3, I hope you find your answers and have successful treatment and hopefully avoid adt.

I’ve read a lot of discussions in this area The doctors swear that the biopsy doesn’t even spread the cancer in the prostate.

The information I have seen says it’s an extremely rare and theoretically possible risk, but there has been no strong evidence to show that it has caused prostate cancer to spread.

I really don’t know anything about the Vesicourethral Anastomosis, or how it might bear on rising PSA. Do you have any references on this? I’m curious.

Our experiences have a lot of similarities from what you describe. It was ten years before my PSA was detectable following RP.

Jeff has laid out some pretty solid criteria for starting salvage radiotherapy.

It is possible that some benign prostate tissue was left behind, especially in a nerve-sparing surgery. One urologist suggested that to me when my PSA rose from undetectable to 0.11 But he also quickly ordered a PET PSMA scan and referred me to an advanced PCa specialist in his group. The PET scan ruled against the benign tissue idea. Without a PET scan, it is pretty hard to assess your situation. And it is possible that with your low PSA, the scan may not show anything.

What was your lowest PSA post-RP? Has it doubled? That is important info for understanding how aggressive that cancer might be, if you do indeed have a recurrence.

Also, your highest Gleason score is important information for risk stratification, as well as grade, and other data.

I have opted for salvage radiation without ADT for my recurrence. A medical oncologist and radiation oncologist both recommended six months of ADT but neither made a convincing case to me that risks would outweigh the benefits. The radiation oncologist I am partnering with now is supportive of just doing radiation. I also read dozens of papers in the medical literature, several of which supported my decision not to go with ADT at this point. Someone else might decide differently. For men in the high risk category, with distant metastases, ADT is pretty much the main therapy. For men who are low risk, surveillance is the main strategy. Men in the intermediate risk category (like myself) fall into a gray area, and this is reflected in the NCCN guidelines for treatment of recurrent PCa (radiation +/- ADT). There are some doctors who will not treat with ADT if PSA is less than 0.5 because the benefits versus the risks seem not to be well established. Some of this depends on what you value as end points—five years free of progression (very common with oncologists), metastatic free survival, overall survival, death from something other than PCa, etc? There are a lot of decisions to make about your life, both in terms of quantity and quality. What do you want out of treatment? A big and important question to address. And with prostate cancer, it can be a bit of a moving target, as you probably know. When I was diagnosed with PCa in 2014, I was concerned about under-treatment. Now, with the recurrence, I am more concerned, or at least equally concerned about over-treatment. I expressed this to my current oncologist, and she didn’t find it odd. Priorities change based on circumstances, new data, and constantly evolving therapies.

Personally, I am very averse to anything that raises my risk for Alzheimer’s or general dementia. Many of the potential side effects of ADT are risk factors for Alzheimer’s, and several studies have shown a link between ADT and increased occurrence of Alzheimer’s. Again, these are my personal priorities and concerns. Every man is different in terms of weighing what is most important to them. And should my circumstances change for the worse down the road, I would revisit the risk-benefit analysis of ADT.

If you don’t have Patrick Walsh’s book, “Guide to Surviving Prostate Cancer” I strongly recommend it as a good starting point for getting your head into everything that is coming at you. He has a good chapter on recurrent PCa with tables that show survival probabilities.

There is nothing that is straightforward about recurrent PCa, especially when your PSA is low/barely detectble. Find a medical team that will partner with you in decision making, and do seek second opinions. With your low, but concerning, PSA you shouldn’t have to rush into anything, unless there high risk factors that force that a bit.

Best wishes, and keep asking question and pursuing insights.

M

@melvinw
@melvinw Thank you for taking the time to respond to my inquiry. The impetus for my asking you about your medical team discussions is a result of your comment in your “Quest Lab vs Labcorp” submittal in which you stated:
“The 0.11 measurement in June set in motion a PET SCAN and a pelvic MRI, both of which showed “concern for recurrence” in the anastomosis.”
I am assuming (bad practice I know) that you are referring to the Vesicourethral Anastomosis (VUA) site where the urethra is reconnected to the remaining bladder neck in a post RP procedure. Is this the site that you are referring to in your above comment about the anastomosis? Has anyone of your medical team mentioned this location as a potential location of post RP BCR?

You asked about references. I tried last night to respond (evidently unsuccessfully) to Jeff Marchi. I am new to this site and I evidently goofed up the process of replying/commenting etc. I will try to include the references that drew my attention to this subject here:

BJUI Vesico-urethral anastomosis sampling: a forgotten tool for guiding salvage radiation after radical prostatectomy
Brennan Timm, Matthew Farag, Peter Liodakis, David Angus, Daryl Lim Joon, Damien Bolton
First published: 10 May 2021
Citations: 1

Last sentence of paragraph 3: Results:
In 7 out of 18 cases, there was histological evidence of recurrent PCa at the VUA in the absence of a positive 68Ga-PSMA PET/CT scan.

Diagnostic and Interventional Imaging
Volume 103, Issue 4, April 2022, Pages 191-199
Review/Genitourinary imaging
Diagnosis of early biochemical recurrence after radical prostatectomy or radiation therapy in patients with prostate cancer: State of the art

Jules Zhang-Yin a, Françoise Montravers a, Sarah Montagne b, Christophe Hennequin c, Raphaelle Renard-Penna b

3.2.1. Local recurrence
3.2.1.1. Local recurrence after radical prostatectomy
Second Paragraph:
Vesico-urethral anastomosis is the most common site of local recurrence after RP, but recurrent lesions can occur anywhere in the prostatectomy bed including the retro-vesical space, the bladder wall, near the seminal vesicles bed, or adjacent to the vas deferent.

The reason that I took an interest in this subject is because during my initial consultation my RO mentioned that this site is a possible source for BCR post RP. NOTE: No probability numbers offered simply possibility.

Now to my background: RARP September 2019. Post RP uPsa undetectable. upsa undetectable until late May 2024 when uPsa became detectable 0.04. Fell back to uPsa test every 90 days. Early April 2025 uPsa 0.08. Math says PSADT= 10 months. Latest uPsa early July 2025 uPsa 0.09. I harbor no delusions – I have post RP BCR. Post RP pathology renders: GS7 (3+4) Grade Group 2. Primary Tumor pT2 (organ confined). 14 lymph nodes extracted: clear. Margins: clear.

PSMA-PET/CT last month. MRI one week ago. I am certainly no radiologist but it appears to me that the PSMA was “inconclusive”, which is what we anticipated at these levels. The MRI results are not in yet. I have not had a post imaging consultation yet.

Back to the interest in the VUA: From what little I have gleaned the VUA involvement often eludes the PSMA effort. There is some discussion of a VUA biopsy option to evaluate this location.

I too am anticipating salvage radiation. Like 110% of all BCR patients, post BCR treatment quality of life (QOL) is a primary concern. Any and all discussions relative to maintaining QOL are on my list. If we can determine a location for my BCR absent imaging targeting then I want to have that discussion. I am a huge fan of “precision strike” vs “carpet bombing”. I too am ADT adversive. All ADT avoidance options are on my discussion list as well.

I am ordering Patrick Walsh’s book in the AM. I appreciate the heads up.

I apologize for the long winded diatribe. This combat encounter is a tough one.

Thank you again for listening,
Chile3

Chile3, Thanks for the clarification and all the data. The VUA terminology was new to me, but now I get it. Happy to have this conversation, especially since there is considerable overlap in our histories.

To your question about recurrence in the VUA, here are excerpts from my PSMA PET and pelvic MRI reports, respectively:

“Focal asymmetric activity along the left aspect of the anastomosis has a maximal SUV of 13.3 g/mL…concerning for local recurrence”

“Posterior to the urethral anastomosis, there is a small amount of T2 hypointense soft tissue with diffusion restriction and early arterial hyperenhancement, measuring approximately 1.3 x 0.6 cm, concerning for local recurrence.”

Neither scan found evidence of metastatic disease. My PSA at the time of the scan was 0.12. DRE by both my urologist and RO have confirmed a palpable nodule, slightly left of center in the anastomosis.

So, yes my local recurrence appears to be at the VUA site. That will be the main target of IMRT therapy, but my pelvic lymph nodes will also be irradiated, prophylactically. I have no information on how common this is beyond what you have provided.

With my low PSA (< 0.5), it is a bit surprising that the lesion in the VUA lit up so much on the PET, but the data are the data. Also, with my low PSA, distant micromets can’t be ruled out, but that will be part of the job of post RT surveillance.

Here are some other data of note in my case.

Pre-RARP biopsy showed cancer in the right lateral apex (GS 3+4, 10% involvement of submitted tissue, negative for perineural invasion and extraprostatic extension), and cancer in the right apex (GS 3+3, 35% involvement of submitted tissue, negative for perineural invasion and extraprostatic extension)

Post-RARP pathology showed in addition to the above: positive margin in right apex, pathologic stage pT2c pNO pM, and perineural invasion

Post-RARP Prolaris Score of 1.7. (considerably more aggressive the average intermediate risk) and 10-year risk of BCR of 53%.

So, emerging BCR after ten years did not come as a shocker to me. Both my urologist and RO agreed that given the preponderance of evidence that a biopsy was unecessary and that we should proceed with EBRT asap.

In a way, I am glad that my BCR is associated with a specific location. As you said, the RT can be a precision strike rather tan carpet bombing. Totally with you on that.

Have a look at those tables in the Walsh book. Given your parameters, it looks like your odds for metastasis free survival and not dying from prostate cancer are pretty good.

Back to the ADT+RT issue: I’ve attached an excerpt from a 2023 article in the ASCO Daily Times that reviews several trials and points out that men with low PSA do not seem to benefit from adding ADT to RT, and in one study were actually harmed by it. It is all somewhat dependent on what end points are prioritized. Also, I’ve linked to a video presentation by Dr Adam Kibel (Brigham and Women’s Hospital in Boston) who emphasizes risk stratification in adding/not adding ADT to RT for treating recurrent PCa. He does not recommend ADT if PSA is < 0.5. (https://youtu.be/JxO6uRM-XiM?si=A21FNdjOmv1pbiPh)

I’ll probably think of more stuff later. Hope I finally addressed your main question about VUA. Happy to continue this conversation as situations evolve.

You have caught your BCR very early. Good news in a bad news situation. Hope you can find exactly where it is occurring.

M