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Urologists make their money doing surgeries and they are correct in that IF the cancer is contained in the prostate, then surgery will remove the cancer.  With your scores, that certainly cannot be guaranteed.  You are also young enough that you should recover from surgery well with minimal issues, ASSUMING that the surgeon is experienced - several hundred if not thousands of procedures required to become proficient.  The fact that he indicates nerve-sparing is unlikely is problematic and I would think you should check out radiation options as well as get a second opinion from another urologists.  Removing the cancer is priority, but other functions, quality of life, etc should be a factor post treatment.

That said, I was 52 when diagnosed and I opted for Cyberknife.  I was only Gleason 6(3+3) and 7 (3+4) so a different scenario but as I reviewed the potential pitfalls of surgery, Cyberknife seems the most appropriate treatment.  In my case, I also opted not to take hormones as the 1-2% increase in cure odds (which was already in mid-90s) didn't seem worth the side effects.  I am a year removed from Cyberknife and PSA was around .7 at last check and everything is working.  I do not know if you are a good candidate for Cyberknife or not at such a high Gleason score. 

Normally, you have a lot of time to figure out approaches but based on the numbers you reported, you should deal with this sooner than later. 

One final point regarding surgery after radiation, who cares?  The correct approach would be additional radiation as surgery at that point would be unlikely to catch everything anyway.  However, there ARE surgeons who will do that work, most urologists do not so I would not use that as a decision point.  I find it somewhat amusing that surgeons tell you to avoid radiation but then tell you that radiation is always the back-up method if surgery doesn't work, really?!  So, I can avoid the potential pitfalls of surgery and just go with radiation upfront?

Good luck with your treatment options, stay positive, you can beat this beast!

The definition from a CT scan many times does not show the cancer. A better test is an MRI using a T3 magnet.  That may show extracapsular extension, and suspicious lesions within the prostate.

Generally with aggressive cancer, the Cancer has escaped the prostate and radiation with hormone therapy is appropriate. The radiation can be controlled to extend beyond the prostate, so there may be a better chance of treating all of the cancer. 

Surgery is not likely to treat all of the cancer in your case and another treatment type will still be required. There are side effects from each treatment type, and they are cumulative.

Keep on asking TG questions, we are here for you.

H

PS In your case where there were signs of cancer that was excitant for several years it is likely that the cancer has excaped the prostate and surgery is not appropriate

Tom,

Please note that we are not doctors and that our exchanged comments are solo based on own experiences and researches, done along the years as survivors.

Surely your added info helps in understanding your condition. In any case a better image study is missing. So far you know that you got a very aggressive PCa (grades of 5 and 4) producing alot of PSA serum (35 ng/ml) occupying a large portion of the gland (Mid and Apex) and, according to (you describe above) your doctor's comments, a negative DRE (no palpable bumps). It seems that hyperplasia (another probable source of PSA serum) is not present for the normal sized gland.

All this information was passed to you by the surgeon that would not recommend radiation if surgery seems capable of accomplishing the job. A radiologist would as well recommend radiotherapy because it would perform equally. The only piece of info you share above that turns the whole discussion ambiguous is for  "... I may have to have radiation after surgery but won't know that until (he sees the) pathology report (analysis on the gland's specimen post RP)". In other words he surely knows about the high risk in your case for existing extraprostatic extensions. This can be accessed via a detail examination with better contrasts and techniques.

Several Gs9 guys here have chosen the "mother of all therapies" to assure cure disregarding the consequences. They started with surgery removing the whole gland, seminal vesicles and nerve bundles, followed, after local healing, with adjuvant combi therapy of radiation plus hormonal (as commented by the urologist). In such cases, surgery is not curative but done with debulking intent. This may lead to incontinence and ED issues. The radiation can cause proctitis and is most prohibitive if the patient has ulcerative colitis. One should get a colonoscopy in advance of a decision.

Nerve sparing technique in Gs9 cases is rare but possible if cancerous tissues are not identified where these run. However, the nerve bundle and seminal vesicles are typically the routes used by the bandit to escape. From there it will travel to close lymph nodes which condition is common in cases of high PSA levels. From your stats one could guess that the nerves are infested. I wonder if any of the 19 needles were directional to the nerves bundle. What is writen in the pathologist's report on the biopsy? Can you tell us which clinical stage has been attributed to your case?

Continue searching about therapies and their involved risks and consequences, while doing important tests (heart and bone health) before treatment (58 years old doesn't free one from other maladies even if one is asymtomatic). Get second opinions, discuss with your family (they are also affected) and decide when feeling comfortable with an option. Treat but do not rush. It is common to take two or three months of preparation while looking for an accommodated solution.

Best,

VGama

Hi,

Listen to your urologist & oncologist to get both side of the story.  Surgery & Radiation are the two major paths most people follow.  Study all the treaments and their side effects and they all  have side effects.  Surgery side effects are usually up front and get better over time while radiation is just the  opposite.  Each peson will vary with their recovery/symptoms based on how severe their "treatments " were so there is no one answer on how long it will take to recover.  Various medicines can help with ED recovery or urine leakage.  It's up to you & only you to decide which treatment method is best for your life.

Dave 3+4

Amazing that your earlier biopsies (TomsNet) didn't find anything considering the high PSA values. The 'needle in a haystack' analogy certainly applied to those prostate biopsies, unfortunately. '

I noted that your cancer parameters are very similar to the ones my urologist found for me (several Gleason 9 lesions and some others, but my PSA was a bit lower; 12). AGGRESSIVE is the word!

The urologist told me I was too old for surgery (bless his heart) and recommended a 'triple play': brachytherapy + IMRT (44 sessions) + ADT (2 years). I have since learned that this combination is not at all unusual for cases such as yours and mine. In fact, it my be a 'standard' protocol (in the USA). The brachy can be done with 'permanent' seeds or with the 'High-Dose' version (typically two applications). The latter technique should really be done by someone who specializes in HD-brachy. (not too many in the USA, I believe).

After some further explorations and education I ended up doing a different 'triple play'. It was guided by a radiation oncologist: SBRT (3 sessions) + 20 sessions of IMRT + ADT (18 months). This approach is still 'experimental' but after umpteen years in biomedical research, I liked the approach, especially since the setting was in an academic hospital and the radiation oncologist had published several papers relevant to the course of action he proposed. The fact that this therapy was a lot shorter compared to the one proposed originally by the urologist also played a major role.

The SBRT was done with the CyberKnife system, but there is now at least one other company that has an instrument to do SBRT.

I don't want to make this too long, but feel free to ask for some detail. Most of my 'journey' took place three years ago and I believe that I survived... Moreover, the side effects were manageable.

Also, I personally don't care much for anecdotal reports such as the above. I clearly broke my own rule because our cases appear similar (except for the 'age' thing) and I thought it would be helpful to 'reach out'.

Good luck with the decision process.