T3a locally advanced prostatectomy?

John,

No one else can answer that question other than you. I can flag up things I would consider, but your considerations are unlikely to be the same.

You can plug your diagnosis into nomograms to find out the likelihood of a RP working first time. You haven't given enough detail (such as PSA at diagnosis).

One research project I looked at compared RP results against the 3 high risk criteria:
PSA >= 20 at diagnosis,
Stage >= T3a,
Gleason >= 8.

The more of these that apply, the less likely the RP is to cure, and hence need salvage RT. Having both procedures generates both sets of side-effects, and increases chances of ED even more which was of concern to me. I had requested RP right from the start (out of ignorance at the time), but this did mean the MDT kept it on the table, and always reported back on it as one option even though they generally recommended something else. In my case, RP wouldn't have been nerve sparing and it would have required adjuvant RT, which wrote it off as a choice for me.

I went for RT, which was 8-9 months ago, a choice I don't regret. No incontinence or ED from the external beam radiotherapy, although I also had HDR brachytherapy as a combined treatment and I did get temporary ED and a little incontinence for a few weeks after that, but all working fine for some time now. Can't eat as much fibre as I was before. I'm still on hormone therapy which comes with a number of side effects, but it's not a big deal for me - it is for some people. You have also got to try it out, so you have some idea the effect on you.

Age is a factor too, and at 57, I was on the young side for RT, and you even more so.

Anyway, just some thoughts that went through my mind, but might not apply to you.

Edited by member 27 Apr 2020 at 19:40  | Reason: Not specified

"So I would say, make a decision about side effects and which are the least bad."

I think Dave's post is brilliant apart from the bit above - I am not sure it says quite what was meant. Generally speaking, the advice on decision making (assuming you get a choice of treatments) is:

- determine which treatment has the best chance of eradicating the cancer
- look at the potential side effects and decide whether you are willing to take those risks
- if not, look at the other treatments on offer and their potential side effects
- choose the treatment that offers you the best chance of full remission with a % risk of side effects that you are willing to live with

Some side effects will happen regardless of which radical treatment you choose; dry orgasms, for example. Others like a smaller penis happen to almost everyone, for different reasons. Anxiety / anger / low mood are also very common. The side effect that must not be downplayed is to be rid of the cancer.

Edited by member 27 Apr 2020 at 22:43  | Reason: Not specified

If you opt for surgery I recommend you find yourself a high-volume surgeon with good outcomes, and then you may be less likely to suffer unfortunate and sometimes inevitable side effects of surgery such as erectile dysfunction and incontinence. Surprisingly, ‘successful’ surgery regarding incontinence is the use of one pad (nappy) a day. I would not call that a ‘success’!

I have no problem in that regard, but I do have a totally limp dick (we doctors call it ED), but two years on I am cancer-free and carefree😀

My own surgeon said he would not send a friend or family member to any surgeon who does less than 100 prostatectomies a year, I suppose on the basis that ‘practice makes perfect’.

Best of luck whichever path you choose.

Cheers, John.

You and many others may never be certain you made the right choice.   I thought about it a lot flipping between the two.  Although it was partly fear of having an op and worry at having 3months hormones, 6 weeks daily RT, 3 - 6 months RT.   I'd had surgery for 2 skin cancers and everyone said cutting it out is the gold standard which for that condition it is and that influenced my thinking.

I was very keen to get it out.  Dave's phlegmatism doesn't enter my vocabulary, perhaps it should.  When the surgeon offered me an op in 10 days my decision was made and 120% certainty and enthusiasm arrived.   After reading on here for about 12 months I became less certain it was as cut and dried and it took a long time for me to accept RT could be as good as RP.  I now think if you have spread RT is probably better in some cases otherwise in from things I've read it's not quite as good.  You say the surgeon mentioned a wide margin and he was confident.  Some might say he would say that but did you trust him? Trust is a great thing.

For me side effects were hardly an issue they could cut the lot off.  I would be sorry to see the old lad go but being here longer is a higher priority.  

The op is quite an easy route I found.  Go to sleep and wake up hopefully without a cancer and I had no pain at all.  There is a month of messing about but it soon passes.

Mine was upgraded from 4+3 to 4+4.  But also downgraded from T3 possible to T2a.   I also wouldn't have feared RT as secondary treatment and the ability to use that route seemed a plus.  I've absolutely no regrets but if it had been 5+4 it would likely have been RT only at my hospital.  From the stats I've seen I don't think my surgeon does ops on people of that grade.  So you could count yourself fortunate to be offered it.

I wonder what Stephen Fry had, his was a high Gleason 9 I think.  Actually I answered it myself, surgery and he said something about it being 4+4 originally upgraded to 9 which could either be 4+5 or 5+4.     https://www.youtube.com/watch?v=jetCGj44kq8

I'd be interested in when will the op take place.  Being on hormones means you've got a start towards RT and if the op takes a few weeks it narrows the time gap even more.  In my opinion people with high Gleason should be given priority and perhaps you could push that one.

I just re-read the above and it doesn't come out clear but perhaps some bits will add something to your pondering.   It's a tough one and many write on here of the same.   All the best.  Peter

If you are a high risk patient (PSA >= 20, or gleason >= 8, or stage >= T3a), I was told they treat the seminal vesicles and pelvic lymph nodes even if there's no spread identified there (sometimes called "whole pelvis" by oncologists, but that means something completely different to radiographers). This was done with 75% dose in my case (46Gy), which minimises any risk of lymphodema and limits other collateral damage. The prostate was topped up to 100% (61Gy) with HDR brachy. This was at Mount Vernon - I don't know how widespread this protocol is. The treatment is called HDR Boost.