Can't understand why anyone would choose surgery over Brachytherapy? I must be missing something?

Hi Phillip,

It's a difficult choice, but if you have been given options that's good some men don't have the diagnosis to choose.

There are no easy options which one you choose, there are no right or wrong decisions, the decision you make is right for you only time will tell.

I was on Active surveillance for 3years but in November 2020 I had a prostatectomy during the course of my active surveillance I studied all the different treatments in great depth and sought advice from others, my surgery went fantastic a full nerve sparing was possible, I am now fully continent had very little problems after catheter removal, ED will take a little longer spoke with my surgeon this morning and he has referred me to a ED Clinc even though I'm not that far off.

I had no problem with recovery I'm retired but after 2 weeks I could easily have returned to work I could drive no problem everything now healed.

I have no regrets whatsoever and I know if further treatment was ever required then I could have radiotherapy, but if that is the first choice then surgery becomes less of an option due to the changes after radiotherapy alters the tissues.

Good luck it's a personal choice go with what you think is best for you don't rush it.

"that increased risk of worse side effects meant that they wouldn’t do a prostatectomy as salvaging treatment if radiotherapy / brachy didn’t succeed. Is that right? No idea where I read that - is that ever true in the UK?"

It is true - an irradiated prostate becomes gloopy or sticky so it is more difficult to remove cleanly - and nerve sparing is not possible so ED is more or less guaranteed and incontinence is more likely. There are just a few urologists that will attempt the op in the right cases and we have a couple of members who have gone down this route.

However, there is a whole myth that has been built around the idea that 'at least you can have RT after surgery but not surgery after RT'. In fact, if the first treatment fails, the statistical likelihood of salvage treatment being successful is quite low, whichever order you do them. It makes sense to choose the treatment that is most likely to be successful rather than the one that can be followed up if it fails.

Edited by member 16 Jan 2021 at 20:56  | Reason: Not specified

When I was first diagnosed Jan 2018 (age 62) it was with a "low risk" Gleason 6, and I was put on AS.  When they found a new "high risk" Gleason 8 tumour in Oct 2019 (age 64) and clinical intervention became necessary my first thought was go for surgery.  I think it's a pretty classic response, get rid of prostate get rid of PCa!  Then the MDT advised me against it.  They wanted to remove lymph nodes too and they thought, given my physical state and lifestyle, that the potentially five hour op under GA would carry too high a morbidity risk.

So I settled for EBRT, which finished last August.  Had some pretty unpleasant side effects since, some of which have cleared up now but some such as,nocturia (average four times a night which leaves me wasted the next day), radiation cystitis and piles, are still giving me a lot of pain and grief.

Part of me still wishes I'd had the thing whipped out, especially as I have a non-secreting tumour so the regular follow up PSA tests are not a reliable indicator as to whether the cancer is still there and growing.  That said, I met a guy in the waiting room while having my EBRT.  He'd had his prostate surgically removed four years previous.  Told me he thought he was "cured".  Then four years on a routine blood test showed his PSA had rocketed.  So he was back in for EBRT.

Not sure what point I'm making here to be honest, other than no option offers a 100% certain outcome, and all options can and will have a knock-on effect on your life.

Edited by member 24 Jan 2021 at 20:38  | Reason: Not specified

Hi Phillip,

A very well thought out and reasoned post. Choice of treatment can be difficult. I was lucky in that the MDT gave me no choice; my cancer was T3, surgery would probably not have got all of it so I had the same treatment as ANDY62. At my hospital they didn't give it the fancy name "HDR boost", they just called it HDR Brachy followed by ebrt, plus HT. I was 53 at diagnosis so like you relatively young.

I don't know if you are aware that brachy comes in two varieties HDR and LDR, if not then a little research on the Web will show you the differences.

Like you and most people my first inclination was surgery, but I do think this is usually an irrational, emotional first reaction. If you take a step back and look at all the options in a rational way then it may be that surgery is the best option but it may be that another treatment is better. Personally I think cutting people open with a knife and expecting to do much good is a long shot. Having said that if the cancer is T2 then surgery will probably remove all of it and you will be cured, but once you are talking T3 you need to be trying to get those cancer cells which may be just beyond the prostate.

I know HT has not been mentioned to you yet, but I suspect if you start talking with the medics about the brachy options then HT and EBRT will get mentioned as combining all these together seems to have the best chance of success. 

Surgery will take a while to recover from, but HDR boost, will involve about four weeks of going to the hospital for EBRT, and may involve two years of HT which is not dreadful, but isn't great. So the surgery begins to sound like the quicker option.

There is the risk of the radiation causing cancer years down the line and if your in your 50s you have more years ahead of you than if you're in your 60s. 

My life expectancy before I was diagnosed with PC was 85, now if you put my details in to nomogram, even though I think my treatment is successful my life expectancy is 70. I'm hoping to beat that, but I do know I will die one day. So I now live a more hedonistic and adventurous life to try and increase my chances of not dying from cancer. 

As far as treatment is concerned I like to think that I would have made the rational choice rather than the emotional choice, but I don't know whether I would have, fortunately the medics made the decision for me. 

Edited by moderator 18 Jan 2021 at 11:46  | Reason: Not specified

You can make a case for or against any form of treatment. There are many factors that should be taken into account when deciding which of the treatment options a man is offered to plump for. In some cases the situation is make easier when you are told your individual situation means you are more suited to one form of treatment over another but this is not always the case. Sometimes both your urologist and oncologist (who tend to favour their own area of expertise) will say surgery or radiation would be suitable. You need to fully understand what is involved both in the treatment and potential side effects both short and long term although these can vary.

I suggest you download or obtain a copy of the 'Tool Kit' which is informative and gives an impartial view on Prostate Cancer (PCa) and effects of treatments. Consider this and then make your choice. https://prostatecanceruk.org/prostate-information/our-publications/publications/tool-kit?_ga=2.206109653.795867346.1564408880-1013787081.1564408880

Very smart Post!

Since I had a RP surgery operation I asked my self why did I have to go ahead with surgery options?

I was perfectly fine with toilet visits sometimes day time I was ok not to visit toilets 4-5 hours.

Relationship were great in that department. 

No pains.

Nothing all I said to my GP was sometimes when i go to bathroom i feel i dont fully empty my bladder...yes i had the operation over a year ago and still i get same feelings for not to empty bladder. 

So if it was going to be like this than why did they force me to have a surgery?

After all those times I can't even lift up for 4 -5minutes  a little child.

Bedroom life is over 

Pains all over my tummy, abdominal area

Kidney

Liver 

Gallstones 

Left testicle pains always there 

Partner left ,became unemployed 

My life has changed because of the surgery operation but if I did not go ahead with it than life would have been great.

I can't imagine why anybody would want to "frame you up". And did somebody really "force you" to have surgery? Did they frogmarch you? (:

Your post suggests a lot of anger which may have been spared if you had done your homework before being "forced". However, I sincerely hope you are coming to terms with your situation and seeking counselling if you are suffering anger symptoms.

Hi Philip,

Sending best wishes for your upcoming surgery, I mentioned in an early post that I had surgery on the 25th November 2020.

I have made great progress no problems with the continence, but still do the kegel exercises which I started as soon has I made the decision to have surgery and like you had no problems prior but realised you need to strengthen the muscles there pre and post op for life.

I can honestly say it was not a bigger deal as I thought it would be, a bit of advice stop the pain medication ASAP it causes constipation along with the anathesectic, the only discomfort I had and I stopped them after 2 days paracetamol are fine, take the laxatives they prescribe whatever you do. 

The only other bugbear is the Foley catheter, but it is a necessary nuisance, just keep everything clean sleeping is awkward but you get use to it, change to a night bag surprising how much you pass.

Regards

Daily

T2c is sometimes on the intermediate risk side, and sometimes on the high risk side, depending which paper you read. The "risk" is that of there being micromets outside the prostate which don't show up on a scan, and later cause recurrence.

I might guess that if you've had it long enough to be on both sides, it's also more likely to be outside. However, prostate cancer is often multi-focal (starting in several places separately), so this may not always be the reason it's on both sides.

Update

Nerve sparing Open RP - 1/3/21 In Solihull 

TWOC - 8/3/21

Follow up review with surgeon - 21/3/21, Histology showed clear surgical margins. No evidence of spread outside of the prostate, so the early signs are promising.

12 week PSA test in a couple of weeks !

It’s just over 10 weeks since surgery, recovery going very well. The wound is healing nicely, easily able to walk about 2-3 miles a day after about 4 weeks, very tired at first but loads better now. Up to about 5-6 miles now in one go but not every day. Lots of weird aches and pains, and a couple of really painful areas (not all the time only when i bend down) a couple of inches either side of my big scar. No infection so I'm guessing it's just muscle/nerves repairing and will hopefully get better.

I was dry pretty much the day after the catheter came out. Had one little accident but that was 100% my fault as i was doing something i was warned not to do (bending, twisting and pushing all at the same time !!). Before the surgery I was way more concerned about the incontinence side of things , but thankfully that doesn’t seem to have caused me much of a problem. However (unsurprisingly I suppose) there is absolutely nothing there erection wise. Having never had a problem before the surgery I was stupidly expecting at least something fairly soon after surgery. But after trawling this site for info I now realise I have unfortunately, vastly underestimated the issue. This side of the recovery it is starting to get me down a bit but hopefully things will improve with time. I'm on 5mg Tadalafil daily and getting to grips with Somaerect vacuum device. After 3 weeks of steady use I'm back to almost full size so it does work, but its brutal and you certainly know you have done a work-out when you're finished, and there is no way one of those rings is going anywhere near it, the high tension ultra rings look like they would cut it clean off!!! Can't see me ever using it for anything other than the rehabilition side of things.

No stirrings from the Tadalafil so might try a Viagra as well to see if that has any impact.

So bloods in a couple of weeks and hopefully a good result so i can reduce my stress level a bit. I have blood cancer as well (under control and responding very well to some insanely expensive treatment) and the covid thing is a real risk for me so I'm fit to burst with stress at the moment, having one less thing to worry about can only be a good thing.

All the best

Finally :-

A message to all those 'younger men' with no previous ed issues reading this, who are currently doing what i did. The ED side effects are a real problem and WILL more than likely (unless you are very lucky) take many months to resolve themselves, maybe years. Do not underestimate it, like i did. Prepare yourself for the real possibility that he won't be working for a while. I didn't and I'm sure that's part of the reason i feel so down now.

16 months on from open RP - Still here, has it gone - more than likely, will it ever come back – who knows !

PSA at 3 months 0.014

PSA at 6 months 0.012

PSA at 12 months 0.013

So within the realms of testing tolerance still all ok – a ‘less than’ symbol in front would be even better but I’m kind of ok with it.

Waterworks wise I was continent almost the day after the catheter came out – the odd dribble here and there after I’ve been for a wee which can be annoying but not the end of the the world, but on a normal day to day basis I have full control.

Erection wise still nothing of any consequence to speak of – using the vacuum device 2/3 times a week and on 5mg of tadalafil daily – these tablets make a small improvement and when coupled with the infamous durex ring I can muster a rather un-impressive semi - but the tablets make my legs ache really badly so I do have breaks from them and when I don’t take them there’s nothing there at all.

Tried a full dose of tadalafil - no further improvement and a full dose of sidenafil made my head feel like it was going to explode so haven’t bothered again.

I frequently question my decision to go for the RP – as physiologically the loss of erections is massive for me at the moment – Its having a much bigger impact on me mentally than I ever thought it would - but at the time of having to make the choice I didn’t ever think it would be an issue for me as I was only 51, had never suffered with ED before at all plus the surgeons didn’t really see it as being that much of a problem - the emphasis was much more on the possible incontinence side effects.

Would Brachytherapy have been any different - I don’t know, and never will? Erection wise things would probably be better now but who knows what it would be like in the future? Plus could I cope with the knowledge that ‘it’ was still inside me – when the engineer in me knows the best thing to do with a bit that’s gone wrong is get rid of it as soon as possible. Again I don’t know.

So if your reading this thread looking for some guidance/advice, I think the only thing that I can say for sure is whichever way you go it’s going to be a lot tougher than you imagine and things are unlikely to ever be the same ever again.

As a side note – I’m kind of wishing the surgeons had been a little more realistic with me up front – not sure it would have changed my decision but it might have levelled my expectations of my ED recovery - if it’s really going to take 2 years plus to see any improvements , then just says so. All this 3 months then you should start to see something is in my mind (and lots of other people I have spoken to and read posts from) not really being honest – yes some lucky guys may see improvements early on but in my research the vast majority don’t.

Phil