After RARP Gleason 9 (4+5) and urethra infiltration

Hi again Fragen.

I'm not medically trained. My prostatectomy pathology was T3a, with extraprostatic extension and Gleason 9(4+5), but fortunately had negative margins. I believe that your husband's post op report is similar to mine but unfortunately shows R1, which in his case is a positive surgical margin in the urethral area.

As for his post op histology Gleason being raised, this is quite common. Mine went from Gleason 8(3+5) to 9(4+5). Apparently having HT prior to surgery can also result in a higher Gleason score because it alters the look of the cells.

I've read a lot of peer reviewed research on what factors affect the chances of needing follow up treatment.

This research

https://pmc.ncbi.nlm.nih.gov/articles/PMC8749855/

includes:

According to the latest guidelines of the European Society of Urologists, patients that show two of the three high-grade features (positive margins, pT3 stage and grade group 4 or 5) are candidates for adjuvant radiation therapy. 

Your husband, unfortunately, fits all 3 features which is why they'll be considering further treatment. His first post op PSA will also be significant to their decision. I fitted two of the features but my first post op PSA was undetectable so I assume that why it was decided that I needed no further treatment.

I can't find any any data or research on how common 'urethral infiltration' is or whether or not it is worse or better than any other positive margin.

If it's any comfort to you, I'm now over two years post op and my PSA is still undetectable.

From the outset, I've been following your story. All through it, your husband has had a tremendous work ethic, I hope he doesn't overdo things. Perhaps focusing on his job is helping him.

I wish you both luck going forward and hope that his next PSA results are favourable.

I must emphasis that I am not medical qualified but there are others, far more knowledgeable than me on here, who will put me right if I'm wrong.

Edited by member 31 May 2025 at 14:21  | Reason: Additional text.

Hi I am so sorry to hear that your post op pathology report has brought such unwanted news.

I know you do not live in the UK and I recall your husband was wanting to delay his treatment because of his work commitments. I think in the UK your husband would have started treatment earlier because of his high PSA. High PSA can be as a consequence of spread which thankfully  appears not to be the case for your husband and sometimes, but certainly not always as the opposite can be true, indicative of more aggressive cancers. It would appear that your husband’s high PSA is a consequence of the aggressive nature of his cancer and the localised spread to the uretha lining.

The positive news is that your husband has had his surgery and his first post op PSA test is likely to inform what will happen next. If his PSA is undetectable they may adopt  a wait and see approach. I think you should ask what is the likelihood of reoccurrence give his pre op PSA, Gleason score, positive margin and some localised spread. It is likely that will mean he is at high risk of BCR but that is not a given. If his PSA is not undetectable I expect they will want to start immediate treatment which is likely to be hormone therapy and radiotherapy. It may be worthwhile looking at the adjuvant therapy offered where you live.

I admire your husband’s work ethic and his desire to get back to work and no doubt work assists his MH but I suggest he takes his time as he starts his recovery.

i wish you both all the very best for the future.

Fragan, I was diagnosed March 2024 with locally advanced adenocarcinoma and straightaway started Hormone Therapy. I had 20 fractions of standard high dose radiotherapy June to July. Since then PSA has been undetectable. At a meeting on 28 March the oncologist agreed that I could stop the HT. I stopped taking the Abiraterone and the 5th injection of Leuprorelin Acetate (Prostap) in March is hopefully the last. Radiotherapy is much like an X-Ray, painless. Depending on what is being targeted will dictate side effects. For me the effect on my bowel and bladder until rents have been challenging. There is ample information to be found on the side effects of HT. Although as far as I am concerned that one in March was my last I was told the side effects will continue another 6 to 8 months. I took the view that I had really no choice to take the HT and RT but I am not prepared to keep putting myself through the side effects for another 2 years which. Is what I was told gives the best chance of prolonging my life. The oncologist was satisfied the cancer’s gone -his words which is all due to RT so don’t shy away if it’s recommended.
Good luck with whatever you have done to you.

John from Scotland

Hi Fragen,

Ideally after a prostatectomy your husband's PSA should be undetectable. Unfortunately it appears his isn't. It's low though. I believe that over here, salvage treatment is not usually considered until 0.2. Let's hope his PSA remains below this level and further treatment is not required.

I wish you both the best of luck .👍

All the best for you too!

We are meeting the drs on Wednesday.