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opinions sought re use of mri, laser, for prostate biopsy and treatment

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Posted 9/18/2011 3:30 PM (GMT 0)
hello,
i'm new here and my situation is as follows. comments sought and welcome.

during a recent digital exam, my brooklyn urologist "felt something on the left side...two small bumps" that weren't there before. he recommended a biopsy. i asked if the biopsy could target where he felt something. he said he did not have that capability.

i went for a second opinion, revealing to the second doctor only that my first urologist "felt something and recommended a biopsy." the second urologist (a prominent nyc surgeon) gave me the longest digital exam ever and said, "nothing jumps out at me...there was something on the upper left but it wasn't on the prostate, so i wouldn't recommend a prostate biopsy unless your psa is 2 or higher." later, my psa later came back as 1.8.

meanwhile i was wondering what was it that the second doctor did feel, where exactly it was, and what if anything needs to be done. (in my euphoria, i had neglected to ask him about all this. i will ask him that when he gets back from vacation tomorrow.)

meanwhile research led me to a site which i find to be impressive and promising: sperlinglaserassociates.com/. i am in the process of setting up an mri there to determine where exactly those two bumps are on the left side. good idea? i was also wondering what the opinions are here at this forum re mri's for prostate diagnosis, mri assisted/targeted biopsy, use/effectiveness of laser ablation to go after tumors deemed cancerous. my search of this forum found only limited discussions of this topic, none very current.

my father died of prostate cancer at age 54 after it had spread. that was back in 1978. it was a horrible two years of failed treatments/suffering for him. i am 64 and want to avoid the risks of incontinence and impotence, hence i'm not too keen on radical removal (if deemed necessary), even if robot assisted. i live and work in nyc and have some good recommendations for surgeons, including a couple from the person who advised this forum--he's a prostate cancer survivor but suffering from incontinence for two years (mildly now, he can't have caffeine or alcohol which i'm not sure i could live without;-) after robot-asisted prostate removal by a prominent nyc surgeon.

thoughts? opinions? suggestions?

thanks,
--d
Posted 9/18/2011 4:16 PM (GMT 0)
Pick up a copy of "Guide to surviving prostate cancer" by Dr. Patrick Walsh and read it.....

Today, there is only one way to confirm the existence of prostate cancer and that's a biopsy.

There are advanced Color Doppler ultrasound machines that in the hands of an expert can guide the biopsy needles to suspicious areas of the prostate gland a little better than the 12 core shotgun approach that is generally used....
Posted 9/18/2011 4:19 PM (GMT 0)
I had an mri for diagnosis at a leading cancer facility. They found nothing helpful in the biopsy. Apparently the mri is useful only for a rather large lesion.

Here is the conclusion of one article I found: "T2w eMRI cannot exclude prostate cancer with lesions smaller 10 mm and 0.4 cm3 respectively. The
detection rate for lesions more than 20 mm (1.6 cm3) is to be considered as high."

If you google around for mri, prostate, specificity, you will find plenty of articles saying the same.
Posted 9/18/2011 4:35 PM (GMT 0)
Current MRI technology is pretty good at seeing the main prostate areas, but is inaccurrate in identifying anything in the anterior region.
There are enhanced MRIs using contrast agents and fusion technology with other scans such as color doppler. MRI guided biopsy technology is only in the very early stages and will have a very tough time being accepted. Very few urologists would ever give a referral to a radiologist for a biopsy as this is a territory that they feel is theirs only. A better and certainly less expensive option that has been is use for years is a Color Doppler Ultrasound guided biopsy which is much better at seeing the anterior region and guiding a biopsy needle to places where a normal biopsy would never reach.
As for laser abalation there is little published on results. Prostate cancer is a very strange disease in that reoccurrances happen years after treatments and many treatment that were thoutht to have potential such as HIFU have suffered with high reoccurrance rates at the 5 and 10 year marks. There are many conventional PC treatments to pick from and newer technologies are suductive, but good 5 and 10 years data is needed to prove their effectiveness.

JohnT
Posted 9/18/2011 4:37 PM (GMT 0)
I have to agree with Fairwind's post. Also with your family history of PC you are 5 times more likely to have it in your life time. Even without a family history a man over 50 today has a 1 in 6 chance of getting PC in his life time. There are examples of members in this forum who had low PSA numbers but have been diagnosed with PC. If you do have PC it most likely is small and not as aggressive leaving you with several treatments options other than surgery  including watchful waiting. Living in the NYC area you really have so many more options than  many of us have where we live.

I went from 1.5 to 3.5PSA in 18 months and 5.25 2 months after the 3.5.  My biopsy found a large G7 tumor and after surgery the pathology showed 60% tumor involvement in my prostate. I never had any positive DRE's even prior to surgery. My URO's best guess was I had cancer cells when my PSA was 1.5 and most probably when it was 2.5 a year before my surgery.

Good luck and keep us informed

 

 

 

Posted 9/19/2011 5:26 PM (GMT 0)
In my humble opinion, a PSA reading of 1.8 indicates you are not a candidate for a biopsy, at least not yet.

This typically slow-growing cancer can be monitored for periods of time that allow you and your doc to evaluate changes. If your PSA next year stays the same, then you can celebrate! If it rises, you and your doc need to consider how fast and to what degree it rose, and then you can "enjoy" the biopsy.

We were all neewbies at one point and nothing makes a person sit up and take notice like a cancer diagnosis. The fact that we generally have time on our side, as well as a multitude of treatment (or no treatment) options is a double edged sword. Lots of responsibility for making the right decision for YOU.

This web site is an amazing resource. Read, read and read. The first person here to tell me there is no such thing as a stupid question was Purgatory, and in the year now since my diagnosis, have heard him repeat it countless times.

Good luck.
Posted 9/19/2011 8:38 PM (GMT 0)

I would echo TWG and Fairwinds posts. I had a PSA of 0.4 with an irregular DRE but went ahead with a biopsy - didn't want to take chances with PCa. It's confusing when you get conflicting opinions from urologists. Do you have the option for getting a third opinion - just to be sure before you decide to wait or get a biopsy? My humble opinion would be to go for a biopsy at some point in the future - at least to make sure that it isn't PCa. As GTOdave mentioned - you do have time on your side.

Good luck!

Posted 9/19/2011 9:26 PM (GMT 0)
With a 1.8 total psa, the prior psa history would potentially be relevant. If it has been 1.8 or thereabout for 10 years, that would be different than if it was .6 and then 1.0 and then 1.4 and then 1.8. Of course, that presupposes that you have had a series of prior psa tests. (I am not a doctor, so my advice on medical issues is not worth much -- but I am a guy in my late 40s with an above-normal psa of 1.5, and a family history of prostate cancer, so I watch this pretty carefully and think about the "at what point to do a biopsy" issue too).
Posted 9/24/2011 6:07 PM (GMT 0)

thank you ALL very much for the feedback, information, and suggestions.  an update of my own situation and particulars follow, fyi, along with replies to individual messages.

i called my second urologist and he said the small bumps were vascular and outside the prostate.  but he seemed more cautious this time around and said “with your family history and a father who died young [54] of prostate cancer, we have to be very careful.” thus, he recommended another psa test in november (after two months) and “if it is still two-ish” (which i take includes the most recent psa of 1.8), he would recommend a biopsy.  i didn’t ask him if it would be a local procedure or at a facility where they knock you out (which my first urologist wanted to do).  thoughts on this?

 

meanwhile, i decided to get the mri at http://sperlinglaserassociates.com/ as i had a hunch about this, and wanted to check out the facility.  the facility was first rate and the mri showed nothing in the area where my first urologist said he felt something.  but...there were two other questionable spots that could be something or could be the prostatitis i'm now enduring.  dr sperling said it was my choice if i wanted to do a biopsy to ease my mind.  he recommended another urologist (dr stephen scionti) at nyu who specializes in alternative treatments (tho not laser which is the province of the radiologist, and the newest thing on the block).  so i will seek yet one more opinion (first week of october) from dr. scionti before deciding if and when to do a traditional (trus) biopsy. 

Fairwind,

i checked out on amazon the "Guide to surviving prostate cancer" by Dr. Patrick Walsh.   i see the (c) date is 2007.  i electronically searched thru and found nothing on mri laser biopsy/ablation (which i think came after 2007). 

re: “there is only one way to confirm the existence of prostate cancer and that's a biopsy.”  understood, and i may go that route.  thanks for the info on “Color Doppler ultrasound machines that in the hands of an expert can guide the biopsy needles to suspicious areas of the prostate gland a little better than the 12 core shotgun approach that is generally used.” very good to know.

 

jxmuldoon,

re: “I had an mri for diagnosis at a leading cancer facility. They found nothing helpful in the biopsy. Apparently the mri is useful only for a rather large lesion.” 

i directed this issue to dr sperling and john the mri operator (for want of a better title).  john indicated that if it can be felt, it will show up on their mri.  dr sperling said that they can pick up 4mm.

John T

re: “Current MRI technology is pretty good at seeing the main prostate areas, but is inaccurate in identifying anything in the anterior region.” 

i directed this issue to dr sperling and john the mri operator.  they said that their mri can see the whole prostate effectively. 

re: “Very few urologists would ever give a referral to a radiologist for a biopsy as this is a territory that they feel is theirs only.” 

understood.  but my first urologist is a stand-up brooklyn guy and he wrote me the mri Rx at my request. 

re: “As for laser ablation there is little published on results...[a] good 5 and 10 years data is needed to prove their effectiveness.” 

agreed.  i may roll the dice anyway, because i dread the incontinence and impotence side effect issues associated with standard protocols.  my father suffered from both of these (incontinence front and back) until his death and for him it was torture.

Water Guy

re: “Also with your family history of PC you are 5 times more likely to have it in your life time.” 

various sites (sorry, i did not keep track of the url’s) have various increments.  one had double (vs 5x) and said if a father AND brother had it then you are 5x more likely. 

re: “low PSA numbers but have been diagnosed with PC.” 

yes, somewhere i read that 15% of the men with normal psa’s had pc!  and 65% with abnormal psa’s did not test positive on the biopsies!  not very encouraging stats (if accurate). 

GTOdave,

re: “In my humble opinion, a PSA reading of 1.8 indicates you are not a candidate for a biopsy, at least not yet.” 

yeah, that’s pretty much what my second urologist said.  i’ll see what the third urologist opinion brings. 

abaa2011,

re: “I had a PSA of 0.4 with an irregular DRE but went ahead with a biopsy.” 

may i ask, what were the results, and how do you proceed now? 

yes, i can go for a third opinion, and will go for a third uologist opinion as noted above.  trying to feel my way as to where the proper cutoff might be.  ugh!

medved

agreed, “With a 1.8 total psa, the prior psa history would potentially be relevant.”  but maybe not...see http://blogs.wsj.com/health/2011/02/25/psa-velocity-doesnt-help-predict-prostate-cancer-study/

i have had psa’s for many years but did not kept careful track of numbers.  they’d tell me normal (or high, e.g., if i was suffering from prostatitis, which plagues me) and i’d not ask about/keep track of the actual numbers. or they’d give me the numbers and i’d quickly forget.  i went back and reconstructed a few years worth from my brooklyn urologist (see above).  i will go back to my gp and see what his records show.  and i will be diligent in the future.  there was a time i was below 1.0 when i was on propecia for a year and that lowered my psa results (no hair gain). 

re: “I am a guy in my late 40s with an above-normal psa of 1.5...” 

i thought 4.0 was normal?  i think my psa numbers were around 3 when i was in my 40s, and they were telling me that was normal, if i am recalling correctly (can’t swear to it).

 

thanks again, everyone!

--d

Posted 9/24/2011 8:20 PM (GMT 0)
I believe that Dr Sconti uses the Color Doppler to guide biopsies and his speciality is cryosurgery.
Posted 9/25/2011 2:49 AM (GMT 0)
It is very interesting that your doc claims such predictive value for his mri. Does he have any statistical evidence to back up his view that he can catch 4mm lesions, or is this just impressionistic?

For a less optimistic view of the relevant mri, see

Tumorsize dependent detection rate of endorectal MRI of prostate cancer—A histopathologic correlation with
whole-mount sections in 70 patients with prostate cancer Matthias C. Roethkea, 1, , , Matthias P. Lichya, 1, Leo Jurgschata, Jörg Hennenlotterb, Ulrich Vogelc, David Schillingb, Arnulf Stenzlb, Claus D.Claussena and Heinz-Peter Schlemmera
Posted 9/25/2011 3:52 AM (GMT 0)
jxmuldoon.
not sure what the basis was, i did not inquire. the article you cite is about "endorectal mri." is that the same mri as the "uromri" described here http://sperlinglaserassociates.com/diagnosing-prostate-cancer/mri-vs-ultrasound/ ?
Posted 9/25/2011 5:04 AM (GMT 0)
An endorectal mri involves using a coil inserted in the rectum to improve the mri signal. You might get your doctor to explain what a uromri is. I suspect it is simply using an mri in connection with the biopsy. This has been done now for a while, with limited success. Unless the "uromri" involves taking an appropriate number of samples (at least 12), it will not replace the value of a biopsy. Your doc may state otherwise. Still, I think you would do well to get another opinion. Dr. Scionti seems like a good idea to me.
Posted 9/25/2011 10:51 AM (GMT 0)
ok, thank you for your input. just to be clear, there was no biopsy with the uromri, just "picture taking," if you will. curiously, despite what the website says about using a uromri guided biopsy in place of a trus, dr sperling said that the standard of care for prostate biopsies is still the trus, and recommended seeing dr scionti to discuss that. (which makes me think that the website literature needs editing.) glad to hear that getting dr scionti's opinion seems like a good idea to you. thanks.
Posted 9/25/2011 5:09 PM (GMT 0)
I did a lot of research on prostate imaging a couple of years ago and what JX says is basically correct. I also had a E MRIS that failed to see a 2cm tumor, and had the Combidex which did identify it as did the color doppler twice. This whole process got me interested in imaging. The uroMRI seems interesting as it targets blood leakage and water molecules associated with tumors and not the tumor itself, much like the Color Doppler which targets blood flow. There is no data on how well it works. I had an interesting discussion with Dr Barantsz, who is the leading researcher in prostate imaging in the world. The trend seems to be heading towards multimodality fusion technology in which many scans, MRI, CT, CDU and DCE are combined in order to get a more accurate picture of the prostate as no one scan is able to see everything and each scan has the ability to see different things. When you put them all together a better picture is obtained.
JT
Posted 11/2/2011 11:31 PM (GMT 0)
update:  mri showed area on left side suspicious for cancer.  dr scionti did a biopsy taking 16 (vs 12) specimens, targeting the suspect area.  nonaggressive cancer (1.2 cm, gleason 6) was located there.  i am opting for targeted (left side/40% of prostate) hifu treatment in december. 

of note, dr scionti said that mri's were "a hundred times more accurate" than dre's.  his dre showed nothing suspicious.  without targeting the suspect area discovered via mri, the cancer might not have been found during a standard shotgun biopsy.  as my psa is relatively normal at 1.8, that too would not have been an indication of cancer.

 

so...i will roll the dice with hifu ($25k, may not be covered by insurance), and see what happens.  i opted for hifu over the laser treatment as the laser treatment ($20K that may not be covered by insurance) is so very new (a year old) with no track record--maybe 50 people total in the u.s. have had it done since inception. 

the cryo treatment would have been covered by insurance, but high risk of of impotence and incontinence (as with radical surgery) turned me off to that.  in comparison, hifu has low risk of these side effects, which is crucial for me.

given my family history of cancer (my father died at age 54 from prostate cancer that was apparently aggressive), "active surveilance" was not appealing. 

best website i've come across is here http://prostate-cancer.med.nyu.edu/

 

Posted 11/3/2011 9:00 PM (GMT 0)
The tradeoff for HIFU is a considerably reduced risk of SE's against apparently a higher frequency of recurrence.
Not saying it's a bad trade, since I made it.

I would recc against the targeted treatment. The disease, unfortunately, is multi-focal, meaning you can have several other small tumors/cell clusters that even the best MRI will not find, in addition to the tumors Scionti did find. I suggest the increase in risk of SE's is small, and the potential gain from treatment of unknown tumors is significant, if you have the entire gland treated.

I have done the Bermuda trip twice, and am happy to share suggestions of what i would and would not do again.
Posted 11/4/2011 2:58 PM (GMT 0)
THANKS MUCH, Larch. i know no one who has done hifu and so would very much welcome hearing anything and everything you have to offer on this subject, including your experiences, suggestions of what you would do/not do again, etc.

re: "I suggest the increase in risk of SE's is small, and the potential gain from treatment of unknown tumors is significant, if you have the entire gland treated." can you put numbers/percentages to this? i am preparing an email to dr scionti (was he your doctor? thoughts?) with a bunch of questions. a draft of that email is below. would welcome your comments on the proposed questions.

how/what was your catheter experience, especially flying home?

what hotel did you stay at and what were the rates, and your experiences? the recommended hotel looks very pricey. how long were your stays in bermuda?

proposed questions to dr scionti follow--your input would be most welcome.

(1) How long will the catheter be necessary? I believe you said 5 days. The materials sent to me say that the catheter “will be in anywhere from two to four weeks.”
(2) For the possible risks associated with HIFU, the consent form lists the side effects below (among others). Can you please tell me how great each of these risks is percentage-wise?
· Urinary Incontinence (leakage of urine). I believe you said the risk was less than 5%, correct?
· Impotence (the inability to have an erection. I believe you said the risk was less than 5%, correct?
· Urethral stricture, bladder neck contracture (a narrowing of the tube from the bladder to the outside of the body, either near the bladder or at another point). The Smilow website indicates a 5% risk, correct?
· Possible return of cancer after treatment. I believe you said that the literature indicated that there was a 20% chance of recurrence after 8 years, correct?
· Retrograde Ejaculation (passing of semen back into the bladder instead of out of the penis upon ejaculation); (This seems to be a result of the biopsy itself—will that correct in time?)
· Rectal wall injury and / or rectal fistula (an abnormal hole in the rectum);
· Rectal incontinence (leakage of stool);
· Damage to the rectal wall (rectal fistula) from the heat generated from the treatment.
· Sudden, complete inability to urinate;
· Dysuria (difficulty with urination);
· Urinary tract infection (UTI);
· Prostatitis (infection of the prostate).


(3) After HIFU treatment, what will be the follow-up protocol to see if the cancer has returned?

(4) Under what medical circumstances would the HIFU procedure have to be postponed, e.g., cold, flu.

(5) Assuming impotence as a side effect of the HIFU, would use of a vacuum pump and constriction rings provide capable erections?

(6) I was planning on having some dental work done (capping two front teeth) asap in 2011 after i recover from HIFU (and catheter is out and things are safe). Any problem with that?
Posted 11/4/2011 3:03 PM (GMT 0)
D,

A biopsy is not the end of the world. Mine took maybe 10 minutes, they used local anesthetic, and it was over. Uncomfortable, yes slightly, but not as bad as stubbing your toe! And I had mine at a VA hospital. If they had only read the slides correctly, and determined I was a 3+4 rather than a 4+4, I'd still have nerve bundles. The moral of that story is, have a biopsy and if the results seem really bad, get a second opinion on the slides. My PSA was 2.1, no family history.
Posted 11/4/2011 3:30 PM (GMT 0)
thanks fertree, you must be responding to my earlier post--see my most recent post immediatelyh above yours. but you are right. with 5mg of valium an hour before, and local anesthetic (lidocaine) of the prostate, the biopsy really was no big deal. 15 minutes to do 16 cores. worst part is now cumming blood and not cumming the same. seems some kind of retrograde thing is going on. hoping that is temporary. dr said it takes about 15 shots and 5-6 weeks to clear your cum of blood. but then, it'll be hifu time for me, if plans remain the same.
Posted 11/4/2011 9:39 PM (GMT 0)
I did have Scionti perform both HIFU's.

Flying home with the cath was shockingly easy, even security

The Princess is expensive, look for 4 nights for price of 3 deals, and the hotel across the street sometimes is less expensive.
That being said, the walkin shower in Bermudiana rooms in the Princess are worth serious money for the first two days.
Arriving two days before and flying back the second day after the procedure works well

As guesstimate %'s, consider multifocal to be 50% and risk of increased SE's to be under 5%

The Q's are fair, but no one is giving you a 5% est on impotence. He might say 15%, which sounds high, but is half to third the % for other procedures.

You need gauze 4x4's for the cath insertion site - bring 20 - and alcohol wipes - these are the key to avoiding UTI's.
Wipes can be bought for like 100 for $2

Skip the gym pants that other recc. Go for style of pants you like, just get waist size 2-4 inches larger to account for tubing.
If you recently lost weight, bring the old pants.
Get into better shape now, especially crunches to slim down and improve your abdominal wall.
Learn what Kegels are and practice a bit. Not critical as for other treatments, but can be helpful to limit small leaks

Walk a lot and drink water or vitamin waters like a fish after the procedure. No alcohol, no caffeine.
When the tube is pulled, stop walking and drinking for a few hours, and lie flat to let the wound close
Even months later, alcohol and caffeine will trigger small leaks if you are not careful.

Skip the leak pads, you won't need them
Whenever you get good at a technique, like emptying the bags, you won't need to do that anymore within 48 hours

The real SE's with the refinements that Scionti has acquired are impotence, UTI's and incontinence.
I think the UTI's are there because some patients were not fanatic about taking the Cipro on schedule and using the alcohol wipes with each change of the gauze around the cath site.
The incontinence is very likely under 5%.
The impotence Scionti is excellent at avoiding, but sometimes the biology of where the blood and nerve vessels are and how the treatment has to occur break wrong, which is why I would be much surprised if you get an est under 15%

The NYU facility for prostate cancer is quite large, so while you can use other Uro's, if you are in NYC, you might want to stay with Scionti/NYU fro post-treatment care.

Good luck
Posted 11/5/2011 7:13 PM (GMT 0)
thanks much, larch for all the great info, and for sharing your experiences. i hear you on the "get it all out" approach. however, as i continue to do research on this matter, i am still leaning to focal treatment. i found an article here http://www.ucl.ac.uk/news/news-articles/0910/09102201
citing emberton whom scionti reportedly trained under
(see here http://www.nyhifucenter.com/?gclid=CLPkiOSToKwCFQd_5Qodk2hU3Q),
so perhaps that is where dr scionti's 5% failure rate originated. the article states as follows:
“The first two trials aim to treat the cancer wherever it is. They are near completion and early results show that 95% of men have return of erections and control of urine after treatment with no back passage symptoms. The cancer was eradicated in 90% of men, and in those where there was residual cancer, HIFU was repeated successfully..."
Posted 6/18/2012 1:44 PM (GMT 0)
I had the left side of my prostate ablated via HIFU in December 2011. All went well. PSA before HIFU was only 1.85 (but up from 1.21 a year before). MRI indicated 80% chance of cancer and biopsy confirmed.

HIFU procuedure went well...no complaints re the Bermuda facility. Catheter (the worst part) was out in 6 days. Soon thereafter, erictile and urinary functions returned to pre-procedure level and maybe a little better.

One month after HIFU, PSA was 0.4, after three months 0.24, and after six months (June 2012) 0.17. So a downward trend. Had MRI and (darn it) one radiologist says he sees something suspicious and recommends a biopsy. Another team of radiologists "don't necessarily agree" with the first radiologist's interpretation and my new/local urologist said, based on the team's take and the very low PSA of 0.17, no biopsy recommended at this time; come back in six months.

The issue now is whether to biopsy or wait the 6 months. Will be making arrangements to go over all this with my HIFU doc who has moved to a different city, and see what he thinks. His will likely be the tie-breaking vote for me re getting a biopsy.

Toughts? Comments?

Thanks!

Post Edited (5dino5) : 6/18/2012 7:47:31 AM (GMT-6)

Posted 6/18/2012 1:58 PM (GMT 0)
good to hear from you again. very few here have ever expperienced HIFU, and opinion runs across the spectrum. on the surface, it looks like it did well for you, and with the subsequent decreases in PSA, one would think they "got it", as reference to the cancer. however, its also possible, that some cancer was left behind, thus producing the PSA that you are still reporting.

with HIFU, I don't know what the measure of sucess is considered with PSA. If you had surgery for a primary treatment, a .17 would be terrible and considered a sign of failure or recurrance. If you had radiation as secondary treatment, a PSA of .17 would also indicate failure.

With your HIFU, what are you options for a secondary treatment, if, and God forbid, additional cancer were found via another biopsy? What can still be done if that is the case, or if you ever had recurrance in the future?

I hope none of this is the case, and another round of professional opinions is definitely paramont in your situation. My best to you, please keep us well posted, want to make sure that you will be okay.

David in SC
Posted 6/18/2012 2:28 PM (GMT 0)
thanks for the reply, david.  i was unaware of the psa indicators re surgery and radiation.  i guess that makes sense because surgery and radiation patients no longer have any prostate, and should have 0 or near 0 PSA.  i'm also guessing that the same would be true if one had his full prostate ablated via HIFU.  i have more than half (about 60%) of my prostate left. 

my current hometown (nyc) urologist said if my psa got up to two points above the lowest psa (2 + 0.17 = 2.17) then he would say do an MRI and if indicated, a biopsy.  but he also said that "we are in unchartered territory here," so there really are no reliable benchmarks, which naturally concerns me. 

my new (NYC) urologist was of a mind to NOT do any MRI--but did so at my request, which was triggered on a passing statement made by my HIFU doc (who moved out of NYC) some months before.  for me the trickiest question is, can cancer emerge while PSA is going down?  i suppose anything is possible.

if there is a recurrence, more hifu should be an option.  laser ablation may be as well, tho no one has told me that directly.

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