Considering High-Dose Rate Brachytherapy

Good to see that you weighed all your options. And the SE do weigh in the decision process (at least for me).
Good luck and keep us posted!

My RO is Dr. Biagioli Medical Director Florida hospital. As to being a 100% sure, that is my hope but I think my decision making, in the end, will come down to an intuitive belief.

My current thinking is each of the major treatments has similar positive outcome statistics and similar SEs. The HDRBT is a much simpler procedure the post-op recovery is very easy and quick.

Subdenis said...

My current thinking is each of the major treatments has similar positive outcome statistics and similar SEs.

Denis, I think if you will read back on many of the studies posted on HW re SE's, particularly those posted by Tall Allen, you will find that the SE's are NOT similar. Your inclination toward HDR Brachy should yield a significantly better chance of avoiding ED and incontinence than if you chose surgery.

Jim

I would say the opposite, problems increase with time regardless of which treatment we choose.

American Cancer Society said...
Two years and 5 years after treatment, men in the prostatectomy group were significantly more likely than those in the radiation group to report urinary leakage and erectile dysfunction. But the problems increased in both groups over time, and 15 years after treatment, the likelihood of having these side effects was similar between the 2 groups. At 15 years, almost all the men reported having erection problems – 87 percent in the prostatectomy group and 93.9 percent in the radiation group.

Bowel urgency also increased in both groups over time until the extent of the problem was fairly similar between the 2 groups. Two years and 5 years after treatment, men in the radiation group were significantly more likely than those in the prostatectomy group to report bowel urgency. But at 15 years, researchers found no significant differences between the 2 groups.

Someone quoted my previous post, then asked the question, “Are you saying that ED gets better for men after prostatectomy?” I saw this just before going out to lunch, and said to myself that, first of all I thought the answer to this was well known, but secondly that this question deserves a well-thought response…which I would do after lunch.

Upon return, I see that the poster has since returned and deleted that post/question, but in the spirit of “there are no bad questions,” I will give a (perhaps shorter) response to the now absent question…

Somebody said...
“Are you saying that ED gets better for men after prostatectomy?”

Yes, absolutely. ED recovery is different on an infinitely-varying scale case-by-case, but I will speak to the well-understood, well-documented general trend which most medical descriptions of the post-surgery experience align with. Moreover, and perhaps equally as important, it aligns closely with the personal (albeit anecdotoal) experiences of many here at HW/PC.

First and foremost, the most obvious determinant of postoperative ED is the preoperative potency status. It’s not going to get better after RP; and there are other factors which affect ED (broad topic; another day)…but high level is that if you had ED before surgery, that’s something that doesn’t improve. The other somewhat obvious factor is nerve-sparing; someone who did NOT have nerve sparing surgery is immediately subject to a much higher stack of issues. For the rest of this discussion, I’m really talking about nerve-sparing cases (such as Subdenis would likely have).

Second is the understanding that some men never recover erectile function from treatment even with meds…although (ultimately) a mechanical implant (another surgery) can simulate functionality (another broad topic for another day). The recovery CAN be influenced by the experience level of the surgeon due to the highly technical nature of RP, BUT broad randomness (rather, unidentified/unassigned causes) appears to be a greater factor because plenty of patients from very experienced surgeons experience extended or complete ED…it’s fact, though, that this happens more frequently with less experienced surgeons. Choose an experienced surgeon to stack the controllable odds in your favor for the best possible outcome. Period.

Finally, to the main point of the question, ED generally gets better after a post-PR recovery period. The recovery period varies like an impulse decaying function. Not to geek out too much, but our electrical engineering 101 textbooks provide similar graphical representations where the x-axis is time, but the y-axis is erectile funcationality. (See THIS) There is an impulse (surgery) and immediate response (ED), some recover functionality in weeks, others months, most within a couple years (and some never, as mentioned). [Some may argue with the use of this impulse response chart as a visual description…I think it’s a pretty good visual description, but I’ll point out one key difference influenced by the first factor which I talked about above, which is that the level of erectile function after RP rarely (never) returns to the same pre-surgery level…it’s going to be at least a little worse. Might be functionally similar, but not as good.]

Why is this 3rd point true? There is actual physical recovery which takes place. There is, for example, mechanically induced nerve stretching that may occur during prostate retraction, thermal damage to nerve tissue caused by electrocoagulative cautery during surgical dissection, injury to nerve tissue amid attempts to control surgical bleeding, and local inflammatory effects associated with surgical trauma. Different, "newer" surgical techniques can help to reduce some of these contributors (and there is continuous process improvement in surgical techniques), but no technique completely eliminates them. For example, lower heat energy—most obviously from cauterization, but also simply from the laparoscopic lighting techniques—is understood to result in better outcomes.

OK, got a little longer than I thought in response to the question which was deleted…but if someone stepped forward to ask the question (even though they then deleted it), then that tells me that there are probably many others who are thinking the same question and afraid to ask. Don't be ashamed to ask. No dumb questions.


Time to disconnect! Adios, have a great weekend...!

Post Edited (NKinney) : 12/8/2017 12:07:57 PM (GMT-7)

NKinney said...
Someone quoted my previous post, then asked the question, “Are you saying that ED gets better for men after prostatectomy?” I saw this just before going out to lunch, and said to myself that, first of all I thought the answer to this was well known, but secondly that this question deserves a well-thought response…which I would do after lunch.

Upon return, I see that the poster has since returned and deleted that post/question, but in the spirit of “there are no bad questions,” I will give a (perhaps shorter) response to the now absent question…

Somebody said...
“Are you saying that ED gets better for men after prostatectomy?”

Yes, absolutely. ED recovery is different on an infinitely-varying scale case-by-case, but I will speak to the well-understood, well-documented general trend which most medical descriptions of the post-surgery experience align with. Moreover, and perhaps equally as important, it aligns closely with the personal (albeit anecdotoal) experiences of many here at HW/PC.

First and foremost, the most obvious determinant of postoperative ED is the preoperative potency status. It’s not going to get better after RP; and there are other factors which affect ED (broad topic; another day)…but high level is that if you had ED before surgery, that’s something that doesn’t improve. The other somewhat obvious factor is nerve-sparing; someone who did NOT have nerve sparing surgery is immediately subject to a much higher stack of issues. For the rest of this discussion, I’m really talking about nerve-sparing cases (such as Subdenis would likely have).

Second is the understanding that some men never recover erectile function from treatment even with meds…although (ultimately) a mechanical implant (another surgery) can simulate functionality (another broad topic for another day). The recovery CAN be influenced by the experience level of the surgeon due to the highly technical nature of RP, BUT broad randomness (rather, unidentified/unassigned causes) appears to be a greater factor because plenty of patients from very experienced surgeons experience extended or complete ED…it’s fact, though, that this happens more frequently with less experienced surgeons. Choose an experienced surgeon to stack the controllable odds in your favor for the best possible outcome. Period.

Finally, to the main point of the question, ED generally gets better after a post-PR recovery period. The recovery period varies like an impulse decaying function. Not to geek out too much, but our electrical engineering 101 textbooks provide similar graphical representations where the x-axis is time, but the y-axis is erectile funcationality. (See THIS) There is an impulse (surgery) and immediate response (ED), some recover functionality in weeks, others months, most within a couple years (and some never, as mentioned). [Some may argue with the use of this impulse response chart as a visual description…I think it’s a pretty good visual description, but I’ll point out one key difference influenced by the first factor which I talked about above, which is that the level of erectile function after RP rarely (never) returns to the same pre-surgery level…it’s going to be at least a little worse. Might be functionally similar, but not as good.]

Why is this 3rd point true? There is actual physical recovery which takes place. There is, for example, mechanically induced nerve stretching that may occur during prostate retraction, thermal damage to nerve tissue caused by electrocoagulative cautery during surgical dissection, injury to nerve tissue amid attempts to control surgical bleeding, and local inflammatory effects associated with surgical trauma. Different, "newer" surgical techniques can help to reduce some of these contributors (and there is continuous process improvement in surgical techniques), but no technique completely eliminates them. For example, lower heat energy—most obviously from cauterization, but also simply from the laparoscopic lighting techniques—is understood to result in better outcomes.

OK, got a little longer than I thought in response to the question which was deleted…but if someone stepped forward to ask the question (even though they then deleted it), then that tells me that there are probably many others who are thinking the same question and afraid to ask. Don't be ashamed to ask. No dumb questions.


Time to disconnect! Adios, have a great weekend...!

I was the one who asked the question (as you can tell I am a newbie) and do not have the vast knowledge that some of you may have with years of being a member of the "club". McKinney your answer seems to conflict with that of Tall Allen (an SBRT guy). I believed what most of the items that Tall Allen mentioned above regarding Surgery and Radiation. I am trying to get my hands around the long/short term effects of surgery vs. Radiation and was under the impression that the SE from surgery may be much more severe short and long term (in terms of ED etc.). I know 4 people who had surgery and after about 6-10 years have severe ED issues etc. (does not mean that is always the case, but still true). Again I am gathering information so I can make an intelligent decision someday down the road in terms of treatment. SE will certainly effect my decision if I have choice in treatment! Sorry if I offended anyone...Happy Holidays all and wish everyone a great and healthy 2018!

NKinney said...
dbell, glad you came back to the thread...

Maybe I misunderstood your question first time around.

Hope this clarifies...you might have been asking a different question than I answered. In hindsight, I can see how your original question (“Are you saying that ED gets better for men after prostatectomy?”) could mean either of the two scenarios I listed here...

Nkinney, thanks for the clarification. Again, I was reacting to the general statement that "ED gets better after surgery"! I was not aware that in MOST cases, this is true. Thanks again for the clarification.

NKinney said...
So more accurately/more completely, the original short but potentially ambiguous statement would likely be better re-stated to: "The typically severe erectile dysfunction which is caused as an immediate side effect of prostate removal surgery generally improves after weeks or months of recovery, although typically lower or near the same, and never to a higher performance level, than it was before surgery."

I have little doubt that most of our PC "vets" knew the complete context of the original statement, but it always helps to get reminded of the newcomer's perspective. I was also a newcomer 8-years ago...sometimes I forget. thanks

Thanks, that is little different than your original statement, but I hear ya. I will stop being a newbie someday, but for now it is what I am. I am also part of a club I never wanted to join as well...thanks!

garyi said...

NKinney.....you ain't half bad either

Gee, thanks. I think.

Apologies to the OP for kidnapping his thread about hdr-BT...

dbell said...
I was not aware that in MOST cases, this is true.

You are quite right that it is not true in most cases, at least not with the average treatment. The PROSTQA study showed that, in a national multi-institutional sample, as of 2 years post-prostatectomy, only 37% of previously potent men who had bilateral nerve sparing were still potent enough for intercourse. So it is true that if close to 100% of previously potent men have at least temporary impotence immediately after surgery, 37% will have regained sufficient potency for intercourse by 2 years. Many of those 37% regain potency within the first year, and almost all the rest by the second year. Very few continue to improve after 2 years, but a few do.

www.europeanurology.com/article/S0302-2838(13)00847-6/fulltext

Results can be better if we focus on a world-class institution like MSKCC. There, patients were treated by top surgeons and had multidisciplinary follow-up (including penile rehab supervised by Mulhall). 48% of previously potent men had regained potency sufficient for intercourse by 12 months. Of the remaining 52%, 22%, 32%, and 40% had regained good erectile function by 2 years, 3 years, and 4 years, respectively. So that brought the total up from 48% at 1 year to 59% at 2 years to 65% at 3 years and to 69% at 4 years. This should provide encouragement to continue penile rehab.

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4605865/

However, even at MSKCC, only 16% with good baseline erectile function got back to baseline function after prostatectomy without ED meds:

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4742368/

Lots of good discussions here, thanks, everyone. One of the factors that have me leaning towards HDRBT is the ease of the procedure as compared to other RT and surgery. My doc said you could play golf the next day. Now that got my attention.

I also believe that this is a matter of risk mitigation. SE risk, treatment risks, and lifestyle risks. We each value certain things in life, which will drive our decision. Thanks again for proving your opinions and input. Denis

WOrks out glad it is going well for you we are similar age and state of disease. My wife and I finalized the decision today HDRBT. Now move to get er done stage. Denis