Orchiectomy--any considerations that might be overlooked?

[cigafred]

It has been suggested to me that I reconsider an orchiectomy (versus first-line ADT) after opting for degarelix, then lupron for the last few years. Of course the decision depends in part on my own situation, but I am asking for opinions as to the following:

–might an orchiectomy preclude participation in some clinical trials?

–I am not aware of any RCTs, but as best I can discern from the literature (see sample below) the side effects of an orchiectomy, though slightly different, are similar enough to the side effects of injections that they can be disregarded for someone in good health.

–Any other external factors to consider (yes, I know, an orchiectomy rules out iADT)?

I have read, and appreciated, “Surgical Castration. Why is it uncommon?” pjoshea13

and also a retrospective study:

prostatecancerinfolink.net/...]

All 3,295 patients included had a primary diagnosis of metastatic prostate cancer (i.e., these were not men whose cancer was diagnosed at an earlier stage and then progressed over time).

Compared to patients treated with LHRH agonists, the patients treated by surgical orchiectomy had

Lower risk for bone fractures (hazard ratio [HR] = 0.77; P =0.01)

Lower risk for peripheral arterial disease (HR = 0.65; P=0.004)

Lower risk for cardiac-related complications (HR = 0.74; P =0.01)

Similar risk for diabetes

Similar risk for cognitive disorders

Thanks,

[Magnus1964]

Having an Orchiectomy does not eliminate you from clinical trials or intermittent ADT protocols (even though I am not a fan of iADT). It is something done as a last resort for a particular drug.Having an orchiectomy does not preclude the use of any future ADT drugs.

An orchiectomy poses the same risk of osteoporosis as extensive use of ADT protocols. This is countered with xgeva in either case.

I hope I have answered your questions. If I have missed anything let me know.

[Hidden in reply to Magnus1964]

what was the reason for you deciding for it?

[Magnus1964 in reply to Hidden]

Back in the early '90s all of the new scans used to detect Pca in the surrounding tissue of the prostate were not available. So when I was to have my prostate removed the cancer was found outside in the surrounding tissue. The prostate was not removed and my surgeon recommended the orchiectomy. Lupron was not around either.

I don't regret it. It gave me the years I needed for all of the new research and drugs that were developed when it came time.

[Tall_Allen]

You may have seen these, but here's what I have in my files:

pubmed.ncbi.nlm.nih.gov/317...

eu-openscience.europeanurol...

pubmed.ncbi.nlm.nih.gov/306...

bjui-journals.onlinelibrary...

ascopubs.org/doi/pdf/10.120...

ncbi.nlm.nih.gov/pmc/articl...

The other factor to weigh for some men is the superior cardiac profile of Firmagon in some men with pre-existing cardiac problems (I don't know if this applies to you). Firmagon, and presumably Relugolix (when it becomes available) may suppress FSH, which may mitigate cardiotoxicity of LHRH agonists or orchiectomy. Firmagon is a monthly shot, and Relugolix will be expensive pills.:

ascopubs.org/doi/abs/10.120...

urotoday.com/conference-hig...

[cigafred in reply to Tall_Allen]

Fantastic. If you ever teach a class in setting up a filing system, save me a place. Yes, I started on degarelix for the reasons you state, but after a couple of years I was getting vertigo and even a couple of fainting spells on the day after injections, so switched to lupron (especially since the cardiac advantages of degarelix seem to be mainly in the first year). From your citations, two (that came out after my initial research a few years ago) give me pause:

"This study further demonstrates that orchiectomy causes greater increases in fat accumulation compared with GnRH agonists and that these increases are associated with an increase in insulin resistance."

bjui-journals.onlinelibrary...

02 November 2018

"Triptorelin injections resulted in 29% (95% CI 17.2, 41.7) lower testosterone levels compared to subcapsular orchiectomy (p<.001). A significantly higher proportion of men receiving triptorelin had testosterone levels <20 ng/dL at 12 and 48 weeks compared to men undergoing orchiectomy (97% versus 79% and 100% versus 87%, p<.05)."

ncbi.nlm.nih.gov/pmc/articl...

June 2017

Thank you sir

[Tall_Allen in reply to cigafred]

If the cardiac effects are because of FSH, you can also discuss adding estrogen patches. Estrogen inhibits FSH, but also pushes T levels lower, decreases hot flashes, and helps prevent fat accumulation/maintain lean body mass. It does have higher risk of blood clots, but not as high as estrogen pills.

[Proflac in reply to cigafred]

Hi cigafred. Do you mind telling me how you resolved this one? My husband is looking at this option at the moment. He is HSMPc and on decapeptyl and Zytiga. It is not a question of a problem with shots in any way - there is no cost to us on the NHS and he does not regard it as an inconvenience to have a 6 monthly injection. So, there would have to be some other positive reason for orchiectomy, or at least it would need to be fairly clear that there was no major disadvantage (e.g. less effective at keeping T low). The reason for considering it is that he thinks it just feels better to have fewer drugs, if there is an equally effective alternative. We are not clear if any of the side effects of ADT are due totally to low T per se or if there might be some advantage of orchiectomy in reducing some of the adverse SEs? I think he is most impacted by the mood swings and depression - and I wonder if orchiectomy would make any difference to that at all? I kinda think its unlikely. He is on anti-depressants not after getting desperate and counselling therapy not helping massively. He will be staying on the abiraterone of course. I have looked at some of the research papers following the links provided by T_A which discuss possible physical differences in outcome but they dont seem to be definitive. Is there any more recent RCT evidence on this that you are aware of? Many thanks.

[cigafred in reply to Proflac]

I have nothing additional to what I posted. I have now been on Lupron, then Eligard for years, PSA now <0.02, Testosterone <2.5.

[MateoBeach in reply to Tall_Allen]

Just curious if there is any evidence (perhaps in other cultures) about whether castration at the end of reproduction or earlier results in lower incidence of prostate cancer later in life? Possible prophylactic strategy for BRCA positive and very strong family history?

[Shooter1]

Stage 4, gleason 9/10 and life time lupron. Had orchiectomy instead of third lupron shot after discussion with my wife and three brothers, all agreed. No regrets and sure don't miss shots. My now 4 yr old grandson does shake his balls and penis at me in the shower and tease me about my empty sach, but I can handle his teasing. My two RN daughters also agreed with decision.

[Hidden in reply to Shooter1]

Hey shooter . That grandson is a chip off the ol block.My docs agreed that for me it was a good move . The uro surgeon was happy to snip me. Although it was my idea. 3yrs with no lupron shots ! Worth it for me . Take care “Conductor”

[j-o-h-n in reply to Shooter1]

Hey Shooter,

You do think you and your grandson could be convinced to tape that scene for "America's Funniest Home Video?"....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 07/27/2020 5:28 PM DST

[Shooter1 in reply to j-o-h-n]

He would probably love to, but we could get caught with child pornagraphy .

[Hidden]

It’s such a personal decision . Some guys would rather die than chop the boys . I did it 9-17 and for me it was a relief of worries . Like chopping the dead wood from a tree . I as already chemically castrated . The surgery is simple with some discomfort for a month . I went into a depression thinking my life was over and I was put out to pasture so to speak . That lasted a few months . But then afterwards I’ve been happy . It allowed me to drop the lupron shots . I’m still on a defunct adt test drug that my dr wants me to stay on .Once we get into a clear zone with pc then there might be talk of returning to T ,but once the boys are gone we would have to inject t .. Do what is best for you . Your life , your balls . I looked at my balls as a hindrance to my healing . So addios juevos! No going back on this one 😂💪

[billy1950 in reply to Hidden]

How are you doingcurrently…? Any SEs?

Thanks…

[addicted2cycling in reply to billy1950]

Unlike Hidden, my Orchiectomy happened in 2015 with 2 healthy-high T producing testicles resulting in immediate side effects that I found acceptable given the information that was available regarding the possible SE's from ADT. Have been on "T" replacement since 10 months after the castration and do not recognize and physical improvement following T injections even though the levels increase to 1,600ng/dL.

[FinalBossMatt]

I did it when I was diagnosed stage 4 Gleason 7 and PSA was 2450.

Although I still take medicine, no regrets.

[Hidden in reply to FinalBossMatt]

🤙🏽🏋🏻‍♂️

[cigafred]

Thank you all for your insights. See my reply to Tall Allen, above, for where my thinking is heading.

[RonnyBaby]

It has been suggested that the 'one way / no return' result from the surgery can't be reversed (as if that is of such importance ??) - so don't do it ???

I would look at it this way - why continue to take these drugs (ADT types) and put up with all these side effects, when I could eliminate them from my life forever ? My loss of 'T' would occur, no matter how I tackled it.

I just answered my own question - BUT - these is some resistance out there from the surgeons / specialists about it. I already asked about it and was strongly discouraged considering that option.

What about the costs / savings etc ... ???

Seems some arguments don't carry enough weight.

[Hidden in reply to RonnyBaby]

My Doctors didn’t disagree with me . I’d imagine that in the third world that an orchiectomy is common solely due to the cost effectiveness .. ??

[j-o-h-n]

I think it may be a good idea to remove one at a time.... as a test..... (family jewels)

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 07/27/2020 5:42 PM DST

[Hidden in reply to j-o-h-n]

No half -assing this decision. It’s dos or nada!