Burt, you  don't mention if you've had any further PSA checks or DREs
in the last year. If you haven't, that is certainly the top priority.
If the PSA has gone up by any substantial percentage, I think I
personally (as the patient - I'm not a doctor) would be pushing for
another biopsy. If the nodule can still be felt, even though there's
no major change in the PSA level, that for me would also be grounds
for another biopsy - as Dan says, the first one can miss things,
especially if it's a sextant (six-core) one. I notice quite a lot of
recent literature indicating a significantly higher 'find' rate with
more cores.

I'd suggest the sequence could be:

1. Get another PSA check, if at all possible using the same lab which
did the first one. (Especially at these lower levels, there can be
significant variations in score between different labs). You and your
doctor would be looking for a substantial increase from the score last
time.

2. Get a second urologist with a good reputation to do a DRE, to see
whether he also finds that there is a nodule.

3. If either 1 or 2 continue to suggest a possible problem, get a
biopsy done at a good hospital - taking at least 12 cores, and
focusing particularly on the area of the nodule if the second opinion
agrees there is one.

4. If 1, 2 and if necessary 3 are all negative for the likelihood of
cancer (great!), get a simple (external) bladder ultrasound done, plus
a uroflow test. They are both quick and easy, and will tell you
whether you currently have an obstruction which needs active treatment
- what you don't want is to allow your bladder or kidneys to
deteriorate, whether or not your current symptoms are really
troublesome.

5. (a) If either your flow rate is lower than it should be, or the
amount of urine in your bladder is higher , get treatment. The pattern
of flow in the uroflow test would probably help establish what your
problem is (it might possibly be something like a stricture or a
bladder neck problem rather than BPH), but the urologist might want to
do one or two other tests to make sure. (I note you had a cystoscopy
done a year ago - what did it show?) Assuming the diagnosis is BPH,  I
would try medication first; some people have few side-effects and good
results for several years at least - though you'd probably eventually
need something more, a few years down the track. If medication doesn't
work (it didn't do much for me), or the side-effects are unacceptable,
you can then start considering things like PVP.

(b) If the flow is OK and the scan suggests you aren't retaining much
urine, you then need to decide how bothersome your current symptoms
are. If they are bad enough to be a nuisance, again it's time to try
medication in the first instance. Otherwise, just keep checking the
situation at least once every year - PSA, DRE, and possibly uroflow
and ultrasound especially if you think your flow is getting slower.

For me that would strike the right balance between hypochondria and
not doing enough - but I must emphasise that I'm not a doctor, just a
fairly experienced and moderately well read BPH sufferer!

One final thing: I doubt if your urologist was suggesting removing the
*whole* of your prostate - that would be a radical prostatectomy and
would only ever be done if cancer had been confirmed. (It's a really
major operation, and while it could be life-saving, it has pretty
nasty side-effects!) He was suggesting taking out the middle part,
rather like coring an apple, to leave a good space for the urine to
flow through; that is what is done for BPH - in a TURP, and indeed
also in a PVP. Confusion can arise because both the cancer operation
and the BPH procedure are referred to as 'prostatectomy'.

Richard Slessor