Do I Need Surgery for Prostate Cancer?

Being diagnosed with prostate cancer does not automatically mean you need surgery.

In many cases, prostate cancer grows slowly and can be safely monitored. In others, early treatment offers the best chance of long-term cure. The key question is not simply whether surgery is needed, but whether it is the right treatment for your specific cancer.

Mr Philip Dundee is a Melbourne-based urological surgeon who specialises in helping patients understand their options and make informed decisions about prostate cancer treatment.

to discuss your diagnosis and treatment options.

When is surgery recommended?

Surgery is typically recommended when:

The cancer is confined to the prostate
The cancer is intermediate or high risk
Life expectancy is greater than 10 years
Long-term cancer control is the goal

When might surgery NOT be needed?

Surgery may not be required when:

The cancer is low-risk and slow growing
There are no concerning features on MRI or biopsy
Active surveillance is a safe option
Some patients with intermediate-risk cancer may be suitable for surveillance

The decision depends on a combination of imaging, biopsy results, and individual patient factors.

Who is most likely to benefit from surgery?

Patients most likely to benefit from surgery are those with unfavourable intermediate-risk or high-risk prostate cancer and an estimated life expectancy of greater than 10 years. Although some patients outside these groups may also benefit from surgery, the majority of men undergoing prostatectomy fall into these categories.

When is surgery not the best option

Patients with low-risk prostate cancer, and some patients with small-volume favourable intermediate-risk disease, are at very low-risk of dying from prostate cancer and are often best managed with active surveillance. Although there are exceptions, the vast majority of patients in these risk categories are unlikely to ever be harmed by their prostate cancer.

CLINICAL SCENARIOS

When surgery is recommended — and when it isn't

The following examples illustrate how MRI findings, biopsy results, PSA density, age, overall health and life expectancy influence whether surgery, radiotherapy, active surveillance or observation is the most appropriate management strategy.

Example 1: Active surveillance

A 65 year old man has a PSA of 8.2 ng/mL, which remains stable on repeat testing. MRI demonstrates a small equivocal lesion (PI-RADS 3), and biopsy shows a single focus of ISUP Grade Group 1 (Gleason 3+3=6) prostate cancer.

Although surgery and radiotherapy are treatment options, this patient has low-risk prostate cancer and is most appropriately managed with active surveillance.

Example 2: Surgery or radiotherapy

A 55 year old man has a strong family history of prostate cancer. His PSA has risen from 1.8 ng/mL to 3.3 ng/mL over a short period. MRI demonstrates a PI-RADS 4 lesion, and biopsy confirms ISUP Grade Group 2 (Gleason 3+4=7) prostate cancer, including cancer visible on MRI.

Although active surveillance remains an option, the patient’s age, family history and MRI-visible disease suggest a higher risk of progression. Definitive treatment should therefore be strongly considered. For a man of 55 years with a life expectancy of approximately 30 years, surgery would often be favoured because it provides definitive pathological staging and avoids the potential long-term urinary, bowel and secondary malignancy risks associated with radiotherapy.

What does surgery involve?

Robotic prostatectomy is a minimally invasive procedure used to remove the prostate gland.

This approach allows:

Precise dissection
Preservation of surrounding structures, including the nerves required for sexual function when appropriate
Reduced blood loss
Faster recovery

Functional outcomes

Key considerations include:

Urinary continence
Erectile function

These outcomes depend on:

Cancer characteristics
Patient factors
Surgical technique and experience

Is it safe to wait?

In carefully selected patients, delaying treatment is safe and appropriate.

However, delaying surgery in higher-risk disease may:

Allow cancer progression
Reduce the chance of cure

This is why accurate risk assessment is critical.

My prostate cancer requires treatment – should I consider surgery?

Not all prostate cancers require treatment, and not all patients requiring treatment are best managed with surgery. However, for many men with localised prostate cancer, robotic prostatectomy offers excellent long-term cancer control while preserving urinary continence and erectile function where possible.

The following page provides further information about prostate cancer treatment, including robotic prostatectomy, the Retzius-sparing approach, continence outcomes and factors that influence treatment selection.

Can prostate cancer go away without treatment?

No. However, some prostate cancers grow so slowly that they may never cause harm.

Is it better to remove the prostate early?

Not always. Early treatment is beneficial in some cases but unnecessary in others.

What happens if I choose the wrong treatment?

Most treatment decisions can be adapted over time, but initial decisions should be made carefully with specialist input.

Should I get a second opinion?

Yes. Many patients benefit from a second opinion before making a treatment decision.

Who is most likely to benefit from surgery?

Patients most likely to benefit from surgery are those with unfavourable intermediate-risk or high-risk prostate cancer and a life expectancy of greater than 10 years. Although some patients outside these groups may also benefit from surgery, the majority of men undergoing prostatectomy fall into these categories.

When is surgery not the best option?

If you have been diagnosed with prostate cancer, a consultation can help clarify whether surgery is necessary and what the most appropriate treatment approach is.