Prostatectomy vs Radiotherapy for Treatment of Prostate Cancer

Most men will be suitable for a range of treatment options for prostate cancer. Some may clearly be more suitable than others due to a range of factors as technical aspects, safety aspects and preferences. You should get a balanced view of your options and I do recommend you seek this before deciding on what suits you the best. Have at least a discussion with your urologist and a radiation oncologist before you decide. There are also even less commonly pursued treatment options such as HIFU and cryotherapy which you may want to research as well. This article will cover Prostatectomy (surgery) and Radiotherapy.

A prostatectomy is an operation and there are different ways it can be done. It requires a general anesthetic and a period of recovery as well after the operation. The prostate is removed in a single session. Sometimes the pelvic lymph nodes are also sampled or removed as well. If this goes well, it will be the only treatment you require. It will also be very reassuring and satisfying to see your PSA blood count drop to zero or undetectable levels. If, however, the pathologist, who analyses the tissue, reports a positive margin, this means you are very likely to still have prostate tissue or prostate cancer tissue in your body. You will require close observation and depending on the PSA levels on your subsequent blood test monitoring, you will require further treatment with radiotherapy, if you want another attempt at being cured of prostate cancer. Further scans may be required as well prior to radiotherapy.
It may be that your specimen from your prostatectomy was reported as having a negative margin but your PSA is still elevated. This could mean there is still prostate cancer somewhere in your body and most likely it will be within the pelvis if your staging scans had not shown concerning features. Radiotherapy may be recommended as well in this situation depending on your PSA result.

Early prostate cancer can be very successfully removed completely by a prostatectomy, but prostate cancer that is more locally advanced and is of a higher stage, may mean you have a high chance of requiring further treatment after the operation with radiotherapy. In such situations, your urologist may counsel you to avoid having two treatments (a prostatectomy and radiotherapy) and just have the one treatment, with radiotherapy alone. This will reduce your exposure to the unnecessary risk and side effects of a prostatectomy. It may also require the addition of androgen deprivation therapy (ADT). I would recommend you seek treatment from a urologist who works closely with a radiation oncologist, together they can help you navigate the options best suited for treating your prostate cancer.

If both a prostatectomy and radiotherapy are suitable for treating you, then the choice you make hinges on which side effects or lack of are more appealing to you. Your clinicians will inherently work to minimise these as much as possible but there will always be some risks. Seek an open and honest opinion about this. Some of these side effects can sound scary but the probability of them occurring is so low that even your clinicians may never have encountered them in their practice. Ask about this.

Side effects from a prostatectomy can include bleeding risks and infection risk from the operation and also anesthetic risk. Commonly experienced side effects include a period of urinary incontinence which most men will recover from with pelvic floor exercises over a period of time. This will mean you need to wear urinary pads until you recover. There is also a high chance of becoming impotent but discuss this with your urologist as there may be ways your urologist can help reduce the chance of this occurring. This can affect a man’s confidence levels and also affect relationships. A prostatectomy will however avoid the possible risks of radiotherapy.

Side effects from radiotherapy are different from a prostatectomy, and may entail potential bowel bother, bladder bother, and pelvic and hip bony injuries as well as a 2nd cancer risk. Linac based radiotherapy is noninvasive and there are no bleeding risks or infection risks nor any anesthetic risk. Radiotherapy also avoids the urinary leakage side effects and is a better option if maintaining erectile function is preferred.

There is an important difference to understand when choosing between a prostatectomy vs radiotherapy. If the prostatectomy is unsuccessful in curing you, you may still have a contingency plan with pursuing radiotherapy. If, however, radiotherapy is chosen first, and it is unsuccessful in that your PSA continues to climb, then most urologists would not offer you a prostatectomy as the radiotherapy may make the tissues in the pelvis more difficult to operate in. Other means to intervene can be explored such as Nanoknife or HDR brachytherapy. Advances are being made and soon it may become routine to re irradiate the prostate with SBRT if there is recurrent disease post radiotherapy.

Unlike a prostatectomy, it does require several sessions to treat your prostate cancer with radiotherapy. You do need a good bowel preparation and bladder filling for the precision involved in each radiotherapy session, and your treating team will help you monitor and achieve this. Pelvic nodal areas, where prostate cancer can spread to, can also be comprehensively targeted at the same time when your prostate cancer is being treated with radiotherapy. Your PSA count will drop to a much lower level over a period of time. It does not become zero or undetectable, unlike that achieved with a prostatectomy. This is because you will still have an intact prostate gland which produces PSA. Your radiation oncologist will usually put a plan in place to monitor you with PSA tests to ensure the treatment is successful. If you have been placed on ADT, it can make your PSA undetectable but over a period of time, the effects of the ADT wear off and the PSA count may become detectable.

Again unlike a prostatectomy, with radiotherapy your chance of having normal urinary continence is much higher and you have a much greater chance of retaining erectile function. There may be bowel bother and bladder bother as a result from radiotherapy but in the majority of patients, these will improve over a period of several weeks post radiotherapy. If you had an operation to improve urinary flow or had a previous prostatectomy, there may be a chance of having a urethral stricture many years after the radiotherapy. This can result in a poorer urinary flow and you might need help from a urologist to improve the situation. There is a risk of the radiotherapy causing bony injuries to the pelvic bones and the hips but these occur very rarely and usually may take over 10 years or more to turn up. Radiotherapy can cause another cancer in the pelvic but again this is rare and usually a couple of decades may pass before it occurs. As mentioned above, if radiotherapy is unsuccessful, you are unlikely to be offered a prostatectomy to treat you. There are possible other options that might be reasonable to investigate in this situation but are uncommon and not readily available. These salvage options can include HDR brachytherapy and Nano-Knife amongst others.

Gather your information from your clinicians and other recommended sources, discuss with those you trust and also seek opinions from prostate cancer support groups before you decide on which treatment suit you best.

© Ramesh Pandey March 2025