Does Prostate Cancer Always Require Surgery? Treatment and Survival

Not every prostate cancer is treated with surgery, as management depends on tumor stage, grade, patient age, comorbidities, and risk classification. Active surveillance, radiotherapy, hormone therapy, or multimodal approaches may be preferred over surgical intervention in selected cases.

Localized low-risk prostate cancer management often prioritizes active surveillance protocols, which include regular PSA monitoring, imaging, and biopsies. This approach minimizes overtreatment and preserves quality of life while maintaining oncological safety in carefully selected patients.

Advanced prostate cancer treatment options typically involve androgen deprivation therapy, radiotherapy, or systemic treatments rather than surgery alone. In metastatic or locally advanced disease, surgery has a limited role and is generally not considered first-line therapy.

Radical prostatectomy indications are usually reserved for patients with localized or selected locally advanced disease and sufficient life expectancy. Surgical decision-making requires multidisciplinary evaluation to balance oncological control, functional outcomes, and patient-specific clinical factors.

Is Prostate Cancer a Fatal Disease?

This is the most fundamental and justified question in the mind of every man and his family who receive this diagnosis. In short and clear terms: prostate cancer is often not a fatal disease, especially when detected at an early stage. Understanding the nature of this disease is the first step toward eliminating unnecessary panic. The danger potential of prostate cancer depends entirely on the stage at diagnosis and the characteristics of the cancer cells.

If the disease is still localized, meaning it has not spread beyond the prostate gland, the statistics are extremely encouraging. For patients in this situation, the 5-year survival rate is over 99%. This nearly 100% rate tells us the following: the overwhelming majority of men diagnosed early will not lose their lives because of this disease. What makes prostate cancer dangerous and frightening is the scenario in which the disease becomes metastatic, meaning it spreads to other parts of the body such as the bones or distant organs. In this advanced stage, survival rates unfortunately decrease, but this situation represents only a small portion of all diagnosed patients. There are many important factors that affect the overall course of the disease.

Some key elements that determine the overall prognosis, meaning the future course of the disease, are as follows:

• The stage of the cancer (Is it confined to the prostate or has it spread?)
• Gleason score (The degree of aggressiveness of the cancer cells)
• PSA level in the blood
• The patient’s age at the time of diagnosis
• The patient’s general health status and comorbidities

Is Treatment Necessary for Every Prostate Cancer?

Absolutely not. The idea that “if prostate cancer is diagnosed, it must be treated” is an outdated approach that is no longer valid. One of the greatest achievements of modern medicine is understanding that not all cancers are the same and shaping treatment accordingly. A significant portion of prostate cancers grow so slowly and have such an “indolent” character that they may not pose any serious threat throughout a patient’s lifetime. We refer to these types of cancers as “clinically insignificant” cancers. That is why today the main goal is to distinguish these indolent cancers from aggressive ones and to avoid unnecessary treatments.

To make this distinction, a system called risk stratification is used. This system objectively reveals how dangerous the cancer is and outlines the treatment roadmap. The basic parameters used to determine a patient’s risk group form the cornerstone of the treatment decision.

These fundamental parameters guiding the treatment decision include:

• The stage of the tumor (TNM classification)
• The grade of the tumor (Gleason Score in the pathology report)
• The level of PSA (Prostate-Specific Antigen) in the blood

By combining these three main components, patients are classified as very low, low, intermediate, or high risk. The treatment plan is then shaped entirely according to this risk group. While monitoring is generally sufficient for low-risk cancer, more effective treatments are required for high-risk cancer.

How Is Prostate Cancer Follow-Up Without Surgery Performed?

The fact that many prostate cancers progress slowly gives us an important option: not treating every patient immediately. Especially for patients classified as low risk, “wait-and-see” strategies are now accepted as the gold standard. This does not mean abandoning the patient to fate; on the contrary, it means managing the cancer intelligently and closely. There are two main non-surgical follow-up approaches.

Active Surveillance: This is the most common and most proactive follow-up method. Rather than a passive wait, it is a strategy that aims to move to treatment only when necessary by keeping the behavior of the cancer under regular control. The goal is to protect the patient from side effects that reduce quality of life, such as urinary incontinence and erectile dysfunction, which may be caused by radical treatments, or to delay these effects as much as possible. Active surveillance is ideal for patients who have a good general health status and a long life expectancy, and who would not lose the chance of treatment if the cancer progresses. During this process, the patient is closely monitored with a structured schedule.

The basic steps of the active surveillance protocol are:

• Periodic PSA blood tests
• Annual digital rectal examination
• Prostate MRI imaging at specific intervals
• Confirmatory or follow-up biopsies when necessary

Watchful Waiting: This is a less intensive form of follow-up compared to active surveillance. It is generally preferred for older men with significant comorbidities and a shorter life expectancy. The goal here is not to completely eradicate the cancer (cure), but rather to ensure the patient’s comfort by treating symptoms such as urinary retention if they arise.

When Does Prostate Cancer Surgery (Radical Prostatectomy) Come Into Consideration?

Radical prostatectomy is the surgical removal of the entire prostate gland and has been one of the cornerstones of prostate cancer treatment for many years. It is certainly an effective method in terms of cancer control. However, this effectiveness comes with potential side effects. Therefore, the decision for surgery is made very carefully and is not considered a “one-size-fits-all” solution, but rather an option only for patients who meet certain criteria. The aim of surgery is to completely eliminate the cancer from the body and achieve a full cure. Selecting the right candidate is of critical importance to achieve this goal.

There are key factors that determine whether a patient is a good candidate for radical prostatectomy.

• The disease being confined to the prostate (no metastasis)
• The patient having a health status that can tolerate general anesthesia and major surgery
• Generally having a life expectancy of more than 10 years
• The cancer being in the intermediate- or high-risk group, considered too aggressive for active surveillance

For patients who do not meet these criteria—for example, those of very advanced age, with serious heart or lung disease, or whose cancer has spread beyond the prostate—surgery is generally not considered a good option.

What Are the Possible Risks of Prostate Cancer Surgery?

The success of radical prostatectomy in cancer control is undeniable. However, this success may come at a cost, and this cost is generally related to functional outcomes that directly affect the patient’s quality of life. The prostate gland is anatomically located in a very sensitive area. Immediately adjacent to it are both the muscles that ensure urinary continence (sphincter) and the nerve bundles responsible for erection. No matter how much care is taken during surgery, there is always a risk of damage to these structures. Therefore, every patient considering surgery should be aware of these possible outcomes and make their decision accordingly.

The most important potential risks patients may face after surgery, which most significantly affect quality of life, include:

• Erectile dysfunction
• Urinary incontinence (with coughing, sneezing, or exertion)
• Bleeding
• Infection
• Development of hernia at the surgical site
• Formation of urethral stricture

These risks, especially urinary incontinence and erectile dysfunction, cause many men to hesitate about surgery and seek alternative treatment options. This search has brought forward less invasive and function-preserving methods offered by modern medicine.

What Solutions Does Interventional Radiology Offer in Prostate Cancer Treatment?

Interventional radiology is one of the most innovative and rapidly developing fields of medicine. It is the art of performing diagnosis and treatment without large incisions, usually by entering through a needle hole, under the guidance of advanced imaging technologies such as ultrasound and MRI. In the management of prostate cancer, interventional radiology now plays a central role at every stage of the process. It offers solutions that cause less harm to the patient (minimally invasive), are more comfortable, and focus on preserving quality of life. These approaches expand the treatment spectrum by filling the gaps left by traditional surgery and radiotherapy.

We can summarize the main contributions of interventional radiology to prostate cancer patients under several headings.

• Precise and targeted diagnosis (MR-fusion biopsy)
• Treatments that destroy only the cancerous tissue (focal therapies)
• Preparation for high-technology radiotherapy (marker placement)
• Management of cancer-related symptoms (Prostate Artery Embolization)

Thanks to these methods, the dilemma of “get rid of cancer but lose your quality of life” is increasingly being replaced by the philosophy of “get rid of cancer and continue your normal life.”

What Is Focal Therapy and How Is It Applied in Prostate Cancer?

Focal therapy is one of the most exciting developments in prostate cancer treatment and falls within the field of expertise of interventional radiology. The basic philosophy of focal therapy is quite simple and logical: if the cancer is only in a specific part of the prostate, why sacrifice the entire prostate? Unlike the “destroy the whole organ” logic of radical treatments (surgery or radiotherapy), this approach precisely targets and destroys only the cancerous tumor within the prostate. In this way, the surrounding healthy prostate tissue, the nerves responsible for erection, and the urinary continence mechanisms are preserved. This offers an excellent “middle ground” between active surveillance and radical treatments.

Focal therapy can be performed using different types of energy. The choice of method depends on the size and location of the tumor and the patient’s characteristics. These energies are directed directly to the tumor through needles or probes and destroy the cancer cells.

The main focal therapy methods used in prostate cancer are:

• Cryoablation (destruction by freezing)
• HIFU (destruction by heating with sound waves)
• TULSA (destruction by internal heating under MRI guidance)
• IRE / NanoKnife® (destruction with high-voltage electrical current)
• Focal Laser Ablation (destruction by burning with laser energy)

Each of these methods aims to effectively control cancer in appropriately selected patients while preserving quality of life at the maximum level.

What Are the Differences Between Focal Therapies and Surgery in Prostate Cancer?

When evaluating a treatment option, patients naturally ask, “Which is better?” The answer to this question depends on what we mean by the word “better.” If the only criterion is eliminating cancer, both surgery and focal therapies are successful in their respective domains. However, if we define success on a three-legged stool of cancer control, urinary continence, and preservation of sexual function, the picture offered by focal therapies becomes much more attractive. Scientific data and clinical experience show that focal therapies offer significant advantages over surgery, especially in terms of functional outcomes.

Compared to traditional surgery, focal therapies provide important benefits to patients.

• Much lower risk of urinary incontinence
• Much higher preservation of erectile function
• Usually same-day or next-day discharge
• Less pain and faster return to normal life
• Minimal risk of complications such as bleeding and infection
• Does not eliminate the possibility of other treatment options (including surgery) in the future if needed

In summary, for a properly selected patient, focal therapy provides a level of cancer control comparable to surgery while offering incomparably superior results in terms of quality of life. This means that the patient can continue life after treatment much as before.

Is Prostate Artery Embolization (PAE) a Treatment for Prostate Cancer?

Prostate Artery Embolization (PAE) is a procedure in which the arteries supplying the prostate are blocked using angiography, and it is another important tool of interventional radiology. At this point, it must be stated very clearly: PAE is not a primary curative (healing) treatment method for prostate cancer. In other words, it does not aim to completely eradicate cancer on its own. However, it plays a very valuable supportive and symptom-relieving (palliative) role in the management of prostate cancer patients. Especially in certain challenging situations, it can increase the effectiveness of other treatments or significantly improve the patient’s quality of life.

There are specific situations in which PAE is used in the context of prostate cancer:

• Reducing prostate size before radiotherapy
• Stopping uncontrollable urinary tract bleeding caused by cancer
• Helping catheter-dependent patients become free of the catheter
• Increasing comfort by alleviating urinary difficulties in advanced-stage cancer

Thus, although PAE does not directly target cancer, it is a modern and minimally invasive method that makes important contributions to the treatment process by resolving cancer-related problems or preparing the ground for primary treatments.

Conclusion

The journey related to prostate cancer no longer has to be filled with fear and uncertainty. Advances in science and technology offer us personalized, rational options that prioritize quality of life in the management of this disease. The fact that not every prostate cancer is fatal and not every diagnosis requires surgery forms the foundation of modern treatment understanding.

While intelligent monitoring methods such as active surveillance help protect patients with low-risk cancers from the side effects of unnecessary treatments, traditional methods such as surgery remain valid for more aggressive cancers. However, between these two extremes lie revolutionary innovations such as focal therapies offered by interventional radiology. These minimally invasive approaches are redefining treatment standards by aiming to preserve urinary continence and sexual function—two of the most important elements of a man’s quality of life—without compromising cancer control. Today, the goal is not only to survive, but also to live well, with quality and fulfillment. Therefore, when a diagnosis is made, discussing all options with a multidisciplinary team is the most accurate step to take in order to determine the most suitable roadmap for you.

Frequently Asked Questions

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez is one of Türkiye’s leading interventional radiology and neuroradiology specialists, focusing on minimally invasive endovascular treatments. His primary areas of expertise include aneurysm and stroke treatments, embolization procedures, non-surgical treatments of thyroid and parathyroid diseases, interventional oncology, and peripheral vascular interventions. He currently serves as the Head of the Interventional Radiology and Neuroradiology Department at Istanbul Memorial Göztepe Hospital.
Graduating from Istanbul University Cerrahpaşa Faculty of Medicine in 1997, Prof. Dr. Kılıçkesmez received advanced training in interventional radiology and oncology as a Clinical Fellow at London Guy’s & St Thomas’ and King’s College Hospital between 2012 and 2013. He earned the title of Professor in 2020 and, in the same year, became the Founding Interventional Radiologist at SBÜ Çam and Sakura City Hospital. He also holds the EBIR (European Board of Interventional Radiology) certification.
Prof. Dr. Kılıçkesmez has 94 international and 40 national publications and over 2500 citations. He serves as a reviewer for prestigious journals such as the American Journal of Roentgenology (AJR) and Diagnostic & Interventional Radiology. With his clinical and academic expertise, he is a nationally and internationally recognized authority in stroke treatment, brain aneurysm, embolization, tumor ablation, and minimally invasive treatments of thyroid/parathyroid diseases.