Robotic prostatectomy is often associated with early, low or intermediate-risk prostate cancer. But surgery can also play an important role for men with more aggressive disease. For some men with high-risk cancer, surgery is the first step in a treatment plan that may include other therapies.
What high-risk means
Prostate cancer is usually placed in a risk group based on PSA, grade and stage. NICE guidance on prostate cancer defines high-risk localised cancer as having one or more of:
- a PSA above 20 ng/ml
- a Gleason score of 8 to 10
- a clinical stage of T2c or higher
Our guide to Gleason scores and Grade Groups explains these terms.
Locally advanced cancer, which has grown just outside the prostate, may also be treated with surgery in some men.
Why surgery may be recommended
For high-risk cancer, the two main approaches that aim to cure are surgery and radiotherapy with hormone therapy. Surgery may be favoured because:
- Complete removal: the whole prostate and nearby tissue are removed.
- Accurate staging: the removed prostate and lymph nodes are examined, giving precise information about the cancer.
- Clear follow-up: after surgery, PSA should become undetectable, so any recurrence is easy to spot.
- Radiotherapy kept in reserve: radiotherapy can be given afterwards if needed.
- Fewer long-term bowel effects: compared with radiotherapy.
How surgery differs for high-risk disease
The operation is often more extensive than for low-risk cancer:
- Wider removal: to reduce the chance of leaving cancer behind, the surgeon may remove more tissue around the prostate.
- Nerve-sparing: may be limited on one or both sides if the cancer is close to the nerves. MRI helps guide this, as described in our article on how MRI helps plan your prostatectomy.
- Lymph node removal: often recommended, to check for spread and remove any affected nodes.
A multimodal approach
For high-risk cancer, surgery is often one part of a wider plan. This is called multimodal treatment. It may include:
- Radiotherapy after surgery: either soon after the operation, called adjuvant radiotherapy, or if PSA starts to rise, called salvage radiotherapy.
- Hormone therapy: sometimes given alongside radiotherapy. Our guide to hormone therapy explains how it works.
Your multidisciplinary team will recommend the right combination based on your pathology results and PSA after surgery.
Recovery and side effects
Recovery is similar to other robotic prostatectomies, with most men going home after one or two nights and a catheter for one to two weeks. However:
- continence may take longer to recover if more tissue is removed
- erections are less likely to recover fully if nerves cannot be spared
- side effects can increase if radiotherapy is added later
Discussing these possibilities before surgery helps set realistic expectations. Starting pelvic floor exercises early, and asking about support for erectile recovery, can help men make the best possible progress. Specialist nurses and physiotherapists can support both.
Follow-up
PSA is checked regularly, usually starting around six weeks after surgery. If it does not become undetectable, or rises later, further treatment can be started promptly.
Is surgery right for you?
Surgery for high-risk cancer suits men who are fit for an operation and whose cancer has not spread to distant parts of the body. It is important to speak to both a surgeon and an oncologist before deciding, so you understand how each approach would fit into your overall plan and what side effects each combination may bring. Prostate Cancer UK has information on treatments for high-risk disease.
Professor Prokar Dasgupta treats men with high-risk prostate cancer as part of a multidisciplinary team at The London Clinic. Our page on radical robotic prostatectomy explains the operation. Please contact the clinic to arrange a consultation.