Surgery or Radiotherapy for Prostate Cancer? Here's What the Evidence Shows

Ajouté : 2026-05-15

[00:00:00]Is surgery better than radiotherapy to manage prostate cancer? That's the question that almost every man that I see in my clinic asks me. And here's what surprises most of them. Studies show that for localized prostate cancer, the long-term cancer specific survival rates are almost identical between the two. But here's where the decision gets genuinely complicated. The side effects are completely different. The failure modes are different. And critically, if one treatment fails, the options for a second bite of the apple are very different depending on what you choose first. In this video, I'm going to break down exactly what surgery does versus what radiotherapy does, show you the evidence on cancer control, and give you what I call the decision making framework, the four factors that should actually determine which treatment is right for you. I'll give you the verdict before the halfway mark. For those of you new to the channel, I'm associate professor Charles Shabar. I'm a urologist and director of the prostate clinic and have been helping men navigate this exact decision for well over 20 years. Have you been through a prostate cancer diagnosis? Are you facing this decision? If you're prepared to share your story, leave it in the comments section down below. And if you get benefit, please thumbs up and subscribe for more content like this.

[00:01:06]Now, let me start with something that changes how most men think about this situation. When men ask me which treatment is better, they're hoping for a clear winner. surgery beats radiotherapy or the other way around.

[00:01:22]The honest answer is for localized prostate cancer, meaning cancer that has not yet spread beyond the pro prostate elsewhere, the evidence doesn't show that one is clearly superior to the other in terms of killing cancer. The Protek trial, one of the largest prostate cancer studies ever conducted, followed around 1,600 men for 15 years.

[00:01:46]Some who had surgery, others who had radiotherapy, and the third group were monitored. Now, prostate cancer specific mortality was low across all three groups and was similar between surgery and radiation at roughly 3%. It should be made aware, however, that the majority of men in that study had low or intermediate risk prostate cancer. Why does this decision matter so much? In essence, it's related to side effects.

[00:02:18]And the side effects are where surgery and radiotherapy diverge significantly.

[00:02:24]And because if treatment fails, the options available to you are very different depending on which treatment you choose first. Radical prostatctomy means removing the entire prostate together with the semen vicles. And in my practice since 2010, that's been done robotically with a da Vinci robotic system. It gives us great precision.

[00:02:46]It's significantly reduced blood loss and a much faster recovery when compared to open surgery. of those aspects there is no doubt at all. Now the main advantage to surgery number one pathological certainty we get rid of the prostate we send it to the lab and we know exactly what we're dealing with. We know the final gleon score. We know how big the cancer was. We know if it was fully contained within the prostate or if microscopically there was any extension through the shell. Now that information is invaluable particularly if we need to make treatment related decisions down the track. Secondly, no prostate. Your PSA goes to zero. So, we have an undetectable PSA after a successful radical prostatctomy. If your PSA drops and then starts rising several months or years later, we know for sure that there are recurrent cancer cells and we've got a clear pathway with regards options moving forward, including salvage radiotherapy. Thirdly, it's a single procedure. Surgery is done in one operation. The majority of my patients are in hospital overnight. You don't need to attend a radiation center 5 days a week for a prolonged period of time. Now, the downsides, and I want to be direct with you here, urinary incontinence is the main shortterm issue. Most men do have some degree of leakage of urine in the weeks after surgery. For the majority of men, it has settled down within several months after the operation itself, as long as they're diligent with pelvic floor exercises.

[00:04:13]Now with robotic surgery, in my experience, continent's recovery has improved dramatically, but the risk is not zero. Erectile function is the other significant concern. How much a man's erections are affected depends very much on whether or not we are able to preserve the neurovvascular bundles or the nerves that supply the penis and allow a man to have an erection. in men with good pre-op erectile function where we spare both of the nerves. Most of these men have meaningful recovery of erectile function within around 12 to 18 months. But here's what most men don't know. The comparison to radiotherapy on sexual function is not as straightforward as it first appears.

[00:04:50]Now, let me explain why. Radiotherapy for prostate cancer comes in several forms. The most common in 2026 is external beam radiotherapy, EBRT. It delivers precise targeted radiotherapy, radiation treatment to the prostate from outside the body. Now, modern-day techniques like IMRT allows us to sculpt around the prostate to give a slight dose around the edge with the aim of avoiding healthy tissues and structures adjacent to the prostate, the bladder and the bowel. Stereotactic body radiotherapy, SBRT, sometimes called cyber knife. We've done a video on this.

[00:05:33]Delivers high doses of radiotherapy in fewer sessions typically in around five treatments rather than the traditional 20 to 40. Now that can also be done with other forms of SBRT that are not necessarily cyber knife and brachi therapy which involves implanting radioactive seeds directly into the prostate. Now the advantages to radiotherapy, no surgery, no general anesthetic, no recovery period. So for men with significant medical conditions, think heart disease, diabetes, where the surgical risk is higher, radiotherapy is an excellent treatment option with equivalent cancer control. Now sexual function in the short term is often preserved better with radiotherapy compared to surgery but radiation doesn't immediately disrupt these nerves or neurovvascular bundles the way surgical dissection does but it can cause effects with time. Now the downsides, bowel side effects. Radiation passes through or near the rectum. The bowel in fact is only 1 millm away from the back wall of the prostate. And so even with modern-day precision techniques, some men experience bowel urgency, loose stool, or in a small number of cases can actually have bleeding from the bowel. It's usually manageable, but these side effects are real and you need to be aware of it.

[00:07:12]Urinary irritation, frequency, urgency, rushing to the toilet, getting caught short, getting up more at night, and men can experience some burning and stinging during and after treatment. Now, in men who already have some obstruction from an enlarged prostate, this can make matters far worse. Now, here's the point about erectile dysfunction that most men aren't told about with radiotherapy, and it affects erections gradually. So, unlike surgery where the impact is immediate and then often recovers, with radiation, the effect can develop slowly and gradually over several years. So, that the short-term advantage for sexual function narrows considerably with time.

[00:08:02]And the most important difference of all is what happens if treatment fails.

[00:08:10]Let's put surgery and radiotherapy side by side directly. Cancer crawl control for localized disease the same at 10 years. Neither wins here. The evidence is clear. Staging accuracy i.e. knowing exactly what we have. Surgery wins here.

[00:08:29]Hands down. We get the pathological confirmation of exactly what grade and stage your cancer is. With radiation treatment, the prostate stays in your body and we don't get a post treatment staging analysis.

[00:08:45]Urinary side effects. Well, surgery causes more incontinents up front, which usually recovers over the ensuing weeks to months, whereas radiation treatment causes more irritation, more irritative symptoms, rushing, frequency, getting caught short, and getting up at night, and that can be during and after treatment.

[00:09:07]sexual dysfunction. Radiotherapy is better in the short term, but surgery and radiotherapy likely converge usually beyond about 12 months following treatment and neither is riskfree.

[00:09:21]Bowel side effects, radiotherapy carries more bowel risk. Surgery in experienced hands essentially none. Now salvage options if treatment fails. And this is where surgery really holds a significant structural advantage. If surgery fails, salvage radiotherapy, adding on radiotherapy after surgery is a wellestablished, widely available option. If radiotherapy fails and surgery were to be subsequently needed, a salvage radical prostatctomy after radiation is actually far more complex and a higher risk procedure. There's actually very few surgeons that perform this because of the high complication rate, most notably bowel injury and longerterm incontinents.

[00:10:13]Recovery and lifestyle. Well, radiotherapy probably wins in the short term. No, hospital stay back to normal activity quickly. But for some men, daily attendance at a radiation center, depending on where they live, for extended periods of time, carries its own logistical and psychological burden.

[00:10:33]So, which is better? Well, here's my verdict. After 20 years in this specialty of looking after men with prostate cancer, for a younger man, less than 70 in good health with a Gleason score of seven or more, I tend to lean towards surgery. We get the pathological information. We get a clear PSA endpoint and we have robust salvage options that are more advantageous than going down the radiotherapy route. for older men over the age of 70 who've got significant health issues potentially heart disease, diabetes or obesity that are increased surgical risk. I tend to recommend radiotherapy as an entirely appropriate firstline option with equivalent cancer control. There's no oncological or cancer cancer penalty for choosing radiation treatment. For a man where preserving sexual function is an absolute shortterm priority, radiotherapy does have an advantage.

[00:11:38]Although I want to be honest here that that advantage definitely diminishes with time. But here is the single most important thing that I will say in this entire video. The quality of the team delivering the treatment matters as much as the treatment itself. A highly experienced radiation oncologist at a high volume prostate cancer center will get far better outcomes than a general surgeon who performs 10 radical prostatctomies a year. Volume and specialization matter. Find someone who does this every week, not occasionally.

[00:12:18]Now, I know this decision can feel overwhelming, not to scare you, but to give you the information that could genuinely change your outcome. These are your options. Know them. Before you leave for your next specialist appointment, ask these four questions.

[00:12:34]Number one, based on my Gleon score, stage, and age, what is your personal recommendation and why? Number two, if this treatment fails, what are my salvage options? Number three, what is your cent's annual volume of prostate cancer surgery or radiotherapy?

[00:12:56]And four, given my specific anatomy and overall health, what side effects am I most likely to experience? And what's the realistic recovery time? Write them down. Take them with you. A good specialist will welcome those questions.

[00:13:13]If you haven't subscribed, please do. If you'd like to know more about your prostate, have a look here or alternatively at this video here. Until the next time, take care of your prostate.