Prostate Cancer Surgery vs Radiation: How Decisions Are Really Made
This article forms part of Dr Deanne Soares’ urologic cancer education series, providing evidence-based guidance on the diagnosis, treatment and recovery pathways for urological cancers.
One of the most common questions I am asked in clinic, as a urologist treating prostate cancer in Australia, is deceptively simple:
“Should I have surgery or radiation?”
It is a question raised by men and people with prostates soon after diagnosis, often after weeks of uncertainty, online research, and well-intentioned advice from friends, family and colleagues. It is also a question referring GPs ask early, when trying to guide patients through what is often the most confronting decision of their care.
Having worked across the Australian public and private health systems, and alongside radiation oncologists in multidisciplinary settings, I have seen how both prostate cancer surgery and radiation can be highly effective treatments in the right context. I have also seen how poorly framed decisions can lead to regret — not because the “wrong” treatment was chosen, but because expectations and trade-offs were not clearly understood from the outset.
This article is not about promoting one treatment over the other. It is about how decisions are actually made in real clinical practice: how cancer biology, patient priorities, functional considerations and long-term planning intersect. In other words, how experienced clinicians approach these decisions — not how treatments are marketed.
Start with the cancer, not the treatment
Before comparing surgery and radiation, the most important step is understanding the cancer itself.
Prostate cancer is not a single disease. Two people may both be told they have “prostate cancer” and yet be dealing with cancers that behave very differently over time.
Key factors that shape decision-making include tumour grade (ISUP grade group), cancer volume on biopsy, PSA level and PSA density, MRI findings, and clinical stage. In Australia, the widespread use of MRI-targeted biopsy has improved risk stratification considerably, but even with modern imaging, uncertainty remains. Microscopic extension beyond the prostate cannot always be predicted with certainty.
That uncertainty is precisely why treatment decisions must be thoughtful rather than formulaic.
The real question is not “Which treatment is best?” in isolation.
It is “Which treatment makes sense for this cancer, in this person, at this point in time?”
What surgery and radiation are both trying to achieve
At their core, both prostate cancer surgery and radiation aim for durable cancer control while preserving quality of life as much as possible. Where they differ is in how that goal is pursued, and how risks and side effects are distributed over time.
Surgery: removing the prostate
Radical prostatectomy removes the prostate and seminal vesicles, with lymph node dissection performed selectively based on risk. The cancer is physically removed, and PSA levels should fall to undetectable levels.
Surgery provides:
definitive pathological staging,
information about margins and tumour extent,
and a clear PSA baseline for follow-up.
It also introduces immediate anatomical change, with short- and longer-term implications for continence and sexual function.
Radiation: treating in situ
Radiation treats the prostate where it sits, usually over several weeks, although shorter courses are increasingly used in selected patients. Hormone therapy may be added depending on cancer risk.
This approach avoids surgery and its immediate recovery, but cancer control is assessed over time rather than instantly, and side effects often emerge gradually rather than all at once.
Neither approach is “less serious”. They are simply different paths toward the same objective.
What patients are often really asking
When someone asks whether surgery or radiation is better, the question underneath is usually one of the following:
Which option gives me the best chance of cure?
What will my life look like afterwards?
Which option am I more likely to regret?
The difficulty is that these questions do not always point to the same answer.
How cancer risk level influences the decision
Low-risk disease
For low-risk prostate cancer, the most important decision is often whether treatment is needed at all.
Active surveillance is commonly appropriate and avoids exposing patients to the risks of surgery or radiation when the cancer is unlikely to cause harm in the near or medium term. In this setting, the surgery-versus-radiation debate is often premature.
Intermediate-risk disease
This is where decision-making becomes most nuanced.
Both surgery and radiation offer excellent cancer control for appropriately selected patients. Choices are often shaped by:
age and life expectancy,
baseline urinary and sexual function,
tumour location and MRI features,
and personal tolerance for different types of side effects.
Some patients value the clarity of removing the prostate and having an undetectable PSA. Others place greater weight on avoiding surgery and its immediate recovery.
There is no inherently superior choice here.
High-risk disease
In higher-risk prostate cancer, treatment planning often involves sequencing rather than choosing a single modality.
Surgery may be used first, with radiation added later if pathology or PSA behaviour suggests residual risk. Alternatively, radiation combined with hormone therapy may be favoured upfront.
These decisions are best made within a multidisciplinary framework. Patients should expect — and welcome — balanced input rather than a single-discipline recommendation.
Functional trade-offs: where lived experience matters
Urinary function
Surgery and radiation affect urinary function in different ways.
After surgery, most men and people with prostates experience some degree of urinary leakage initially. For many, this improves steadily over weeks to months, particularly with pelvic floor physiotherapy. A smaller proportion experience more persistent issues.
Radiation is less likely to cause immediate leakage, but can lead to urinary urgency, frequency or irritation over time. In some patients, late urinary effects emerge years after treatment.
Baseline urinary symptoms matter. Someone with pre-existing urgency or overactive bladder may experience radiation very differently from someone with strong baseline function.
Sexual function
Sexual side effects are often discussed in broad terms, but recovery trajectories vary widely.
Surgery typically causes an abrupt change, with recovery measured in months to years and influenced by nerve sparing, baseline erectile function, age, vascular health and rehabilitation strategies.
Radiation may preserve erections initially, but changes can occur gradually, particularly when hormone therapy is added. Neither pathway guarantees preservation, and neither should be chosen on the promise of a particular outcome.
Bowel effects
Bowel side effects are uncommon after surgery but can occur with radiation. These are usually mild, but in a small number of patients may be persistent — an important consideration for those with pre-existing bowel conditions.
Sequencing and salvage options: thinking beyond first treatment
One of the less visible but critical considerations is what happens if the first treatment does not achieve durable control.
Surgery followed by radiation is a well-established pathway when needed. Post-operative radiation can be delivered with curative intent in selected cases.
Salvage surgery after radiation, by contrast, is complex and carries higher risks. It is reserved for very carefully selected situations.
In Australian practice — where patients often move between public and private care and rely on long-term GP follow-up — this sequencing conversation is not theoretical. It directly affects access, timing and patient experience.
Judgement matters more than modality
It is tempting to view prostate cancer treatment as a technical decision. In reality, it is a judgement call informed by evidence, experience and patient values.
Two people with similar cancers may make different choices and both be right. What matters is that decisions are made with clarity, honesty and an understanding of what is being traded.
For patients and partners, this means asking about cancer control strategy, functional expectations and realistic recovery timelines.
For GPs, it means supporting patients through uncertainty, encouraging balanced consultations and helping contextualise information that can otherwise feel overwhelming.
Conclusion: choosing clarity over certainty
Prostate cancer surgery and radiation are both valid, effective treatments.
The challenge is not choosing the “best” option in isolation, but choosing the most appropriate option for a particular person, at a particular time, with a clear understanding of what follows.
Good decisions are rarely driven by absolutes. They are built on realistic expectations, thoughtful sequencing and honest discussion of trade-offs. When patients feel informed rather than persuaded, they are more likely to move forward with confidence — and less likely to look back with regret.
That is what good prostate cancer care is meant to support.
About the author:
Dr Deanne Soares is a Melbourne-based urologist with a subspecialty focus in robotic prostate, kidney and bladder cancer surgery, offering advanced minimally invasive cancer care.
