Around one in eight men in the UK will be diagnosed with prostate cancer in their lifetime, making it the most common cancer diagnosis in men. The majority of cases are slow-growing, and when detected at an early, localised stage, outcomes from treatment are excellent. Understanding the pathway from a raised PSA to definitive treatment helps patients navigate each stage with more confidence and fewer surprises.
Prostate cancer is the most common cancer in UK men · Most localised cases are highly curable · Surgery and radiotherapy offer equivalent cancer control for localised disease · Choosing between them is a personal decision — discussed openly at consultation · No GP referral is needed for a private specialist opinion
What is prostate cancer?
The prostate is a walnut-sized gland sitting just below the bladder, surrounding the urethra. It produces seminal fluid. Prostate cancer arises when cells in the prostate begin to divide abnormally. The most common type is adenocarcinoma, which accounts for over 99% of cases.
Cancers are graded by how aggressive they look under a microscope — the Gleason grading system, recently superseded by Grade Groups 1 to 5. Grade Group 1 (Gleason 3+3=6) represents the least aggressive pattern; Grade Group 5 (Gleason 9–10) the most. This grading, combined with clinical staging and PSA level, determines risk category and guides treatment decisions.
Risk factors
The biggest risk factor is age — risk increases substantially after 50 and most diagnoses occur after 65. Family history matters: a father or brother with prostate cancer approximately doubles a man's lifetime risk. Men of Black African or Black Caribbean descent are 3–4 times more likely to develop prostate cancer than white men, and are typically diagnosed at a younger age.
Inherited gene variants, particularly BRCA2, also increase risk — and are associated with higher-grade disease. Men on finasteride or dutasteride for benign prostate symptoms should be aware that these medications halve PSA levels, meaning a measured PSA of 2 in this context is equivalent to a PSA of 4 untreated.
Symptoms — and why early cancer often has none
Early, localised prostate cancer typically produces no symptoms. This is one reason why it is so often detected incidentally — through a PSA test requested for another reason, or during assessment of urinary symptoms that turn out to be related to benign prostate enlargement rather than cancer.
Urinary symptoms — hesitancy, weak flow, frequency, nocturia — are far more commonly caused by benign prostatic hyperplasia than by cancer. Their presence alone is not a reliable indicator of prostate cancer. Advanced or metastatic disease may cause bone pain, weight loss, or haematuria, but waiting for these symptoms to appear means missing the window for curative treatment.
Diagnosis — the structured pathway
The modern UK pathway follows NICE guideline NG131 and typically proceeds as follows:
- PSA blood test — interpreted in the context of age, prostate size, symptoms, and any medications that affect PSA. A raised or rising PSA prompts further assessment.
- Multiparametric MRI (mpMRI) — now standard before biopsy in most UK centres. The scan looks for suspicious areas within the prostate and scores them using the PIRADS system (1–5). A PIRADS 4 or 5 lesion on MRI substantially increases the probability of clinically significant cancer.
- Targeted transperineal biopsy — when MRI is suspicious, a biopsy is performed through the skin between the scrotum and anus (the perineum) under local or general anaesthetic. This approach is safer and more accurate than the older transrectal route. MRI-visible lesions are specifically targeted alongside systematic sampling of the prostate.
- Staging — if significant cancer is confirmed, further imaging (bone scan, CT, or PSMA PET) assesses for spread beyond the prostate.
Raised PSA or awaiting biopsy results?
Mr Sri offers expert PSA assessment including mpMRI and targeted transperineal biopsy. Same-week appointments available.
Treatment options for localised prostate cancer
For localised prostate cancer, the main treatment options are surgery, radiotherapy, and — for very low-risk, well-selected patients — active surveillance. Surgery and radiotherapy offer equivalent cancer control for most risk groups; the choice between them is personal, and both are discussed openly at consultation.
| Option | Best suited to | Primary side effects | Key consideration |
|---|---|---|---|
| Robotic prostatectomy | Fit patients preferring surgery; high-grade localised disease | Urinary leakage (temporary), erectile dysfunction | Definitive tissue pathology; PSA should reach undetectable |
| Radiotherapy + hormone therapy | Good alternative for localised and locally advanced disease | Bowel irritation, urinary frequency, fatigue | No surgical risk; can treat positive nodes with radiotherapy field |
| Active surveillance | Very low-risk, Grade Group 1 disease in older or frailer patients | Anxiety of monitoring; risk of reclassification | Avoids immediate treatment; strict MRI and biopsy schedule required |
| Focal therapy (HIFU, cryotherapy) | Carefully selected unilateral, low-to-intermediate risk disease | Lower side effects than whole-gland treatment | Higher re-treatment rate; not universally endorsed by NICE for cure |
Robotic-assisted radical prostatectomy — what the operation involves
Robotic prostatectomy is the surgical removal of the entire prostate gland and seminal vesicles. It is performed through five small keyhole incisions using the da Vinci robot, which provides three-dimensional magnification and wristed instrument precision beyond the capability of the unassisted hand or standard laparoscopy.
The key technical goals are complete cancer removal with negative surgical margins; preservation of the urinary sphincter mechanism to maintain continence; and — where oncologically safe — preservation of the neurovascular bundles responsible for erectile function (nerve-sparing technique).
Recovery is typically faster than patients expect. Median hospital stay is one day. Most men are dry at night and using a single pad during the day within six weeks. Continence at one year exceeds 90% in nerve-sparing patients in my series, and 80% across all patients.
Pre-operative pelvic floor physiotherapy — starting 4–6 weeks before surgery — is a mandatory part of my prostatectomy programme. The evidence consistently shows faster continence recovery in patients who begin exercises before the operation. All patients are referred to a specialist pelvic floor physiotherapist pre-operatively.
Preparing for treatment — what you can do
Regardless of which treatment is chosen, the period between diagnosis and treatment offers an opportunity to optimise general health. Stopping smoking reduces anaesthetic risk and improves tissue healing. Exercise improves cardiovascular fitness and surgical resilience. Weight management reduces complications. For those proceeding to prostatectomy, starting pelvic floor exercises as early as possible is the single most impactful preparation.
Taking time to understand the options fully — including seeking a second opinion — is always appropriate. For most localised prostate cancers, a few weeks spent considering the decision carefully will not compromise the outcome.
Follow-up and survivorship
After prostatectomy, PSA is monitored regularly — usually every 3–6 months initially, then annually if stable. PSA should become undetectable. A rising PSA after surgery prompts discussion about salvage radiotherapy or other interventions, depending on the timing and rate of rise.
Erectile rehabilitation — with PDE5 inhibitors such as sildenafil, vacuum devices, or injection therapy — begins once wound healing is secure, typically 4–6 weeks post-operatively. Recovery of erectile function after nerve-sparing surgery is gradual and may take 12–18 months.