If you have been told your prostate cancer is high risk, you may wonder whether surgery is still possible. For some people, it can be. If your cancer is localised or selected locally advanced without distant spread, radical prostatectomy may still be considered depending on your health and cancer extent.
Robotic surgery describes how the prostatectomy is performed. Your specialist will consider the wider treatment plan, including whether you may later need radiotherapy or hormone therapy.
What Is High-Risk Prostate Cancer?
High-risk prostate cancer has features that make it more likely to grow, return or spread. Your doctor looks at factors such as your PSA level, biopsy Grade Group and cancer stage when assessing your risk.
In UK practice, NICE uses Cambridge Prognostic Groups. CPG 4 includes disease with one high-risk feature such as Grade Group 4, PSA above 20 ng/mL or clinical stage T3. CPG 5 includes Grade Group 5, stage T4 or two or more of the CPG 4 high-risk features. These groups contain a range of disease severity, so being classified as high risk does not automatically mean your cancer has spread to distant organs.
Can You Have Robotic Surgery for High-Risk Prostate Cancer?
Yes, you may still be able to have robotic prostate surgery if you have high-risk prostate cancer. Surgery can be an option for selected men with high-risk localised prostate cancer and for some people with locally advanced disease when there is no distant metastasis and long-term cancer control is considered achievable.
Your suitability depends on factors such as how far your cancer has spread, your general health and whether surgery is likely to offer a meaningful benefit. If the cancer has spread to distant parts of your body, other treatments may be more appropriate.
What Does Robotic Radical Prostatectomy Involve?
Robotic radical prostatectomy involves removing your prostate and usually the seminal vesicles through keyhole surgery. Your surgeon controls the robotic instruments, using magnified 3D vision to work precisely within the pelvis.
For high-risk prostate cancer, your surgeon may need to remove additional tissue or nearby lymph nodes, depending on how extensive your cancer appears to be. The aim is to remove the cancer while protecting surrounding structures as much as possible.
Who Is Most Likely to Be Suitable for Surgery?
You may be considered for robotic prostatectomy if your cancer is localised or selected locally advanced without distant spread and surgery could offer meaningful long-term control.
Age alone does not decide suitability. Your specialist will also consider your fitness, other health conditions and life expectancy before recommending treatment.
When Might Surgery Be Less Appropriate?
Surgery may be less suitable if your prostate cancer has grown extensively into surrounding structures or has spread to distant parts of your body. In these situations, removing the prostate alone may not control all of the cancer.
Your specialist may instead recommend treatments such as radiotherapy, hormone therapy or other systemic treatments. Accurate staging is therefore important before surgery to help choose the most appropriate approach for you.
How Does Surgery Compare With Radiotherapy for High-Risk Prostate Cancer?
| Treatment consideration | Radical prostatectomy | Radiotherapy-based treatment |
| Main treatment | Prostate and seminal vesicles are removed surgically | Prostate and relevant treatment areas are treated with radiation |
| Hormone therapy | Not routinely given simply because surgery was performed; further treatment depends on pathology, nodal status and PSA | Usually combined with androgen deprivation therapy for high-risk disease |
| Lymph-node information | Removed nodes can provide pathological staging | Nodal assessment relies mainly on imaging and radiotherapy planning |
| Further treatment | Salvage radiotherapy and/or systemic treatment may be needed depending on PSA and recurrence risk | Further treatment depends on PSA response and subsequent disease behaviour |
| Important side effects | Urinary incontinence and erectile dysfunction | Urinary, bowel and sexual effects, together with ADT-related effects |
| Follow-up | Regular PSA monitoring | Regular PSA monitoring |
Why Is Accurate Staging So Important Before Surgery?
Accurate staging helps your doctors understand how far your high-risk prostate cancer has spread before surgery. Your assessment may include your biopsy results, PSA level, MRI and other scans to check for cancer in nearby lymph nodes or distant areas.
This information helps your specialist decide whether surgery is appropriate for you or whether another treatment approach may be more suitable. In some cases, staging can completely change the recommended treatment plan.
What Role Does MRI Play?
An MRI scan helps your specialist understand where your prostate cancer is and whether it appears to have spread beyond the prostate. It can also show whether the tumour is close to nearby structures, helping your surgeon plan the operation.
MRI can be particularly useful when deciding whether nerve-sparing surgery is appropriate. However, scans cannot detect every microscopic cancer cell, so your final pathology after surgery may sometimes show more extensive disease than expected.
What Can PSMA PET/CT Add?
A PSMA PET/CT scan can help your specialist detect prostate cancer that may have spread to nearby lymph nodes or distant areas. In the randomised proPSMA study of men with high-risk prostate cancer, PSMA PET/CT was more accurate than conventional CT and bone scanning for detecting pelvic nodal or distant metastatic disease.
However, a negative PSMA PET/CT cannot completely rule out tiny areas of cancer spread. Your specialist may still recommend lymph-node assessment during surgery if your risk of lymph-node involvement is high.
Does a High PSA Mean Surgery Will Not Work?
A PSA above 20 ng/mL is one feature that can place prostate cancer in a higher-risk group, but it does not automatically mean surgery is unsuitable for you. Your PSA is only one part of the overall picture your specialist will consider.
Your Grade Group, MRI findings and staging scans also help show how extensive your cancer may be. Two people with the same PSA can have very different cancers, so surgery may still be considered if your overall assessment suggests it could provide meaningful cancer control.
Does a High Grade Rule Out Robotic Surgery?
Grade Groups 4 and 5 indicate more aggressive prostate cancer, but they do not automatically mean robotic surgery is unsuitable for you. Your specialist will also consider where the cancer is located, how far it has spread and whether it appears possible to remove it safely.
If surgery is suitable, you should also understand that it may be one part of a wider treatment plan. Your final pathology and PSA after surgery may show that additional treatment, such as radiotherapy, is needed to reduce the risk of the cancer returning.
Can Nerve-Sparing Surgery Still Be Performed?
Nerve-sparing surgery may still be possible if you have high-risk prostate cancer. Your surgeon will base the decision on where your cancer is and how close it is to the nerves.
- Tumour location: Nerve-sparing may be considered if the cancer is not close to the nerve bundles.
- MRI findings: Your scan can help your surgeon assess whether nerve preservation is likely to be safe.
- Cancer control: If the tumour appears to involve or lie very close to a neurovascular bundle, nerve preservation on that side may not be considered oncologically appropriate.
- Erectile function: Preserving the nerves may improve your chance of recovering natural erections.
The priority is to remove the cancer safely while preserving healthy tissue where possible. Your surgeon can explain whether nerve-sparing is appropriate for you.
Will You Need Lymph Nodes Removed?
If you have high-risk prostate cancer, your surgeon may recommend removing nearby pelvic lymph nodes during prostate surgery. This can help identify cancer that may not have been detected on scans and provide useful information for planning further treatment.
Pelvic lymph-node dissection can improve pathological staging by identifying small-volume nodal disease that scans may miss. However, a direct survival benefit from performing lymph-node dissection has not been clearly established. The procedure also adds risks such as lymphocele formation and lymphoedema, so your surgeon should balance the staging value against these potential harms.
Why Might Surgery Be Part of Multimodal Treatment?
With high-risk prostate cancer, surgery may be one part of a wider treatment plan rather than the only treatment you need. Even when the prostate is removed successfully, microscopic cancer cells may sometimes remain outside the prostate and cannot be treated by surgery alone.
Your pathology results and PSA after surgery will help guide what happens next. If they suggest a higher risk of recurrence, you may need radiotherapy, hormone therapy or both, so it is helpful to discuss this possibility with your specialist before surgery.
Evidence Note
A multi-institutional study of 1,100 men with clinically high-risk prostate cancer treated with robot-assisted radical prostatectomy reported 10-year biochemical recurrence-free survival of approximately 50% and clinical recurrence-free survival of 87%. Around 37% had received salvage treatment by 10 years.
These results show both sides of high-risk surgery: many selected patients achieved long-term clinical cancer control, but a substantial proportion later required additional treatment. The study used historical D’Amico high-risk criteria and involved specialist tertiary centres, so the figures should not be used to predict an individual patient’s outcome.
What Does the Pathology Report Tell You After Surgery?
After your prostate is removed, a pathologist examines the tissue to provide a more complete picture of your cancer. The report can show your final Grade Group, how far the cancer has spread, whether the surgical margins are clear and whether any removed lymph nodes contain cancer.
These results help your specialist understand your prognosis and decide what happens next. Depending on the findings and your PSA level, you may need regular monitoring or additional treatment such as radiotherapy or hormone therapy.
What Does a Positive Surgical Margin Mean?
A positive surgical margin means cancer cells reach the inked edge of the removed tissue. It is associated with a higher risk of biochemical recurrence, but it does not prove that viable cancer has been left behind or that recurrence will occur.
Your specialist will consider the margin result alongside your Grade Group, cancer stage and PSA level after surgery. Depending on your overall risk, you may need close monitoring or additional treatment such as radiotherapy.
When Might Radiotherapy Be Needed After Surgery?
Post-operative radiotherapy is not automatically required because your pathology is high risk or a surgical margin is positive. NICE currently recommends against routine immediate post-operative radiotherapy after radical prostatectomy outside a clinical trial, so many patients are monitored with PSA testing before further treatment is considered.
If your PSA later shows biochemical relapse and there are no known metastases, salvage radiotherapy to the prostate bed may be recommended. European guidance is somewhat more individualised for selected very high-risk pathology, which is why your post-operative PSA, Grade Group, pathological stage, lymph-node findings and surgical margins should be considered together before deciding on further treatment.
When Might Hormone Treatment Be Needed?
Hormone treatment, also called androgen deprivation therapy (ADT), is not routinely required simply because you have undergone surgery for high-risk prostate cancer. For pN0 disease, routine adjuvant ADT is not recommended solely because the pathology is high risk.
If lymph nodes contain cancer, or if recurrence develops after surgery, ADT may become part of an individualised treatment strategy, sometimes alongside radiotherapy. The decision depends on nodal burden, PSA, pathology and your wider health rather than the high-risk label alone.
How Will Your PSA Be Monitored After Robotic Surgery?
After robotic prostate surgery, your PSA should fall to a very low or undetectable level because your prostate has been removed. Your specialist will monitor your PSA regularly, as a detectable or rising level may suggest that some cancer cells remain or have returned.
A rising PSA does not automatically mean the cancer has spread. Further treatment, such as salvage radiotherapy with or without hormone therapy, may be considered depending on your individual risk. NICE recommends checking PSA no earlier than six weeks after radical treatment, at least every six months for the first two years and at least annually thereafter.
UK Guidance Note
NICE uses Cambridge Prognostic Groups for newly diagnosed localised and locally advanced prostate cancer. CPG 4 and 5 broadly represent high- and very-high-risk disease. NICE advises against active surveillance in these groups and recommends offering radical prostatectomy or radical radiotherapy when long-term cancer control is considered possible. If radical radiotherapy is chosen, six months of androgen deprivation therapy should be offered, with continuation for up to three years considered for CPG 4 and 5 after discussion of the individual benefits and risks.
After radical prostatectomy, NICE does not recommend routine immediate postoperative radiotherapy or routine adjuvant hormone therapy solely because adverse pathology is present outside a clinical trial. PSA follow-up and appropriately timed salvage treatment remain important if biochemical relapse develops, while European guidance allows adjuvant radiotherapy in selected pN0 patients with Grade Group 4–5 and pT3 disease, with or without positive margins.
How Should You Decide Whether Robotic Surgery Is Right for You?
Choosing robotic surgery depends on your PSA, Grade Group, MRI, staging scans, overall health and personal priorities.
You should also compare surgery with radiotherapy and hormone treatment. Ask your specialist whether complete removal is realistic, whether nerve-sparing is possible and whether further treatment may be needed.
Myth vs Fact
| Myth | Fact |
| High-risk prostate cancer automatically means surgery is impossible. | No. NICE and EAU guidance recognise radical prostatectomy as an option for appropriately selected high-risk patients. |
| A PSA above 20 means surgery cannot work. | No. PSA above 20 is a high-risk feature, but surgical suitability depends on the full staging and risk assessment. |
| A negative PSMA PET/CT proves there is no cancer in the lymph nodes. | No. PSMA PET/CT improves staging but can miss microscopic nodal metastases. |
| Robotic surgery removes the need for any future treatment. | No. High-risk disease often requires a multimodal strategy, and some patients later need radiotherapy or systemic treatment. |
| A positive surgical margin proves cancer has been left behind. | No. It increases recurrence risk but does not prove residual cancer or inevitable recurrence. |
| Everyone with high-risk pathology should immediately receive radiotherapy and ADT after surgery. | No. Current NICE guidance does not recommend routine immediate postoperative radiotherapy or adjuvant hormone therapy solely because adverse pathology is present. |
Key Takeaways
- High-risk prostate cancer does not automatically rule out radical prostatectomy.
- NICE includes radical prostatectomy and radical radiotherapy as treatment options for selected people with CPG 4 or 5 disease when long-term cancer control is considered possible.
- Pelvic lymph-node dissection can improve staging, although a direct survival benefit has not been clearly established.
- Surgery for high-risk disease should be discussed as a potential multimodal strategy, because some patients later need radiotherapy or systemic treatment.
- Current NICE guidance does not recommend routine immediate postoperative radiotherapy or adjuvant hormone therapy purely because pathology is high risk or a margin is positive.
- The choice between surgery and radiotherapy-based treatment should reflect your cancer characteristics, health, expected side effects and personal priorities.
Frequently Asked Questions
1. Can you have robotic surgery for high-risk prostate cancer?
Yes, you may still be suitable for robotic prostate surgery if your cancer is localised or, in selected cases, locally advanced without distant metastases. Your specialist will consider your cancer stage, overall health, life expectancy and whether surgery is likely to contribute to long-term cancer control.
2. Does high-risk prostate cancer mean surgery is not an option?
No, being classed as high risk does not automatically rule out surgery. If your cancer can be removed safely, robotic prostatectomy may be considered as part of your treatment plan. Other treatments may also be needed.
3. Does a high PSA rule out robotic prostate surgery?
No, a high PSA does not automatically mean that surgery is unsuitable for you. Your doctor will also consider your Grade Group, MRI findings and staging scans. Some men with a PSA above 20 may still be candidates for surgery.
4. Can you have nerve-sparing surgery with high-risk prostate cancer?
You may be able to have nerve-sparing surgery if your cancer is not close to the nerves. However, your surgeon may need to remove some or all of the nerve bundles if preserving them could leave cancer behind.
5. Will you need lymph nodes removed during surgery?
You may be offered pelvic lymph-node removal if your risk of lymph-node involvement is high. It can help identify cancer that scans may not detect and provide important information for further treatment.
6. Will you need radiotherapy after robotic prostate surgery?
You may need radiotherapy if your pathology or post-operative PSA suggests a higher risk of recurrence. Some men are monitored first, while others may benefit from early treatment. Your individual risk will guide this decision.
7. Will you need hormone treatment after surgery?
Not everyone with high-risk prostate cancer needs hormone treatment after surgery. It may be considered if cancer is found in the lymph nodes or if your PSA rises. Your specialist will discuss whether androgen deprivation therapy is appropriate for you.
8. What happens to your PSA after robotic prostate surgery?
Your PSA should fall to a very low or undetectable level after your prostate is removed. Regular PSA tests help your specialist check whether the cancer remains under control. A detectable or rising PSA may require further assessment.
9. Does a positive surgical margin mean your cancer has returned?
No, a positive surgical margin means cancer cells were found at the edge of the tissue removed during surgery. It can increase your risk of recurrence, but it does not mean your cancer has definitely returned or that further treatment is always required.
10. How do you decide if robotic surgery is right for you?
Your decision should take into account your PSA, Grade Group, MRI, staging scans, overall health and personal priorities. You should also compare surgery with treatments such as radiotherapy and hormone therapy. Your specialist can explain which approach is most appropriate for your cancer.
Final Thoughts: Is Robotic Prostate Surgery Right for High-Risk Cancer?
Being diagnosed with high-risk prostate cancer does not automatically mean that surgery is unsuitable for you. If your cancer is still localised or has limited local spread, robotic prostate surgery may be considered as part of a wider treatment plan. Your PSA, Grade Group, MRI, staging scans, general health and personal priorities all need to be considered together.
If you are considering robotic prostate surgery in London as part of your prostate cancer treatment, you can arrange a consultation with our team at Prostate Clinic London to discuss whether surgery may be appropriate for your diagnosis and treatment goals.
References:
- National Institute for Health and Care Excellence (2019, updated 2021) Prostate cancer: diagnosis and management. NICE guideline NG131. Available at: https://www.nice.org.uk/guidance/ng131
- European Association of Urology (2026) EAU Guidelines on Prostate Cancer. EAU Guidelines Office, Arnhem, The Netherlands. Available at: https://uroweb.org/guidelines/prostate-cancer
- Abdollah, F. et al. (2015) ‘Long-term cancer control outcomes in patients with clinically high-risk prostate cancer treated with robot-assisted radical prostatectomy: results from a multi-institutional study of 1100 patients’, European Urology, 68(3), pp. 497–505. Available at: https://pubmed.ncbi.nlm.nih.gov/26119559/
- Hofman, M.S. et al. (2020) ‘Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study’, The Lancet, 395(10231), pp. 1208–1216. Available at: https://pubmed.ncbi.nlm.nih.gov/32209449/
- Hinojosa-Gonzalez, D.E. et al. (2024) ‘Oncologic outcome of the extent of pelvic lymph node dissection during radical prostatectomy: a systematic review, meta-analysis, and network analysis’, European Urology Focus, 10(2), pp. 234–241. Available at: https://pubmed.ncbi.nlm.nih.gov/38242825/
- Falagario, U.G. et al. (2024) ‘Prostate cancer-specific and all-cause mortality after robot-assisted radical prostatectomy: 20 years’ report from the European Association of Urology Robotic Urology Section Scientific Working Group’, European Urology Oncology, 7(4), pp. 705–712. Available at: https://pubmed.ncbi.nlm.nih.gov/37661459/