If you have localised prostate cancer and you are offered robotic surgery or radiotherapy, choosing between them can be difficult. You may want to know how the cancer-control results compare, while also considering how each treatment could affect you.
Both treatments can provide excellent cancer control, but they affect you differently. Surgery may cause urinary leakage and erectile dysfunction, while radiotherapy can cause urinary irritation, bowel problems and later erectile difficulties. Your cancer risk, age, general health and what matters most to you can help you and your specialist choose the most suitable option.
Is Robotic Prostate Surgery Better Than Radiotherapy?
If you are suitable for both treatments, neither robotic surgery nor radiotherapy is automatically better. The best option depends on the balance of cancer control, side effects and recovery that matters most to you.
NICE recommends discussing radical treatment and its serious side effects with both a specialist surgical oncologist and a specialist clinical oncologist. This can help you compare how each option may affect urinary, sexual and bowel function before you decide.
Robotic Prostate Surgery vs Radiotherapy at a Glance
| Feature | Robotic Prostate Surgery | Radiotherapy |
| Main approach | Removes the prostate and usually the seminal vesicles | Uses targeted radiation to treat the cancer while leaving the prostate in place |
| Cancer control | Can provide excellent long-term cancer control in suitable patients | Can also provide excellent long-term cancer control in suitable patients |
| Treatment schedule | Usually one operation followed by recovery | External beam radiotherapy schedules vary; treatment may involve 20 sessions, while selected patients in England may be eligible for five-fraction SABR |
| Hospital stay | Usually involves a short hospital stay | Usually does not require an overnight hospital stay for external beam treatment |
| Catheter | A temporary urinary catheter is normally needed after surgery | A catheter is not routinely required |
| Urinary effects | Urinary leakage is more common, particularly during early recovery | Urgency, frequency or burning can occur during or after treatment |
| Bowel effects | Bowel function is generally less directly affected | Bowel urgency, looser stools or other rectal symptoms can occur |
| Erectile function | Erections may decline immediately after surgery and recover gradually | Erectile difficulties may develop more gradually over time |
| Hormone therapy | Not routinely required with surgery itself | May be recommended alongside radiotherapy depending on cancer risk |
| PSA afterwards | Should fall to a very low or undetectable level | Usually falls gradually because the prostate remains in place |
| If cancer returns | Salvage radiotherapy may sometimes be possible | Local salvage treatment can be more complex and requires specialist assessment |
How Do the Cancer-Control Results Compare?
If you have localised prostate cancer, both robotic surgery and radiotherapy aim to remove or destroy the cancer with curative intent. Long-term UK evidence from the ProtecT trial found similar results, with prostate cancer-specific survival of about 97.2% after prostatectomy and 97.7% after radiotherapy at 15 years.
These results show that both treatments can provide excellent long-term cancer control, although modern robotic surgery and radiotherapy have continued to develop since the trial. Your own outlook depends on factors such as your Grade Group, PSA level, MRI findings and clinical stage.
Evidence Note
The ProtecT trial followed 1,643 men with PSA-detected localised prostate cancer and found very low prostate cancer mortality at 15 years after prostatectomy or radiotherapy. However, most prostatectomies in the original trial were open rather than robot-assisted, and radiotherapy techniques and schedules have also changed considerably since the trial began.
The study therefore provides valuable long-term evidence that both radical treatment strategies can achieve excellent outcomes, but it should not be interpreted as proving that every form of modern robotic surgery and modern radiotherapy produces identical results.
What Does Robotic Prostate Surgery Involve?
If you have robotic prostate surgery, your surgeon removes your entire prostate and usually the seminal vesicles through several small abdominal openings. Pelvic lymph nodes may also be removed when the risk of spread is higher.
Your surgeon controls the robotic instruments using magnified three-dimensional imaging. Your bladder is reconnected to the urethra, and you will have a temporary urinary catheter while this new connection heals.
What Does Radiotherapy Involve?
If you have external beam radiotherapy, your prostate stays in place while planned radiation targets the cancer. You usually do not need a general anaesthetic or overnight hospital stay, but you will attend a radiotherapy centre for planning and treatment.
Radiotherapy is designed to limit exposure to nearby organs such as the bladder and rectum. You may receive 60 Gy in 20 treatments, while brachytherapy may be suitable depending on your cancer risk, prostate size and urinary function.
Does Your Prostate Cancer Risk Affect Which Treatment Is Better?
Yes. Your cancer risk is one of the most important factors when choosing between robotic surgery and radiotherapy. Your PSA, Grade Group and clinical stage help determine your risk group and guide the treatment options suitable for you.
For lower-risk cancer, active surveillance may be an option, while surgery or radiotherapy may also be appropriate depending on your CPG, health and preferences. Your specialist can explain which options are recommended for your risk group.
UK Guidance Note
NICE uses Cambridge Prognostic Groups (CPG 1 to 5) to help guide treatment decisions. For CPG 1 disease, active surveillance is offered, with surgery or radiotherapy considered when surveillance is unsuitable or unacceptable. For CPG 2 disease, suitable patients may be offered active surveillance, radical prostatectomy or radical radiotherapy.
For CPG 3 disease, radical prostatectomy or radical radiotherapy is generally offered, although active surveillance may still be considered if someone does not want immediate radical treatment. Active surveillance is not recommended for CPG 4 or 5 localised or locally advanced disease; radical prostatectomy or radical radiotherapy may be offered when long-term cancer control is considered achievable.
What If You Have Intermediate- or High-Risk Cancer?
If you have intermediate- or high-risk prostate cancer, you may still have surgery or radiotherapy as treatment options, but your treatment plan can be more complex. If you choose surgery, your prostate and any removed lymph nodes are examined to give your team a clearer picture of your cancer and whether you may need further treatment.
If you choose radiotherapy, you will often have hormone treatment alongside it, particularly if you have higher-risk cancer. Your specialist can explain which option is more suitable for you and how your choice may affect your recovery, side effects and future treatment needs.
Which Treatment Has the Easier Recovery?
If you choose robotic prostate surgery, you will usually have a short hospital stay and go home with a temporary urinary catheter. Recovery takes several weeks and varies from person to person.
External beam radiotherapy usually does not require an overnight stay or catheter. Treatment may involve 20 sessions or, for selected patients in England, five-fraction SABR. Tiredness and urinary or bowel irritation can occur during treatment.
Which Treatment Is More Likely to Cause Urinary Incontinence?
If you choose robotic prostate surgery, you are more likely to experience urinary leakage, particularly soon after your catheter is removed. You may improve significantly over the following months, although some men continue to need pads in the longer term.
Radiotherapy generally has a lower risk of long-term urinary incontinence, although you may develop other urinary symptoms. Your age, existing urinary function, anatomy and surgical factors can affect your individual risk, so discuss your priorities with your specialist.
Research Insight
A 2024 study of 2,445 people treated for localised prostate cancer found that radical prostatectomy was associated with worse urinary incontinence at 10 years than radiotherapy or surveillance. Among people with less favourable disease, radiotherapy combined with ADT was instead associated with worse bowel and hormone-related function than prostatectomy.
This was an observational study rather than a randomised trial, so it shows associations rather than proving that treatment alone caused every difference. It also evaluated radical prostatectomy as a treatment category rather than demonstrating an effect unique to robotic surgery.
Does Radiotherapy Cause Urinary Problems Too?
Radiotherapy can cause urgency, frequency, waking at night, burning or a weaker urine flow, particularly during or soon after treatment.
These symptoms often improve, but some can persist. If you already have urinary problems, tell your specialist because they may influence which treatment is most suitable for you.
Which Treatment Is Better for Erectile Function?
Neither treatment guarantees that you will keep your erections. After robotic surgery, erectile function may decline immediately and can take many months to recover, even with nerve-sparing surgery.
After radiotherapy, erectile difficulties may develop more gradually, especially if you also need hormone treatment. Your age, erections before treatment and general health also affect your individual risk.
Which Treatment Is More Likely to Affect Your Bowels?
Radiotherapy can affect the nearby rectum, causing looser stools, wind, urgency, mucus or discomfort, although these symptoms often improve.
Surgery generally has less direct effect on bowel function. If you already have bowel problems, discuss them with your specialist before treatment.
Does Radiotherapy Mean You Will Need Hormone Therapy?
Whether you need androgen deprivation therapy, or ADT, alongside radiotherapy depends on your cancer risk and the radiotherapy approach being considered. NICE recommends six months of ADT before, during or after radical external beam radiotherapy for CPG 2, 3, 4 and 5 prostate cancer. For CPG 4 and 5 disease, continuing ADT for up to three years may be considered after discussing the potential benefits and risks.
There is an important exception for selected patients receiving five-fraction SABR in England. NHS England’s 2026 commissioning policy applies to selected low- and intermediate-risk localised prostate cancer where ADT is not required. Your clinical oncologist can therefore explain whether radiotherapy alone or radiotherapy combined with ADT is appropriate for your individual cancer.
How Do Surgery and Radiotherapy Affect Ejaculation and Fertility?
If you have robotic prostate surgery, you will no longer ejaculate normally because your prostate and seminal vesicles are removed. You can still experience an orgasm, but it will usually be a dry orgasm, and natural conception through intercourse is no longer possible.
Radiotherapy leaves your prostate in place, but it can reduce ejaculation and may permanently affect your fertility. If having biological children matters to you, you should discuss sperm storage with your specialist before treatment.
How Is PSA Follow-Up Different After Each Treatment?
If you have robotic prostate surgery, your PSA should fall to a very low or undetectable level because most PSA-producing prostate tissue has been removed. If your PSA later becomes detectable and continues to rise, your team may investigate whether the cancer has returned.
After radiotherapy, your prostate remains in place, so your PSA usually falls gradually rather than becoming immediately undetectable. You will therefore be monitored by looking at your PSA trend over time. NICE recommends checking PSA no earlier than six weeks after treatment, at least every six months for two years and then at least annually.
What Happens If the Cancer Returns?
If your cancer returns after surgery, radiotherapy to the prostate bed may be possible if there are no known metastases.
After radiotherapy, local salvage treatment can be more complex and requires specialist reassessment. Your options will depend on where the cancer has returned and your overall health.
Does Your Age or General Health Affect the Choice?
Your age and general health can influence whether robotic surgery or radiotherapy is more suitable for you. Your overall fitness is often more important than age alone.
- Heart and lung health: Major surgery requires you to be fit enough for a general anaesthetic and recovery.
- Mobility: Your ability to recover physically after an operation may affect the decision.
- Existing conditions: Other medical problems can influence the risks of both surgery and radiotherapy.
- Treatment practicalities: Your ability to attend radiotherapy appointments may also need to be considered.
Your specialist will assess your overall health alongside your cancer and personal priorities. The safest and most suitable option will vary from person to person.
Do Your Existing Urinary or Bowel Symptoms Matter?
Existing urinary symptoms can influence treatment choice. Leakage may make continence recovery after surgery more difficult, while radiotherapy can worsen urgency or frequency.
Bowel problems also matter because radiotherapy can affect the rectum. Your specialist should consider your baseline urinary and bowel symptoms before recommending treatment.
Are the Side Effects Immediate or Long Term?
After surgery, urinary leakage and erectile difficulties are often most noticeable early, although recovery can continue for months.
Radiotherapy may cause urinary or bowel irritation during treatment, while some sexual, bowel or bladder effects can develop later. You should consider both short- and long-term effects.
How Should You Choose Between Robotic Surgery and Radiotherapy?
Start by confirming whether both treatments are suitable for your cancer. Then compare urinary, bowel and sexual side effects, recovery and treatment practicalities.
Your future treatment options also matter if the cancer returns. Discuss both approaches with a surgeon and clinical oncologist before deciding.
Myth vs Fact
| Myth | Fact |
| Robotic surgery is always better than radiotherapy. | No. Both can provide excellent cancer control in appropriately selected patients, and the most suitable option depends on your cancer, health and priorities. |
| Radiotherapy always has fewer side effects. | No. Surgery is more strongly associated with urinary incontinence, while radiotherapy can cause urinary irritation and has a greater direct effect on bowel function. |
| Surgery is a one-off treatment with no further treatment needed. | No. You still need PSA follow-up, and some people later need salvage radiotherapy or another treatment. |
| Everyone having radiotherapy needs hormone therapy. | No. ADT is recommended alongside radical external beam radiotherapy for several CPG groups, but NHS England’s 2026 SABR policy applies to selected low- and intermediate-risk patients for whom ADT is not required. |
| Five-session radiotherapy is suitable for every localised prostate cancer. | No. NHS England currently commissions five-fraction SABR for selected people with low- or intermediate-risk localised prostate cancer when ADT is not required. It is not suitable for every person with localised disease. |
| Recurrence after radiotherapy cannot be treated locally. | Not necessarily. Selected patients may be eligible for specialist salvage surgery, brachytherapy or re-irradiation after careful restaging and confirmation of local recurrence. |
Key Takeaways
- Robotic prostatectomy and radiotherapy can both provide excellent cancer control for appropriately selected localised prostate cancer.
- Surgery has a greater impact on urinary continence, while radiotherapy is more likely to cause direct bowel symptoms.
- Erectile function can be affected by either treatment, although the timing and contributing factors differ.
- Whether radiotherapy is combined with ADT depends on your cancer risk and treatment plan. In England, five-fraction SABR is now available to selected low- and intermediate-risk patients for whom ADT is not required.
- Your cancer risk, urinary and bowel health, sexual priorities, general health and possible future salvage options should all be considered before choosing treatment.
Frequently Asked Questions
1. Is robotic prostate surgery better than radiotherapy?
Neither treatment is automatically better for everyone with localised prostate cancer. Both can provide excellent cancer control, but their side effects and recovery are different. Your cancer risk, health and personal priorities should guide your choice.
2. Which has better cancer-control results, surgery or radiotherapy?
Both robotic surgery and radiotherapy can offer excellent long-term cancer control. Your individual outlook depends on factors such as your PSA, Grade Group, MRI findings and clinical stage. Your specialist can explain what the results mean for you.
3. Which treatment is more likely to cause urinary incontinence?
Robotic prostate surgery has a higher risk of urinary leakage, particularly soon after treatment. Your continence often improves during the following months, although some men have longer-term leakage. Radiotherapy generally has a lower risk of persistent incontinence.
4. Does radiotherapy cause erectile dysfunction?
Radiotherapy can affect your erections, although this may develop more gradually than after surgery. Your age, existing erectile function, general health and whether you need hormone therapy can influence your risk.
5. Can radiotherapy cause bowel problems?
Yes. Radiotherapy can affect your rectum because it is close to the prostate. You may experience loose stools, wind, urgency, mucus or discomfort, although these symptoms often improve after treatment.
6. Will you need hormone therapy with radiotherapy?
Whether you need hormone therapy alongside radiotherapy depends on your cancer risk and treatment plan. NICE recommends ADT with radical external beam radiotherapy for CPG 2 to 5 disease, while selected low- and intermediate-risk patients eligible for five-fraction SABR in England are those for whom ADT is not required. Your clinical oncologist can explain which approach applies to you.
7. Can you have children after robotic prostate surgery?
After prostate surgery, you will usually have a dry orgasm because your prostate and seminal vesicles are removed. Natural conception through intercourse is no longer possible. If biological children are important to you, discuss sperm storage before treatment.
8. How does PSA follow-up differ after surgery and radiotherapy?
After surgery, your PSA should fall to a very low or undetectable level. After radiotherapy, your prostate remains in place, so your PSA usually falls gradually. Your doctors will monitor your PSA over time to check for changes.
9. What happens if prostate cancer returns after treatment?
Your treatment options depend partly on which treatment you had first. After surgery, radiotherapy to the prostate bed may be an option if there are no known metastases. Recurrence after radiotherapy can be more complex and may require other treatments.
10. How should you choose between robotic surgery and radiotherapy?
You should consider your cancer risk, general health and existing urinary, bowel and sexual function. Your recovery preferences and personal priorities also matter. Discussing both options with a specialist surgeon and clinical oncologist can help you make an informed decision.
Final Thoughts: Choosing the Right Prostate Cancer Treatment
Choosing between robotic prostate surgery and radiotherapy is a personal decision, and there is no single option that is best for every man. You should consider your cancer risk, general health, urinary and bowel function, sexual priorities, recovery preferences and what matters most to you.
If you are considering robotic prostate surgery in London for localised prostate cancer, you can arrange a consultation with our specialist team to discuss whether surgery or radiotherapy may be more suitable for your diagnosis, overall health and treatment priorities.
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
- NHS England (2026) Clinical commissioning policy: Stereotactic ablative radiotherapy (SABR) for the treatment of localised prostate cancer (adults) [2106]. Available at: https://www.england.nhs.uk/publication/stereotactic-ablative-radiotherapy-for-the-treatment-of-localised-prostate-cancer-adults/
- Hamdy, F.C. et al. (2023) ‘Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer’, New England Journal of Medicine, 388(17), pp. 1547–1558. Available at: https://pubmed.ncbi.nlm.nih.gov/36912538/
- Al Hussein Al Awamlh, B. et al. (2024) ‘Functional outcomes after localized prostate cancer treatment’, JAMA, 331(4), pp. 302–317. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10807259/
- Liu, Y. et al. (2025) ‘Postoperative functional complications and quality of life following robot-assisted prostatectomy and radiotherapy in localized prostate cancer: evidence from a systematic review and meta-analysis’, Journal of Robotic Surgery, 19(1), 314. Available at: https://pubmed.ncbi.nlm.nih.gov/40544416/
- van As, N. et al. (2024) ‘Radical prostatectomy versus stereotactic radiotherapy for clinically localised prostate cancer: results of the PACE-A randomised trial’, European Urology, 86(6), pp. 566–576. Available at: https://pubmed.ncbi.nlm.nih.gov/39266383/