If you have localised prostate cancer, you may be offered robotic prostate surgery or HIFU. Robotic surgery removes your prostate and usually the seminal vesicles, while HIFU uses focused ultrasound to destroy selected prostate tissue.
Surgery treats the whole prostate but can cause urinary leakage and erectile dysfunction, and you will no longer ejaculate semen after the prostate and seminal vesicles have been removed. HIFU may offer a quicker recovery and help preserve your urinary and sexual function, but you will need ongoing monitoring because cancer can remain or return. Your cancer location, Grade Group, MRI and biopsy results, along with your priorities, can help you and your specialist decide which option is most suitable for you.
What Is the Main Difference Between Robotic Surgery and HIFU?
The main difference is how much of your prostate is treated. During robotic surgery, your surgeon removes your entire prostate and usually the seminal vesicles, while focal HIFU targets and destroys the area containing your cancer.
Focal HIFU leaves much of your prostate in place, which may help you preserve urinary and sexual function. Surgery removes the whole gland, giving your team the opportunity to examine the prostate in detail after treatment.
Robotic Prostate Surgery vs HIFU
| Feature | Robotic Prostate Surgery | Focal HIFU |
| Treatment approach | Removes the whole prostate and usually the seminal vesicles | Uses focused ultrasound to destroy selected prostate tissue |
| Amount of prostate treated | Whole gland | Usually only the targeted cancer-containing area |
| Long-term evidence | More established long-term cancer-control evidence | Long-term cancer-control evidence is less established |
| Recovery | Requires recovery from major surgery and abdominal incisions | Usually has a quicker initial recovery |
| Urinary continence | Temporary urinary leakage is relatively common after surgery | Stress urinary incontinence is generally less common |
| Erectile function | Erectile difficulties can occur even with nerve-sparing surgery | May offer better preservation in appropriately selected patients |
| Ejaculation | Normal ejaculation no longer occurs after surgery | Ejaculation may be preserved, although changes can occur |
| Pathology after treatment | The whole prostate can be examined by a pathologist | No complete whole-prostate pathology specimen is available |
| PSA follow-up | PSA should fall to a very low or undetectable level | PSA remains measurable because untreated prostate tissue remains |
| Additional monitoring | Mainly PSA-based follow-up, with further tests if needed | PSA, MRI and sometimes repeat biopsy are usually required |
| Further treatment | Additional treatment may be needed if cancer returns | Repeat HIFU, radiotherapy or salvage surgery may be considered if cancer persists or returns |
UK Guidance Note
Focal HIFU is not currently treated in UK guidance as an established equivalent to radical prostatectomy or radiotherapy. NICE states that its safety evidence is adequate but that evidence for effectiveness remains limited, so the procedure requires special arrangements for clinical governance, consent, audit or research.
NICE’s main prostate cancer guideline remains more restrictive and states that HIFU for localised prostate cancer should not be offered outside controlled clinical trials comparing it with established interventions. Current European guidance recommends offering focal HIFU only within a clinical trial or prospective registry.
How Does HIFU Actually Treat Prostate Cancer?
HIFU treats your prostate cancer using focused ultrasound rather than surgery. A probe is placed in your rectum under anaesthetic, sending high-intensity ultrasound waves into the prostate to heat and destroy the targeted cancerous tissue.
Your MRI and biopsy results help your specialist identify the area to treat. Because much of your prostate remains untreated, accurate cancer mapping is important before focal HIFU.
What Happens During Robotic Radical Prostatectomy?
During robotic prostate surgery, you are under general anaesthetic while your surgeon removes your prostate and usually your seminal vesicles through small abdominal openings. Your pelvic lymph nodes may also be removed if needed.
Your bladder is then reconnected to your urethra, and you will temporarily need a catheter while it heals. Unlike HIFU, your prostate is removed completely and can be examined by a pathologist to assess your cancer in detail.
Who Might Be Suitable for HIFU?
Focal HIFU may be considered for carefully selected people whose localised prostate cancer can be accurately mapped using MRI and biopsy results. However, in the UK it is not currently regarded as an established equivalent to radical prostatectomy or radiotherapy. A small, well-defined area of cancer may be more suitable for focal HIFU than cancer affecting larger areas.
Your cancer stage, Grade Group, prostate size and tumour location can all affect whether HIFU is appropriate for you. It is not simply a less invasive alternative to surgery that every man can choose.
Who Might Be Better Suited to Robotic Prostatectomy?
Robotic prostatectomy may be considered when your cancer affects several areas of the prostate or cannot be reliably targeted with focal HIFU. Because surgery removes the whole gland, it may offer an established radical treatment option when focal treatment is not considered appropriate for your cancer.
Your general health also matters because robotic prostatectomy is major surgery requiring a general anaesthetic and recovery. Your specialist can help you weigh the potential cancer benefits against the risks of surgery.
Why Does Multifocal Prostate Cancer Matter?
Prostate cancer can develop in more than one area of your prostate, which can make focal HIFU more challenging. Even if your MRI and biopsy identify one main tumour, another significant area could remain outside the HIFU treatment zone.
Robotic prostatectomy removes your entire prostate, so this particular concern is reduced. However, you also need to consider the greater potential impact of whole-gland surgery on your urinary and sexual function.
Which Treatment Has Stronger Evidence for Long-Term Cancer Control?
Radical prostatectomy has a more established long-term evidence base for cancer control than focal HIFU. It has been used for decades and is recognised as a standard treatment for suitable localised prostate cancer.
HIFU is promising, but you should know that its long-term evidence is less established. NICE and European guidance highlight ongoing uncertainty about its effectiveness, so you may need careful follow-up after HIFU.
What Do Current HIFU Results Show?
HIFU studies show encouraging results in carefully selected patients, and you may have a good chance of maintaining urinary continence. However, cancer-control results vary between studies because researchers use different definitions of recurrence and treatment success, and long-term comparative evidence remains limited.
You may also need further treatment after HIFU. A 2024 systematic review and meta-analysis of eight observational studies involving 1,819 patients found that 16.2% underwent subsequent focal or whole-gland salvage treatment. The median follow-up was 24 months, so you should discuss both the possibility of further treatment and the limitations of longer-term evidence when comparing HIFU with surgery.
Research Insight
A 2026 systematic review comparing HIFU with robot-assisted radical prostatectomy included five cohort studies and 2,123 patients. HIFU was associated with better early erectile-function and continence outcomes, but the authors concluded that long-term oncological outcomes still need confirmation.
This is important because better short-term functional outcomes do not automatically prove equivalent long-term cancer control. The available direct comparisons are also mainly observational rather than large randomised trials.
Which Treatment Has the Faster Recovery?
HIFU usually offers a quicker initial recovery than radical prostatectomy because there are no abdominal surgical incisions, and you can often go home the same day. You may need a catheter for a short period while swelling settles, but the time it takes to return to normal activities varies between patients.
Robotic prostate surgery requires a longer recovery because your prostate is removed and your urinary tract is reconstructed. If you want a faster return to everyday activities, HIFU may be more appealing to you, but you should also consider its long-term evidence and possible need for further treatment.
Which Treatment Is Better for Urinary Continence?
Available studies generally report lower rates of stress urinary incontinence after focal HIFU than after radical prostatectomy, particularly during early recovery. However, most direct comparisons are observational and longer-term comparative evidence remains limited. You may still experience temporary urinary symptoms after HIFU, but reported pad-free continence rates after focal HIFU are generally high, although results vary between studies and follow-up periods.
After prostatectomy, you may experience leakage after your catheter is removed, although this usually improves as you recover. If preserving your urinary continence is particularly important to you, this difference may be an important part of your treatment decision.
Which Treatment Is Better for Erectile Function?
Focal HIFU may have less impact on erectile function in appropriately selected patients because treatment is limited to selected prostate tissue. However, your outcome depends on the treatment area, cancer location, your age and your erectile function before treatment.
Robotic prostate surgery can cause erectile dysfunction even when nerve-sparing surgery is possible, and recovery may take months or longer. If preserving your sexual function is a priority for you, HIFU may have an advantage, although it cannot guarantee that your erections will remain unchanged.
What Happens to Ejaculation and Fertility?
After robotic prostate surgery, you will no longer ejaculate semen because your prostate and seminal vesicles are removed. You may still have an orgasm, but it will be dry, and natural conception through intercourse is no longer possible.
With focal HIFU, you keep much of your prostate, so you may continue to ejaculate. However, you may notice less fluid or changes in fertility, depending on the treatment area. If having children is important to you, discuss sperm storage with your specialist before treatment.
Can HIFU Cause Urinary Problems Even If Incontinence Is Less Common?
Yes. HIFU can still cause urinary problems because treatment can make your prostate swell temporarily. You may experience a weaker stream, urgency, frequency or difficulty passing urine, and you may need a catheter for several days.
These symptoms usually improve as your prostate heals, but some men need medication or further treatment. HIFU may reduce your risk of stress incontinence compared with surgery, but you should still understand its potential urinary risks.
How Is Follow-Up Different After HIFU?
Follow-up after HIFU is more involved because part of your prostate remains in place. Your specialist needs to monitor for cancer that may remain or return.
- PSA tests: Your PSA remains measurable because healthy prostate tissue is still present.
- MRI scans: Imaging can help identify suspicious changes within the prostate.
- Repeat biopsy: You may sometimes need another biopsy to check for persistent or recurrent cancer.
- Ongoing monitoring: Regular follow-up remains important even when your initial treatment results are reassuring.
After prostate surgery, PSA should usually become very low or undetectable because the prostate has been removed. This generally makes PSA monitoring more straightforward.
Does Surgery Provide More Complete Pathology Information?
Yes. Radical prostatectomy provides a whole-prostate specimen that can be examined by a pathologist. This can give you detailed information about your cancer, including its Grade Group, stage, surgical margins and whether the seminal vesicles or lymph nodes are involved.
With HIFU, your prostate remains in place, so you do not get a complete pathology report from the whole gland. Your specialist instead uses PSA, MRI and biopsies to monitor you after treatment.
What Happens If Cancer Remains or Returns After HIFU?
If cancer remains or returns after HIFU, you may still have further treatment options. Depending on where the cancer is found, you could be offered another HIFU treatment, surgery or radiotherapy.
You should understand that salvage treatment can be more complex after HIFU. Your specialist will consider your previous treatment, cancer location and current findings before recommending the most suitable option.
Can You Still Have Robotic Prostate Surgery After HIFU?
Yes, you may still be able to have robotic prostate surgery after HIFU if your cancer returns or remains. However, previous HIFU can cause scarring, which may make later surgery more technically difficult.
You should not assume that surgery after HIFU will have the same results as having surgery first. Your specialist will assess your cancer, previous treatment and potential risks before deciding whether salvage surgery is suitable for you.
Evidence Note
Focal HIFU does not remove the entire prostate, so residual cancer can remain inside the treated area or clinically significant cancer can later be found elsewhere in the gland. Repeat focal treatment, radiotherapy or radical prostatectomy may still be possible, depending on the pattern of recurrence.
However, salvage treatment should not be assumed to have the same functional outcomes as treatment given first. A systematic review of salvage prostatectomy after focal therapy found acceptable cancer-control outcomes but lower continence and erectile-function outcomes than typically reported after primary radical prostatectomy.
What Treatment Options May Remain After HIFU?
If cancer persists or returns after HIFU, several further treatment approaches may be considered, including repeat focal treatment, radiotherapy or salvage prostatectomy in selected patients.
However, you should not assume that every future treatment will be as straightforward. Each additional treatment can affect the prostate and surrounding tissues, so you need to understand that further procedures and long-term monitoring may be required.
How Should You Choose Between Robotic Surgery and HIFU?
You should first find out whether both treatments are genuinely suitable for you. Ask where your cancer is located, whether it is confined to one area, and what your Grade Group, PSA, MRI and cancer stage show.
If you are considering HIFU, ask how much of your prostate will be treated and what will remain untreated. You should also understand your follow-up plan and what options you would have if the cancer returns.
Myth vs Fact
| Myth | Fact |
| HIFU is an established equivalent to radical prostatectomy for localised prostate cancer. | No. NICE says efficacy evidence remains limited, and EAU recommends focal HIFU only within a clinical trial or prospective registry rather than unrestricted routine practice. |
| HIFU treats the whole prostate. | Focal HIFU targets selected areas; whole-gland HIFU is a different treatment strategy and has different functional outcomes. |
| HIFU has no urinary or sexual side effects. | No. Available studies generally report lower rates of some urinary and sexual side effects after focal HIFU than after radical treatment, but urinary retention, infection, erectile dysfunction and other complications can still occur. |
| A low PSA after HIFU proves that all cancer has gone. | No. Healthy prostate tissue remains and continues to produce PSA, so follow-up also relies on MRI and sometimes biopsy. |
| If HIFU fails, later surgery is exactly the same as having surgery first. | No. Salvage prostatectomy is possible in selected patients, but previous focal treatment can make surgery more complex and functional outcomes may be less favourable. |
| Choosing HIFU guarantees preservation of ejaculation and fertility. | No. Ejaculation may be retained, but evidence on ejaculatory and fertility outcomes is limited and preservation cannot be guaranteed. |
Key Takeaways
- Robotic radical prostatectomy removes the whole prostate, while focal HIFU treats selected prostate tissue and leaves the rest of the gland in place.
- Focal HIFU generally has favourable urinary and sexual functional outcomes, but its long-term cancer-control evidence is less established than radical prostatectomy.
- Current NICE guidance considers HIFU efficacy evidence limited, while EAU recommends focal HIFU only within a clinical trial or prospective registry.
- After HIFU, you need ongoing PSA, MRI and sometimes biopsy surveillance because untreated prostate tissue remains.
- If cancer remains or returns after HIFU, further treatment may still be possible, but salvage surgery or other treatment may carry additional functional risks.
Frequently Asked Questions
1. What Is the Main Difference Between Robotic Prostate Surgery and HIFU?
Robotic prostate surgery removes the entire prostate and usually the seminal vesicles, while HIFU targets and destroys selected cancerous tissue. HIFU leaves much of the prostate in place, which may help preserve urinary and sexual function.
2. Who might be suitable for HIFU?
Focal HIFU may be considered for carefully selected localised prostate cancer that can be accurately mapped using MRI and biopsy results. Your cancer stage, Grade Group, tumour location and prostate size all matter. However, HIFU is not currently regarded in UK guidance as an established equivalent to radical prostatectomy or radiotherapy, so you should discuss its evidence and availability carefully with your specialist.
3. Which treatment has stronger evidence for long-term cancer control?
Robotic prostate surgery has a longer and more established evidence base for treating localised prostate cancer. HIFU has encouraging results, but its long-term effectiveness remains less certain.
4. Which treatment has a faster recovery?
HIFU generally has a quicker initial recovery than radical prostatectomy because it does not involve abdominal surgical incisions. However, the time it takes you to return to normal activities varies.
5. Which treatment may have less impact on urinary continence?
Available studies generally report lower rates of stress urinary incontinence after focal HIFU than after radical prostatectomy, although longer-term comparative evidence remains limited.
6. Which treatment may have less impact on erectile function?
Focal HIFU may have less impact on erectile function in appropriately selected patients because treatment is limited to selected prostate tissue.
7. Will you still be able to ejaculate after HIFU?
You may continue to ejaculate after focal HIFU because much of your prostate remains in place. After robotic prostate surgery, you will no longer ejaculate semen because the prostate and seminal vesicles are removed.
8. How is follow-up different after HIFU and surgery?
After HIFU, you will usually need regular PSA tests, MRI scans and sometimes biopsies because your prostate remains in place. After surgery, PSA should fall to a very low or undetectable level because the prostate has been removed.
9. What happens if prostate cancer returns after HIFU?
If cancer remains or returns after HIFU, you may be offered further treatment such as repeat HIFU, radiotherapy or, in selected cases, surgery. Your specialist will consider the location of the cancer and your previous treatment before recommending the next step.
10. How should you choose between robotic surgery and HIFU?
The right choice depends on your cancer location, Grade Group, PSA, MRI findings, overall health and personal priorities. You should discuss the potential benefits, side effects, follow-up requirements and future treatment options with your specialist.
Final Thoughts: Choosing Between Robotic Prostate Surgery and HIFU
Choosing between robotic prostate surgery and HIFU depends on more than how quickly you want to recover. Your cancer’s location, Grade Group, stage, MRI and biopsy findings all matter, as do your priorities around cancer control, urinary continence, erectile function and future treatment options. While HIFU may offer a less invasive approach with potentially fewer side effects, robotic surgery has a more established evidence base for long-term cancer control.
If you are considering robotic prostate surgery in London and would like specialist advice, you can contact our team at Prostate Clinic London to discuss your treatment options and arrange a consultation tailored to your individual needs.
References:
- National Institute for Health and Care Excellence (2023) Focal therapy using high-intensity focused ultrasound for localised prostate cancer. HealthTech guidance HTG667. Available at: https://www.nice.org.uk/guidance/htg667
- 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
- Peretsman, S.J., Emberton, M., Fleshner, N., Shoji, S., Bahler, C.D. and Miller, L.E. (2024) ‘High-intensity focused ultrasound with visually directed power adjustment for focal treatment of localized prostate cancer: systematic review and meta-analysis’, World Journal of Urology, 42, 175. Available at: https://pubmed.ncbi.nlm.nih.gov/38507093
- Ge, S., Zeng, Z. and Zheng, L. (2026) ‘High-intensity focused ultrasound versus robot-assisted radical prostatectomy for localized prostate cancer: a systematic review and meta-analysis of oncologic and functional outcomes’, Annals of Surgical Oncology, 33(9), pp. 8636–8646. Available at: https://pubmed.ncbi.nlm.nih.gov/42283919
- Blank, F. et al. (2023) ‘Salvage radical prostatectomy after primary focal ablative therapy: a systematic review and meta-analysis’, Cancers, 15(10), 2727. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10216462
- Takemura, L.S. et al. (2024) ‘Salvage local treatment for recurrent prostate cancer after focal therapy: a systematic review and meta-analysis’, Urologic Oncology, 42(12), pp. 449.e1–449.e11. Available at: https://www.sciencedirect.com/science/article/pii/S1078143924006306