If you have localised prostate cancer, you may need to choose between treating it now or monitoring it closely. Robotic surgery removes your prostate, while active surveillance allows you to delay treatment unless your cancer shows signs of becoming more significant.
Neither option is automatically better for you. If you have low-risk cancer, surveillance may help you avoid treatment side effects, while higher-risk features may make active treatment, including surgery in suitable patients, more appropriate. Your cancer risk, age, general health and personal priorities can help you and your specialist decide which option is more suitable for you.
What Is the Difference Between Robotic Surgery and Active Surveillance?
Robotic prostate surgery is an active treatment where your surgeon removes your prostate and usually the seminal vesicles to treat the cancer. You will need time to recover and may experience side effects such as urinary leakage or erectile difficulties.
Active surveillance allows you to monitor your cancer without immediate treatment. You will have regular PSA tests, MRI scans and other checks, so your specialist can identify changes and offer treatment if you need it.
Key Differences Between Robotic Prostate Surgery and Active Surveillance
| Feature | Robotic Prostate Surgery | Active Surveillance |
| Main approach | Removes the prostate to treat the cancer | Monitors the cancer closely without immediate radical treatment |
| Who may be suitable | Often considered when cancer has a greater risk of progression | Most commonly suitable for low-risk and selected favourable intermediate-risk cancer |
| Immediate treatment | Yes, surgery is performed | No, treatment is delayed unless the cancer shows meaningful change |
| Monitoring afterwards | Regular PSA follow-up is needed after surgery | Regular PSA tests, reviews, MRI scans and sometimes repeat biopsies are needed |
| Urinary effects | Temporary or longer-term urinary leakage can occur | Avoids immediate surgery-related urinary leakage |
| Sexual effects | Erectile difficulties can occur, and normal ejaculation no longer occurs after surgery | Usually avoids immediate treatment-related sexual side effects |
| Recovery period | Requires recovery after an operation and temporary catheter use | No surgical recovery period |
| Risk of later treatment | Further treatment may still be needed if cancer persists or returns | Surgery or radiotherapy may be needed later if the cancer progresses |
| Main advantage | Provides immediate radical treatment and detailed surgical pathology | Can delay or sometimes avoid treatment and its side effects |
| Main trade-off | Immediate treatment comes with surgical and functional side effects | Requires ongoing monitoring and acceptance that treatment may be needed later |
Is Active Surveillance the Same as Doing Nothing?
No. Active surveillance means you regularly monitor your prostate cancer with PSA tests, appointments, MRI scans and sometimes repeat biopsies. You are not ignoring the cancer; you are checking whether it remains safe to monitor.
If your cancer becomes more aggressive or extensive, you can move to treatment. This differs from watchful waiting, where management generally focuses on controlling symptoms rather than treatment with curative intent.
Who Is Most Likely to Be Suitable for Active Surveillance?
Active surveillance is most commonly recommended if you have low-risk localised prostate cancer, although selected people with intermediate-risk disease may also be suitable. Your PSA, Grade Group, MRI findings, biopsy results and cancer stage help your specialist decide whether monitoring is safe for you.
NICE recommends offering active surveillance for CPG 1 cancer, while some men with CPG 2 cancer may also have this option. If you have higher-risk features, you may be advised to consider active treatment instead.
UK Guidance Note
NICE uses Cambridge Prognostic Groups to help guide treatment choices. Active surveillance is the first option offered for CPG 1 disease, while people with CPG 2 disease may be offered a choice between active surveillance, radical prostatectomy and radical radiotherapy when radical treatment is suitable.
For CPG 3 disease, radical treatment is generally offered, although surveillance may still be considered if you do not want immediate treatment. Active surveillance is not recommended for CPG 4 or CPG 5 disease.
Can Intermediate-Risk Prostate Cancer Be Monitored?
Sometimes. Active surveillance may be considered if you have carefully selected intermediate-risk prostate cancer, particularly when the amount of higher-grade cancer and other risk features are limited. A 2026 pooled analysis included 18 studies and 3,783 selected patients with intermediate-risk disease.
Around 63% remained on surveillance without discontinuation at five years and 53% at 10 years, although the researchers noted that robust long-term cancer-outcome data remain limited. Your Grade Group, PSA, MRI and biopsy findings therefore remain important when deciding whether surveillance is appropriate for you.
When Is Robotic Prostate Surgery More Appropriate?
Robotic prostate surgery may be more suitable for you when your cancer shows a higher risk of progression. Your Grade Group, MRI findings, PSA pattern and biopsy results can all influence this decision.
Your age, general health and life expectancy also matter. NICE recommends offering radical prostatectomy or radical radiotherapy for CPG 3 disease. For CPG 4 and 5 disease, radical treatment may be offered when long-term cancer control is considered achievable, while active surveillance is not recommended.
What Happens During Robotic Prostate Surgery?
During robotic prostate surgery, your surgeon removes your prostate and usually your seminal vesicles through small abdominal incisions. Your bladder is then reconnected to your urethra, and you will temporarily need a catheter while it heals.
Your surgeon may also remove nearby lymph nodes depending on your cancer risk. The removed prostate is examined to provide detailed information about your cancer, including its stage, Grade Group and whether cancer cells are present at the surgical margins.
What Happens During Active Surveillance?
When you choose active surveillance, your prostate cancer is monitored regularly rather than treated immediately. NICE suggests PSA testing every three to four months during the first year, with PSA trends monitored throughout surveillance. A digital rectal examination is considered at 12 months, with multiparametric MRI at around 12 to 18 months.
From the second year onwards, NICE suggests PSA testing every six months and a digital rectal examination every 12 months. If your PSA pattern, examination or other findings raise concern, your specialist may recommend another MRI and/or biopsy to check for evidence of progression.
Does a Rising PSA Mean You Automatically Need Surgery?
No. If your PSA rises during active surveillance, you do not automatically need surgery. Your PSA can change for several reasons, so your specialist will look at the overall pattern rather than one result.
If your results are concerning, you may need another MRI or biopsy to check for cancer progression. This can help avoid making a treatment decision based on a single temporary PSA change.
What Can MRI Show During Active Surveillance?
During active surveillance, an MRI can help your specialist monitor the size, location and appearance of suspicious areas in your prostate. If your scan shows a concerning change, you may need further investigation or a targeted biopsy.
MRI cannot always detect microscopic changes or confirm that your cancer has become more aggressive. Your specialist will therefore consider your MRI alongside your PSA, biopsy results and other cancer characteristics before deciding whether you need treatment.
Why Might You Need Another Biopsy?
If you are on active surveillance, you may need another biopsy to check whether the amount or Grade Group of cancer has changed. This may be recommended if your PSA or MRI results become concerning.
A repeat biopsy can help your specialist decide whether you can continue surveillance or need treatment. You may experience some discomfort or bleeding afterwards, and there is also a small risk of infection. Repeat biopsy is not required at the same frequency for everyone and may be recommended when your PSA, MRI or other findings suggest that reassessment is needed.
Does Surgery Provide Better Cancer Control?
Surgery can reduce your risk of cancer progression compared with active monitoring. In the 15-year ProtecT trial, metastases occurred in 4.7% of men who had prostatectomy compared with 9.4% of those who had active monitoring.
However, prostate cancer mortality remained low across the groups. This means you need to balance the lower progression risk from surgery against the possibility of treatment side effects from a cancer that may never have become life-threatening.
Does Surgery Improve Prostate Cancer Survival?
The ProtecT trial did not show a statistically significant difference in prostate cancer mortality between prostatectomy and active monitoring at 15 years. Prostate cancer death occurred in 2.2% of men who had prostatectomy and 3.1% of those assigned to active monitoring.
These results came from men with PSA-detected localised prostate cancer, and contemporary risk stratification showed that more than one third had intermediate or high-risk disease at diagnosis. You should not assume the same applies to every cancer, as modern active surveillance uses MRI and other assessments to monitor your risk more closely.
Evidence Note
ProtecT provides exceptionally valuable randomised long-term evidence, but the men entered the study between 1999 and 2009. Multiparametric MRI, MRI-targeted biopsy and contemporary surveillance protocols were not routinely used when the study began.
At 15 years, prostate cancer mortality remained low regardless of whether men were assigned to monitoring or radical treatment, although metastases and clinical progression were more common with active monitoring. These findings help explain the trade-off between avoiding treatment side effects and accepting a greater risk of progression, but they should not be treated as an exact estimate for modern MRI-based active surveillance.
What Are the Urinary Trade-Offs?
Active surveillance lets you avoid the immediate urinary effects of prostate surgery. If you have surgery, you may experience urinary leakage after your catheter is removed, although this usually improves as you recover.
You may still develop urinary symptoms while on surveillance as you age or if your prostate enlarges. The main difference is that surgery can increase your risk of stress urinary leakage, while urinary symptoms such as urgency, frequency or night-time urination can still develop during surveillance because your prostate remains in place and may enlarge with age.
How Do the Options Affect Sexual Function?
If you choose active surveillance, you can usually maintain your existing sexual function initially because you have not had radical treatment. This may be important to you if maintaining erections is a major priority.
Robotic surgery can cause erectile dysfunction, although nerve-sparing surgery may help when it is safe for you. After radical prostatectomy, you will no longer ejaculate semen because the prostate and seminal vesicles have been removed.
Can Active Surveillance Help You Avoid Treatment Completely?
Active surveillance may allow you to delay or sometimes avoid radical treatment if your prostate cancer remains stable. You will still need regular monitoring to check for meaningful changes.
- Avoid immediate treatment: You can delay surgery or radiotherapy while your cancer remains suitable for monitoring.
- Reduce side effects: Delaying treatment can help you avoid immediate urinary and sexual side effects.
- Regular monitoring: PSA tests, MRI scans and other reviews help your specialist watch for progression.
- Treatment if needed: Surgery or radiotherapy can still be considered if your cancer changes.
Some men remain on active surveillance for many years without needing treatment. The aim is to treat the cancer only if there is evidence that treatment has become necessary.
Is It Safe to Have Surgery Later?
If you are suitable for active surveillance, the aim is to monitor your cancer closely and identify meaningful progression while treatment with curative intent remains an option. You can also choose treatment later if you become uncomfortable with continued surveillance.
However, surveillance must be appropriate for your cancer from the beginning. If you have higher-risk cancer, delaying treatment simply to avoid surgery may not be safe, so you should make the decision with your specialist.
What Are the Psychological Differences Between the Options?
Active surveillance can help you avoid treatment side effects, but you may find living with untreated cancer stressful. You may feel anxious before your PSA tests, MRI scans or biopsies, while others feel reassured knowing their cancer is being monitored closely.
Surgery may give you reassurance that your prostate has been removed and the cancer has been treated directly, but you will still need PSA follow-up because recurrence can occur. Your emotional wellbeing matters, so you should discuss these concerns with your specialist when choosing your treatment.
Does Your Age Affect the Choice?
Your age can influence your treatment choice, but your overall health, life expectancy and cancer risk are also important. If you are younger and healthy, you may still be suitable for active surveillance if you have low-risk cancer.
If other health conditions limit your life expectancy or increase the risks of surgery, the potential benefit of immediate radical treatment may be smaller. Your specialist can help you balance your cancer risk, life expectancy and personal priorities when choosing the right approach.
How Should You Choose Between Surgery and Active Surveillance?
You should start by understanding your PSA, Grade Group, MRI, biopsy results and cancer stage. Ask your specialist whether active surveillance is safe for you and what benefit surgery would offer compared with monitoring.
If you choose surveillance, you should know how often you will have PSA tests, MRI scans and other reviews. You should also ask what changes in your cancer would mean that you need treatment, so you can feel confident about your decision.
Myth vs Fact
| Myth | Fact |
| Active surveillance means doing nothing about prostate cancer. | No. It is a structured programme of PSA testing, clinical review, MRI and, when needed, repeat biopsy. |
| A rising PSA automatically means you need surgery. | No. A concerning PSA pattern usually triggers reassessment with MRI and/or biopsy rather than automatically triggering treatment. |
| Everyone with intermediate-risk prostate cancer can safely choose surveillance. | No. Active surveillance is appropriate only for selected people with intermediate-risk disease. Careful assessment is important because progression and long-term cancer risks can be higher than in low-risk disease. |
| Choosing surveillance means you have lost the chance of curative treatment. | No. When surveillance is appropriately selected and followed, the aim is to identify meaningful progression while radical treatment remains an option. |
| The ProtecT trial compared modern active surveillance directly with robotic surgery. | No. ProtecT used an older, less intensive active-monitoring strategy and most surgery was not contemporary robot-assisted prostatectomy. |
| Surgery guarantees that you never need further prostate cancer treatment. | No. PSA monitoring continues after prostatectomy, and some men need additional treatment if cancer persists or later returns. |
Key Takeaways
- Active surveillance is a structured monitoring strategy and is offered to people with CPG 1 low-risk prostate cancer.
- Selected men with CPG 2 or other favourable intermediate-risk features may also be considered for surveillance, but suitability needs more careful assessment.
- Robotic prostatectomy provides immediate radical treatment but can cause urinary incontinence and erectile dysfunction, and normal ejaculation no longer occurs after the prostate and seminal vesicles are removed.
- ProtecT found fewer metastases after prostatectomy than active monitoring, but no statistically significant difference in prostate cancer mortality at 15 years.
- Modern active surveillance uses MRI, PSA trends and biopsy information to identify meaningful progression before deciding whether radical treatment is needed.
Frequently Asked Questions
1. Is Active Surveillance Better Than Robotic Prostate Surgery?
Neither option is automatically better for everyone. Active surveillance may suit you if you have low-risk prostate cancer and want to avoid treatment side effects. Surgery may be more appropriate if your cancer has a higher risk of progressing.
2. Is active surveillance the same as doing nothing?
No. Active surveillance involves regular PSA tests, MRI scans, clinical reviews and sometimes repeat biopsies. Your cancer is monitored closely, and treatment can be offered if there are signs of progression.
3. Who is suitable for active surveillance?
Active surveillance is generally most suitable if you have low-risk localised prostate cancer. Your PSA, Grade Group, MRI findings, biopsy results and cancer stage will all be considered. Some men with favourable intermediate-risk cancer may also be suitable.
4. Does a rising PSA mean you need robotic surgery?
No. A rising PSA does not automatically mean that you need surgery. Your specialist will assess the PSA pattern alongside your MRI, biopsy results and other findings before recommending further investigation or treatment.
5. Can active surveillance delay prostate cancer treatment?
Yes. If your cancer remains stable, you may stay on active surveillance for many years without needing surgery or radiotherapy. Some men may eventually need treatment, while others may never need it.
6. Does robotic surgery provide better cancer control than active surveillance?
In the ProtecT trial, prostatectomy was associated with fewer metastases and less clinical progression than active monitoring at 15 years. However, the trial did not show a statistically significant difference in prostate cancer mortality between the treatment groups.
7. What are the urinary effects of robotic surgery?
Robotic prostate surgery can cause urinary leakage, particularly after your catheter is removed. Your continence often improves during recovery, although some men experience longer-term leakage. Active surveillance avoids these immediate surgery-related risks.
8. How does active surveillance affect your sexual function?
Active surveillance allows you to avoid the immediate sexual side effects of radical treatment. Robotic surgery can cause erectile difficulties, and normal ejaculation no longer occurs after radical prostatectomy. Your existing sexual function and personal priorities should be considered when choosing between the options.
9. Is it safe to have prostate surgery later if you choose active surveillance?
If active surveillance is suitable for you, your cancer is monitored to identify meaningful progression while treatment with curative intent remains an option. You can then move to active treatment if needed. However, surveillance is not appropriate for every risk group.
10. How should you choose between robotic surgery and active surveillance?
You should consider your PSA, Grade Group, MRI findings, biopsy results and cancer stage. Your age, general health, life expectancy and personal priorities also matter. Ask your specialist what benefit surgery would offer compared with continued monitoring.
Final Thoughts: Choosing Between Surgery and Active Surveillance
Choosing between robotic prostate surgery and active surveillance depends on your cancer risk, overall health and what matters most to you. You should understand your PSA, Grade Group, MRI findings, biopsy results and cancer stage before deciding whether monitoring or treatment is more appropriate.
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 (2019, updated 2021) Prostate cancer: diagnosis and management. NICE guideline NG131. Available at: https://www.nice.org.uk/guidance/ng131
- de Vos, I.I., Luiting, H.B. and Roobol, M.J. (2023) ‘Active surveillance for prostate cancer: past, current, and future trends’, Journal of Personalized Medicine, 13(4), 629. Available at: https://www.mdpi.com/2075-4426/13/4/629
- Lane, J.A. et al. (2022) ‘Functional and quality of life outcomes of localised prostate cancer treatments (Prostate Testing for Cancer and Treatment [ProtecT] study)’, BJU International, 130(3), pp. 370–380. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9543725
- Carlsson, S. et al. (2020) ‘Long-term outcomes of active surveillance for prostate cancer: the Memorial Sloan Kettering Cancer Center experience’, The Journal of Urology, 203(6), pp. 1122–1127. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7480884
- 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
- Uleri, A. et al. (2026) ‘Active surveillance for intermediate-risk prostate cancer: a systematic review and pooled analysis’, BJU International. Advance online publication. Available at: https://pubmed.ncbi.nlm.nih.gov/42503039
- Thompson, D. et al. (2023) ‘Long-term health-related quality of life in patients on active surveillance for prostate cancer: a systematic review’, European Urology Oncology, 6(1), pp. 4–15. Available at: https://www.sciencedirect.com/science/article/pii/S2588931122001444