Prostate Cancer at a Glance
Often silent
Early Prostate Cancer rarely causes symptoms. A rising PSA is usually the first clue.
MRI before biopsy
A prostate MRI helps decide whether a biopsy is needed, and where to target it.
Not every cancer needs treatment
Low-risk cancers are often best managed with active surveillance.
Function matters
When surgery is needed, nerve-sparing robotic techniques aim to protect continence and erections.
Symptoms and Who Is at Risk
Urinary symptoms in men over 50, such as a weak stream or waking at night to pass urine, are usually caused by benign enlargement of the prostate rather than cancer. Prostate Cancer tends to cause symptoms only when it is advanced. A urological opinion is worthwhile if you have:
- A PSA above the expected range for your age, or one that keeps rising
- A nodule or hard area felt on rectal examination
- Blood in the semen or urine
- Bone pain, weight loss or leg weakness (these may indicate advanced disease)
Risk factors
The chance of Prostate Cancer rises steadily with age. A father or brother with Prostate Cancer roughly doubles the risk, and inherited changes in the BRCA2 gene are linked with more aggressive disease. Men with these risk factors may reasonably start PSA testing in their mid-40s after discussing it with a doctor.
Understanding Your PSA Result
PSA is a protein made by both normal and cancerous prostate cells, so a single number never tells the whole story. Dr. Singh reads a PSA result alongside several other details:
| What is looked at | Why it matters |
|---|
| Age-related range | PSA naturally rises as the prostate enlarges with age |
| PSA density | PSA divided by prostate volume. A large benign prostate makes more PSA, so density separates the two better than PSA alone |
| Trend over time | A steady rise is more meaningful than one high reading |
| Free-to-total PSA ratio | A low ratio slightly increases the likelihood of cancer |
| Temporary causes | Infection, a recent catheter, ejaculation or cycling in the previous 48 hours can raise PSA |
A repeat test after excluding temporary causes is often the sensible first step. You can calculate your PSA density below if your MRI or ultrasound report mentions prostate volume.
How the Diagnosis Is Made
Multiparametric MRI
An MRI of the prostate is now recommended before any biopsy. It is reported with a PI-RADS score from 1 to 5. A score of 4 or 5 usually means a targeted biopsy is needed, while a normal MRI with a low PSA density may allow a biopsy to be avoided altogether.
Transperineal biopsy
Samples are taken through the skin between the scrotum and the anus rather than through the rectum. This route has a much lower risk of serious infection and samples the front of the prostate better. Targeted cores from any MRI lesion are combined with systematic cores from the rest of the gland.
Staging scans
For intermediate- and high-risk cancers, a PSMA PET-CT is the most sensitive test for spread to lymph nodes or bone. A bone scan with CT is an alternative where PSMA PET is not available.
Grade Group and Risk Group
The pathologist grades the cancer using the Gleason score, which is converted into an ISUP Grade Group from 1 (least aggressive) to 5 (most aggressive).
| Grade Group | Gleason score | What it means |
|---|
| 1 | 3 + 3 = 6 | Slow growing; rarely spreads |
| 2 | 3 + 4 = 7 | Mostly low grade with a smaller aggressive component |
| 3 | 4 + 3 = 7 | Mostly the more aggressive pattern |
| 4 | 8 | High grade |
| 5 | 9 or 10 | Highest grade |
Grade Group, PSA and the clinical stage are then combined into a risk group, which guides treatment:
| Risk group | Typical features | Options usually discussed |
|---|
| Low | Grade Group 1, PSA below 10, confined to the prostate | Active surveillance |
| Favourable intermediate | Grade Group 2 with limited disease | Surveillance in selected men, robotic prostatectomy or radiation |
| Unfavourable intermediate | Grade Group 3, or several intermediate features | Robotic prostatectomy, or radiation with short-term hormone therapy |
| High | Grade Group 4–5, PSA above 20, or disease beyond the capsule | Surgery as part of multimodal care, or radiation with long-term hormone therapy |
| Metastatic | Spread to lymph nodes or bone | Hormone therapy with newer agents, chemotherapy or PSMA-targeted therapy |
Check your risk group or calculate your CAPRA score using the tools below.
Treatment Options
Active surveillance
For low-risk cancer, active surveillance means regular PSA tests, a repeat MRI and, when needed, a repeat biopsy. Treatment is offered only if the cancer shows signs of change. Long-term studies show that this approach is as safe as immediate treatment for suitable men, while sparing many of them the side effects of surgery or radiation.
Robotic radical prostatectomy
The prostate and seminal vesicles are removed through keyhole incisions, with the pelvic lymph nodes when the risk of spread justifies it. It suits men with a good life expectancy and cancer confined to, or just beyond, the prostate.
Radiation therapy
External beam radiotherapy, usually combined with a period of hormone therapy for intermediate- and high-risk disease, gives cancer control comparable to surgery in suitable patients. The side effects are different, affecting the bladder and bowel more than continence.
Advanced disease
When the cancer has spread, treatment is systemic: hormone therapy combined with newer hormonal agents, chemotherapy, or PSMA-targeted radioligand therapy, planned together with medical oncology.
Surgery or radiation? For localised disease, both offer similar cancer control. The choice depends on age, urinary symptoms, bowel health, previous abdominal surgery and personal priorities, and is made after a frank discussion of trade-offs.
What to Expect from Robotic Prostatectomy
- Before surgery: pelvic floor exercises are started a few weeks in advance, which speeds the return of urinary control.
- Nerve-sparing: the nerves for erections lie on the surface of the prostate and are preserved on one or both sides when the cancer allows.
- Hospital stay: most men walk on the day of surgery and go home after 2–3 days.
- Catheter: a urinary catheter stays for about 7–10 days while the join between bladder and urethra heals.
- Continence: most men regain control over weeks to a few months; a small number need further treatment.
- Erections: recovery may take one to two years and is supported with medicines and other treatments.
More about Robotic Surgery.
Follow-Up and Recovery
After surgery, PSA should become undetectable within about six weeks. It is then checked every three to six months for the first few years, and yearly after that. After radiation, PSA falls slowly and is judged against its lowest point.
A rising PSA after treatment is called biochemical recurrence. Its significance depends on how high it is and how fast it is rising. A short PSA doubling time usually prompts a PSMA PET scan and discussion of salvage radiotherapy or systemic treatment.
Urinary control and erectile function are reviewed at every visit using standard questionnaires (IPSS, SHIM and ICIQ), so that recovery can be tracked and supported.
Questions Worth Asking at Your Consultation
- What are my Grade Group, PSA density and risk group?
- Is active surveillance a safe option for me?
- Do I need a PSMA PET scan before deciding?
- What are my realistic chances of staying continent and keeping erections after each treatment?
- Can nerve-sparing be done on one or both sides?
- How will my PSA be followed after treatment?
Frequently Asked Questions
My PSA is high. Does that mean I have Prostate Cancer?
Not necessarily. Benign prostate enlargement, infection, a recent catheter or even cycling can raise PSA. A repeat test and a prostate MRI usually come before any decision about biopsy.
Is active surveillance just waiting for the cancer to grow?
No. It is a structured programme of PSA tests, MRI and repeat biopsy designed to catch any change early. For low-risk cancer it is as safe as immediate treatment and avoids unnecessary side effects.
Why is a transperineal biopsy preferred?
Because the needle passes through the skin rather than the rectum, the risk of serious infection is much lower, and the front of the prostate is sampled more reliably.
How soon can I return to work after robotic prostatectomy?
Most men return to desk work in about three to four weeks, once the catheter is out and energy returns. Heavy lifting is avoided for about six weeks.
Will I need hormone therapy?
Hormone therapy is usually combined with radiation for intermediate- and high-risk disease and is the basis of treatment for spread disease. It is not routinely needed after successful surgery.
Can I take a second opinion before deciding on treatment?
Yes. Prostate Cancer often has more than one reasonable option, and a second opinion is a sensible step before any major decision. Reports can be reviewed in person or by teleconsultation.
