Surgery and Radiotherapy for Prostate Cancer – Which Is Better?

Prostate cancer treatment raises many questions about which option patients should choose, particularly in the early stages. Being informed about treatment options and their outcomes is essential to making the right decision at this point. 

Surgery is often the first option that comes to mind for early-stage prostate cancer. If a patient is not fit for surgery or the tumor cannot be completely removed, radiotherapy and other nonsurgical approaches are considered. This is a valid approach. However, nonsurgical methods are now understood to be as effective as surgery and, in many situations, to cause fewer short- and long-term side effects. 

For early-stage prostate cancer that has not spread, surgery and radiotherapy have similar success rates. When choosing among treatment options and informing the patient, we consider factors such as the cancer's biological aggressiveness and stage, the patient's age, general health, and expectations.

Surgery involves removing the prostate gland, whereas radiotherapy uses high-energy waves to destroy prostate cancer cells. In some cases, additional radiotherapy may be needed after surgery. These treatments can be used alone or together.

Although there is no definitive answer as to which treatment is better, understanding the differences between the options can help patients make an informed decision. This article compares prostate cancer surgery with radiotherapy and details their benefits, side effects, risks, costs, and recovery processes.

Is Surgery or Radiation Better for Prostate Cancer?

According to current scientific evidence, conventional treatments such as surgery, external radiation, and internal radiation show similar effectiveness for early-stage prostate cancer.

There are also alternative approaches for treating early-stage prostate cancer, including HIFU (destroying the tumor with High-Intensity Focused Ultrasound) and cryoablation (destroying the tumor by freezing). These techniques have effectiveness comparable to surgery or radiotherapy.

Treatment choices are generally shaped by the patient's overall health, personal preferences, and the level of risk associated with each method. Each approach's benefits and potential risks can strongly influence the patient's treatment decision.

Surgery for Prostate Cancer

We can recommend surgery for a person in good general health. Sometimes surgery alone can treat cancer that has not spread beyond the prostate gland.

Surgery for prostate cancer uses a procedure known as radical prostatectomy to remove the entire prostate gland. Surgeons may also remove surrounding tissues.

Radical prostatectomy involves cutting the tube that connects the testicles, which produce sperm, to the urethra. As a result, someone who has this operation cannot conceive a child through the usual methods. However, fertility preservation options, such as using a sperm bank, are available.

Radiotherapy for Prostate Cancer

Radiotherapy is another effective method for treating early-stage prostate cancer. It targets and destroys cancer cells using high-energy beams.

Radiotherapy is preferred in the following situations:

• The cancer is slow-growing and at an early stage, confined to the prostate gland.
• Surgery is not possible or carries high risks.
• Surgery would not be able to remove all the cancer.
• The cancer recurs.

Depending on the situation, radiotherapy can be used alone or with surgery. Generally favorable outcomes are achieved in either case.

Data from 2013 to 2019 show that people with localized prostate cancer have a greater than 99% chance of living at least 5 years after diagnosis.

Who Is Eligible for Surgery and Radiotherapy?

Eligibility for prostate cancer treatments depends on many factors, including the cancer's stage, the person's general health, age, and preferences.

We typically consider surgery first in the following circumstances:

• The person is under 75 and is expected to live at least another 10 years
• The cancer has not spread beyond the prostate
• Surgery is highly likely to remove all the cancer
• The person is at low risk from surgery and anesthesia

For someone who does not meet these or similar criteria, we consider radiotherapy. For the best results, we may sometimes use combinations of treatments, which can include androgen deprivation therapy .

Comparing Risks

Both surgery and radiotherapy may carry risks of short- and long-term complications.

Surgery

Like other operations, surgery for prostate cancer carries certain risks:

• Pain
• A reaction to anesthesia
• Bleeding and bruising
• Infection
• Damage to surrounding tissues, nerves, or organs
• Blood clots in the legs

Removing the prostate also carries some specific risks:

• Loss of bladder control
• Impotence
• A change in penis length
• An increased risk of inguinal hernia

Radiotherapy

Radiotherapy generally carries fewer short-term risks than surgery. However, it may cause short-term side effects:

• Rectal bleeding
• Diarrhea
• Urinary problems
• Fatigue
• Dry mouth
• Nausea
• Loss of appetite
• Constipation

In some cases, radiotherapy may cause the following long-term complications:

• Impotence
• Bowel function problems
• Urinary problems

There is also a risk of radiation-induced secondary cancers , which may develop years after the initial treatment.

Comparing Costs

A United States study conducted in 2020 found that the average 1-year treatment costs of surgery and radiotherapy were similar. Stereotactic body radiotherapy cost approximately 28,000 dollars, compared with approximately 22,000 dollars for prostatectomy. The least expensive option was brachytherapy (internal radiation), at approximately 19,000 dollars.

Prostate cancer treatment costs in Turkey are as follows:

• Radical Prostatectomy: Open, laparoscopic, and robotic surgery are used in Turkey. Although robotic surgery is more expensive, it offers a lower risk of complications and a faster recovery. As of 2024, the cost of radical prostatectomy in private hospitals in Turkey ranges from 200,000 to 400,000 TL.
• Radiotherapy: Radiotherapy options in Turkey include external radiotherapy (IMRT, VMAT, SBRT) and brachytherapy. In private hospitals, SBRT costs approximately 50,000 - 100,000 TL, while brachytherapy costs approximately 50,000 - 80,000 TL.

However, the amount a person pays for treatment may vary depending on several factors:

• Where treatment is provided
• The hospital or clinic chosen, whether private or public
• Insurance coverage
• The complexity of treatment
• The need for additional treatment
• Post-treatment care and follow-up services

Comparing Recovery

Recovery processes and experiences can differ substantially between surgery and radiotherapy.

Surgery

Recovery from surgery depends on the type of operation performed. Radical prostatectomy can be carried out using one of three approaches:

• Laparoscopic surgery: Minimally invasive surgery using very small incisions and a camera to access the prostate.
• Robot-assisted laparoscopic surgery
• Open surgery: Involves making a larger incision.

Compared with open surgery, robot-assisted surgery generally involves:

• A faster recovery
• A shorter hospital stay
• Less pain and blood loss

After surgery, patients usually remain in the hospital for a few days. During this period, a catheter—a thin tube extending through the penis into the bladder—is inserted to help drain urine.

Recovery at home may take several weeks. During this time, the person may experience pain, fatigue, and limited mobility.

Common short-term problems, such as urinary incontinence, may take several months to improve. Physical therapy and pelvic floor exercises may help recovery.

Radiotherapy

Recovery from radiotherapy can vary. Some people experience only short-term side effects, which may develop gradually during treatment and improve after it ends. Others may experience long-term side effects that take months to improve or require ongoing management.

People generally receive radiation treatment as outpatients and return home the same day. For most forms of external radiation, treatment is given 5 days a week for at least several weeks.

Frequently Asked Questions

What is the rate of regret after prostate surgery?

According to a survey of 2072 patients published in 2021, men with early-stage prostate cancer who chose surgery were more likely to regret their decision than those who chose radiotherapy or active surveillance.

At 5 years, 13% of the surveyed men experienced treatment-related regret, which varied by treatment type:

• 16% of surgery patients (183) regretted their decision, compared with
• 11% of men who chose radiotherapy (76) and
• 7% of those who chose active surveillance (20).

See the details of the relevant study.

How much does penis length decrease after prostate surgery?

Not everyone who undergoes prostatectomy loses penis length. In fact, a 2018 study showed that more than 60% of people who had prostatectomy regained their penis length within 12 months. Regular use of a medication known as a phosphodiesterase-5 inhibitor may help.

Those who do not regain their length lose an average of 2.35 centimeters (0.92 inches).

How do surgery and radiotherapy differ in terms of sexual function?

Erectile dysfunction is the inability to achieve or maintain an erection sufficient for sexual intercourse.

Long-term rates of erectile dysfunction are lower in patients receiving radiotherapy than in those undergoing surgery. Medications such as sildenafil (Viagra and others) or other erectile rehabilitation methods may be used to preserve erectile function after treatment. 

When is radiotherapy needed after surgery?

In prostate cancer treatment, the need for postoperative adjuvant radiotherapy (RT) depends on the patient's pathological findings and postoperative risk factors. Adjuvant RT is generally considered in the following situations:

1. Positive Surgical Margins:

   • Adjuvant RT may be recommended if not all cancerous tissue was removed during surgery and microscopic cancer cells remain at the surgical margin. Positive surgical margins increase the risk of recurrence.

2. Extracapsular Extension:

   • Adjuvant RT is considered when cancer has spread outside the prostate capsule. This indicates more advanced disease and a higher risk of recurrence.

3. Seminal Vesicle Invasion:

   • Adjuvant RT may be recommended when cancer has spread to the seminal vesicles. This indicates a more aggressive disease course.

4. High Gleason Score:

   • Gleason score 8-10 may warrant adjuvant RT because patients with high-grade tumors have a high risk of recurrence.

5. Positive Lymph Nodes:

   • Adjuvant RT may be needed if cancer has spread to the lymph nodes (positive lymph nodes). This increases the risk of systemic disease spread and recurrence.

6. Prostate-Specific Antigen (PSA) Levels:

   • Adjuvant RT may be recommended when postoperative PSA levels are high or fail to fall (persistent PSA). This may indicate that not all cancerous tissue was removed.

Summary

Both surgery and radiotherapy are effective treatments for early-stage prostate cancer and can treat the condition. However, each option has benefits and drawbacks that may make it more or less suitable for an individual.

Surgery is appropriate when doctors believe they can remove all the cancer. If this is not possible, radiotherapy may be used instead of surgery or in combination with it. Radiotherapy is also an appropriate option for people who cannot undergo surgery or do not want it.

These are not always the only options for treating prostate cancer. People should discuss the next steps in detail with a healthcare professional to understand the benefits and risks of each option.