Prostate Cancer Treatment Options | Dr. Theodore Cisu

The short answer: Localized prostate cancer is cancer that hasn't spread beyond the prostate. Many of these cancers grow slowly, and treatment is matched to your risk group. Low-risk cancers are usually best watched closely with active surveillance. Higher-risk cancers are usually treated with surgery, such as robotic prostatectomy, or with radiation, sometimes combined with hormone therapy.

Written by Theodore Cisu, MD, board-certified urologist. Based on the American Urological Association (AUA) and American Society for Radiation Oncology (ASTRO) guideline on clinically localized prostate cancer (2022, amended 2026). Last reviewed November 2026.

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What is localized prostate cancer?

"Clinically localized" means that, based on your exam, tests and imaging, the cancer appears to be confined to the prostate. That's important news. It means there are good options, and you usually have time to learn about them and make a careful decision. A diagnosis rarely calls for a rushed choice.

How is prostate cancer risk determined?

Your urologist puts several pieces together to place your cancer in a risk group:

• PSA level at diagnosis
• Grade Group (from 1 to 5), which describes how aggressive the cells look under the microscope. You may also hear the older Gleason score.
• Clinical stage, based on the rectal exam and imaging
• How much of the biopsy contains cancer

The AUA/ASTRO guideline uses these risk groups:

• Low risk: Grade Group 1, a lower PSA and a small, confined tumor
• Favorable intermediate risk: a modest step up, such as limited Grade Group 2 cancer
• Unfavorable intermediate risk: more Grade Group 2 or 3 cancer, or other higher-risk features
• High risk: Grade Group 4 or 5, a PSA above 20, or cancer that extends just outside the prostate

What tests might I need after diagnosis?

• Prostate MRI can help show the extent of the cancer and plan treatment for any risk group.
• PSMA PET scans or other scans look for spread. They're recommended for unfavorable intermediate and high-risk cancer. Most men with low or favorable intermediate risk don't need them.
• Genetic testing may be recommended based on your personal and family history and your biopsy results. Inherited gene changes, such as in BRCA2, can affect your care and your family's health.

Treatment options

The guideline puts a lot of weight on shared decision-making. Your risk group, age, health, life expectancy and personal priorities all matter. Here are the main paths.

Active surveillance

For low-risk prostate cancer, active surveillance is the preferred approach. It's also an option for some men with favorable intermediate risk. Surveillance means checking the cancer closely so it can be treated if it starts to change, while avoiding the side effects of treatment you may never need. It typically includes:

• A PSA test, usually no more often than every 6 months
• A rectal exam every 1 to 2 years
• A prostate MRI, especially if you didn't have one before your first biopsy
• Repeat biopsies, often every 1 to 4 years, tailored to your situation

Active surveillance is a plan with regular follow-up. If tests show the cancer is changing, you can move to treatment.

Watchful waiting

Watchful waiting is different. It's for men with other serious health problems or a shorter life expectancy, where the cancer is unlikely to cause harm. Treatment focuses on easing symptoms if they ever appear.

Robotic radical prostatectomy

Surgery removes the whole prostate and the seminal vesicles, using a robotic system through small incisions. It's a standard option for intermediate and high-risk cancer. Dr. Cisu performs robotic prostatectomy.

• When it's safe for cancer control, the surgeon spares the nerves that help with erections.
• Lymph nodes may be removed for staging, depending on your risk.
• A catheter stays in for a short time after surgery.

The most common side effects are urinary leakage, which usually improves over the following months, and changes in erections. Pelvic floor exercises and treatments for erectile dysfunction can help with recovery. After surgery, you'll no longer ejaculate.

Radiation therapy

Radiation is another standard option for most risk groups. It's planned and given by a radiation oncologist. Options include:

• External beam radiation, given over several weeks or in a shorter course of a few higher-dose treatments, depending on your situation
• Brachytherapy, where radiation sources are placed inside the prostate

For unfavorable intermediate risk, the guideline recommends adding a short course of hormone therapy (about 4 to 6 months). For high risk, a longer course (about 18 to 36 months) is recommended. Radiation can cause urinary, bowel and sexual side effects. The guideline notes that proton therapy hasn't been shown to work better than other types of radiation.

Focal therapy

Focal therapies, such as high-intensity focused ultrasound (HIFU) and cryotherapy, treat only part of the prostate. They're appealing because they aim to reduce side effects. The guideline still considers them investigational because long-term comparisons with surgery and radiation are limited. They're best suited to clinical trials or to carefully selected men with intermediate-risk cancer who understand the unknowns. They aren't recommended for high-risk cancer outside a trial. Your urologist can discuss whether focal therapy fits you, and Dr. Cisu can coordinate a referral when appropriate.

How do I choose a treatment?

There's often more than one reasonable choice. Questions worth asking include:

• How likely is my cancer to grow or spread if I don't treat it now?
• What are the chances each option controls my cancer?
• How might each option affect my bladder, bowels and sex life?
• What does recovery look like for my work and family?

The guideline encourages measuring your urinary, bowel and sexual function before treatment, so you and your doctors can track changes and plan support. Meeting with both a urologist and a radiation oncologist can help you compare options side by side.

What happens after treatment?

After surgery or radiation, you'll have regular PSA tests and check-ins about your symptoms. Ongoing help with urinary control, sexual health and emotional well-being is part of good care. Support groups and counseling can make a real difference.

When to see a urologist

• You've just been diagnosed and want to understand your options
• You're on active surveillance and would like a fresh look at your plan
• You've been offered treatment and want a second opinion
• You have a family history of prostate cancer and want to plan screening or genetic testing

Seeing Dr. Cisu for prostate cancer

Dr. Theodore Cisu sees men with prostate cancer at his clinics in Charlottesville and Fishersville and by telehealth from anywhere in Virginia. Our office can request your biopsy report, PSA history and imaging, including MRI and PET scans, so Dr. Cisu reviews them before your visit. Second opinions are welcome, and no referral is needed. Book a visit.

Frequently asked questions

Is active surveillance safe?

For low-risk prostate cancer, the AUA/ASTRO guideline names active surveillance as the preferred approach. It relies on regular follow-up, so keeping your appointments and tests matters.

Is robotic surgery or radiation better for prostate cancer?

Both are standard options for many men, with different side effects and recoveries. The best choice depends on your cancer, your health and your priorities.

Will I be incontinent after prostate surgery?

Leaking urine is common at first and usually improves over the following months. Pelvic floor exercises help. Some men have lasting leakage, and treatments are available if that happens.

Can I keep erections after prostatectomy?

Nerve-sparing surgery aims to protect the nerves for erections when it's safe to do so. Recovery can take time, and your function before surgery plays a big role. Medications and other treatments can help.

What is a Grade Group?

It's a 1 to 5 scale describing how aggressive prostate cancer cells look. Grade Group 1 is the least aggressive. It replaced the Gleason score in everyday use, though you may still see both on your report.

How fast do I need to decide on treatment?

For most localized prostate cancers, you have time to gather information and get a second opinion. Ask your urologist how much time makes sense for your situation.

Sources

• American Urological Association and American Society for Radiation Oncology. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline (2022, amended 2026).
• American Urological Association. AUA releases Clinically Localized Prostate Cancer Guideline amendment (April 2026).

This article is for general education and isn't a substitute for medical advice. Your treatment plan should be based on a full review of your own results with your care team.