Tag Archive for: prostate cancer

Robotic-Assisted Radical Prostatectomy: When Is a Non-Nerve-Sparing Procedure Necessary?

August 28, 2026/0 Comments/in Blog Post, Prostate Surgery/by drjo

Removing the prostate while putting cancer control first

Robotic-assisted radical prostatectomy is a well-established surgical treatment for localised and selected locally advanced prostate cancer. During the operation, the prostate gland and seminal vesicles are removed, and the bladder is reconnected to the urethra. In selected patients, pelvic lymph nodes may also be removed.

One of the important decisions made before and during prostate cancer surgery is whether the nerves responsible for erections can safely be preserved.

This is known as nerve-sparing prostatectomy.

Unfortunately, nerve preservation is not always appropriate. When prostate cancer is close to, involves, or is suspected of extending beyond the outer edge of the prostate near these nerves, attempting to preserve them may compromise the completeness of cancer removal.

In this situation, a partial or complete non-nerve-sparing robotic prostatectomy may be recommended.

The guiding principle is simple:

Preserve the nerves when it is oncologically safe to do so, but do not preserve them at the expense of adequately treating the prostate cancer.

What are the nerves that are being “spared”?

Running immediately alongside the prostate are delicate bundles of nerves and blood vessels known collectively as the neurovascular bundles.

These structures contain nerves that play an important role in producing erections.

They sit extremely close to the outer surface, or capsule, of the prostate. This anatomical relationship creates a challenge during prostate cancer surgery.

If the cancer is safely contained within the prostate and sufficiently distant from the neurovascular bundle, the surgeon may be able to carefully dissect the prostate away while preserving the nerves.

This is a nerve-sparing radical prostatectomy.

If cancer is suspected to extend towards or through the prostate capsule in this area, the surgeon may need to remove some or all of the neurovascular tissue together with the prostate.

This is a non-nerve-sparing prostatectomy.

Why would a surgeon deliberately remove the erectile nerves?

It may initially seem counterintuitive to remove structures that are so important for sexual function.

The reason is cancer control.

The primary purpose of radical prostatectomy is to completely remove the prostate cancer.

If a tumour is growing very close to the edge of the prostate, particularly next to a neurovascular bundle, dissecting too close to the prostate in an attempt to preserve the nerves could potentially leave cancer cells behind.

This is called a positive surgical margin.

In appropriately selected patients, taking a wider margin around the prostate may therefore provide a safer cancer operation.

The decision represents a balance between:

Cancer control

and

preservation of erectile function.

When these two goals conflict, cancer control generally takes priority.

When may a non-nerve-sparing prostatectomy be recommended?

Non-nerve-sparing surgery may be considered when there is a significant risk that prostate cancer has extended towards or into the tissues surrounding the prostate.

Examples include:

Locally advanced prostate cancer

A tumour suspected of extending through the prostate capsule, particularly clinical T3 disease, may require a wider surgical excision.

Cancer close to the neurovascular bundle on MRI

Modern multiparametric prostate MRI can provide valuable information about the location of the tumour and its relationship to the prostate capsule and neurovascular bundles.

Features suggesting extraprostatic extension may influence the decision not to preserve the nerve bundle on that side.

High-grade prostate cancer

Higher-grade cancers, including cancers with an unfavourable Gleason score or ISUP Grade Group, may have a greater likelihood of extending outside the prostate.

The biopsy result alone does not automatically determine whether the nerves can be preserved, but it forms part of the overall assessment.

Extensive cancer on prostate biopsy

Large-volume disease, particularly when concentrated along the outer portion of the prostate near a neurovascular bundle, may make nerve preservation less appropriate.

Very high PSA or other high-risk features

PSA level, PSA density, biopsy findings, MRI appearance and clinical examination are considered together when estimating the likelihood of disease extending beyond the prostate.

Cancer involving one particular side of the prostate

Importantly, nerve sparing does not necessarily have to be “all or nothing.”

If the cancer is predominantly on one side, it may sometimes be possible to preserve the neurovascular bundle on the opposite side.

This is known as unilateral nerve sparing.

Nerve sparing is not simply YES or NO

Modern robotic prostate surgery is more nuanced than dividing operations into completely nerve-sparing and completely non-nerve-sparing procedures.

Depending on the location and extent of the cancer, surgery may involve:

Bilateral nerve sparing
Unilateral nerve sparing
Partial nerve sparing
Wider excision on one side and nerve preservation on the other
Complete bilateral non-nerve-sparing surgery

The surgical plan can therefore be tailored to the individual patient and, importantly, to the cancer on each side of the prostate.

How does nerve-sparing surgery differ from non-nerve-sparing surgery?

During nerve-sparing surgery, the surgeon carefully separates the neurovascular bundle from the surface of the prostate while attempting to minimise traction, heat and other potential injury to these delicate nerves.

During non-nerve-sparing surgery, the dissection is deliberately performed further away from the prostate.

The neurovascular tissue is removed together with the prostate where necessary to obtain a wider cancer margin.

The robotic platform provides magnified three-dimensional vision and highly controlled instrument movement. This allows the surgeon to identify tissue planes with considerable precision.

However, robotic technology cannot make an unsafe nerve-sparing operation safe.

The biology and location of the cancer ultimately determine how close to the prostate the surgeon can safely operate.

What happens to erections after non-nerve-sparing prostatectomy?

This is one of the most important issues to discuss before surgery.

The nerves surrounding the prostate are responsible for signalling increased blood flow into the penis to produce a natural erection.

If both neurovascular bundles are completely removed, the likelihood of recovering spontaneous erections adequate for sexual intercourse is very low.

This is different from nerve-sparing surgery, where the nerves remain anatomically intact but may temporarily function poorly following surgery.

After nerve-sparing prostatectomy, erectile recovery can occur gradually over many months and sometimes over 18–24 months or longer.

After complete bilateral non-nerve-sparing surgery, however, the nerves themselves have been removed rather than temporarily stunned.

The expectations for recovery are therefore very different.

Does non-nerve-sparing surgery affect sensation or orgasm?

This is an important distinction.

The nerves responsible for penile sensation are different from the neurovascular nerves primarily responsible for erections.

Many men can therefore continue to experience penile sensation and sexual pleasure following radical prostatectomy.

Orgasm may also remain possible.

However, radical prostatectomy removes the prostate and seminal vesicles and disconnects the reproductive pathway. Consequently, there is no ejaculation of semen after surgery.

This is sometimes described as a dry orgasm.

The sensation of orgasm can also feel different after prostate surgery.

Does non-nerve-sparing prostatectomy cause infertility?

Yes.

Radical prostatectomy results in permanent infertility because the prostate and seminal vesicles are removed and sperm can no longer enter the ejaculate.

Men who may wish to father children in the future should discuss sperm banking before surgery.

This applies whether the operation is nerve sparing or non-nerve sparing.

Is a non-nerve-sparing procedure reversible?

No.

Once a neurovascular bundle has been surgically removed, it cannot simply be reattached at a later date.

This is an important difference between temporary nerve dysfunction and actual nerve removal.

After nerve-sparing surgery, the nerves may be anatomically preserved but temporarily injured or “stunned”. Recovery may therefore occur with time.

After complete non-nerve-sparing surgery, the erectile nerves have been physically removed as part of the cancer operation.

The procedure itself is therefore not reversible.

However, this does not mean that erections or sexual activity are impossible.

There are several effective treatments available for erectile dysfunction following prostatectomy.

Can erections still be achieved after non-nerve-sparing surgery?

Rarely yes, but they will usually require assistance.

Treatment options include:

PDE5 inhibitor tablets

Medications such as sildenafil or tadalafil are commonly used after prostate surgery.

They rely substantially on functioning nerve pathways and are therefore generally more effective following nerve-sparing surgery.

Their effectiveness following complete bilateral non-nerve-sparing surgery is considerably more limited.

Vacuum erection device

A vacuum erection device creates negative pressure around the penis, drawing blood into the erectile tissues.

A constriction ring can then be placed around the base of the penis to maintain the erection.

Because this technique does not depend on intact erectile nerves, it can be useful after non-nerve-sparing surgery.

Penile injection therapy

Medication can be injected directly into the erectile tissue of the penis.

These medications act directly on penile blood vessels and therefore do not require normal prostate-associated nerve signalling.

For this reason, penile injections can be highly effective even after bilateral non-nerve-sparing prostatectomy.

Penile prosthesis

For men with persistent erectile dysfunction who wish to restore reliable erections, a penile prosthesis can provide an effective long-term solution.

An inflatable penile prosthesis allows an erection to be mechanically produced when desired.

For appropriately selected men, satisfaction rates following penile prosthesis surgery are generally high.

What about penile rehabilitation?

Penile rehabilitation may be discussed following radical prostatectomy.

The objectives can include maintaining penile tissue health, encouraging regular oxygenation of the erectile tissues, minimising shortening and fibrosis, and assisting the return to sexual activity.

A rehabilitation program may involve:

PDE5 inhibitor medication where appropriate
Vacuum erection therapy
Penile injection therapy
Regular sexual stimulation
Early assessment and management of erectile dysfunction

The appropriate program depends heavily on whether surgery was bilateral nerve sparing, unilateral nerve sparing or completely non-nerve sparing.

It is therefore important that expectations are realistic.

After complete bilateral nerve removal, rehabilitation cannot make the removed nerves grow back. Instead, treatment focuses on maintaining penile health and providing alternative ways of achieving an erection.

Can the surgeon decide during the operation whether to spare the nerves?

Sometimes.

The intended degree of nerve sparing is usually planned before surgery using information from:

Prostate MRI
Prostate biopsy
PSA
Clinical examination
Location and volume of cancer
Gleason score and ISUP Grade Group
Estimated risk of extraprostatic extension
The patient’s existing erectile function
The patient’s priorities regarding cancer control and sexual function

However, the final surgical approach may occasionally need to be modified according to findings encountered during the operation.

The most important objective remains adequate removal of the cancer.

Does non-nerve-sparing surgery improve cancer cure rates?

Not every patient benefits from wider surgery.

For men with cancer safely confined within the prostate, unnecessary removal of the neurovascular bundles may produce significant functional consequences without providing additional cancer benefit.

Conversely, when cancer is suspected of extending close to or beyond the prostate capsule adjacent to a neurovascular bundle, wider excision may reduce the risk of leaving tumour at the surgical margin.

This is why the decision must be individualised.

The best operation is not automatically the operation that preserves the most nerves. It is the operation that provides appropriate cancer clearance while preserving as much normal function as can safely be preserved.

What about urinary continence?

Nerve sparing primarily relates to erectile function, rather than the urinary sphincter responsible for continence.

Urinary control after radical prostatectomy depends on several factors including:

Age
Pre-operative urinary function
Pelvic floor strength
Urethral length
Bladder function
Surgical anatomy and technique
Previous prostate treatments
Individual healing

Pelvic floor rehabilitation before and after surgery can be an important part of recovery.

Non-nerve-sparing surgery does not automatically mean that a patient will remain incontinent.

Questions worth asking before surgery

If a non-nerve-sparing robotic prostatectomy has been recommended, useful questions to discuss with your urologist include:

Why is nerve preservation considered unsafe in my particular cancer?

Is the concern on one side or both sides of the prostate?

Could unilateral or partial nerve sparing be considered?

What does my MRI show about the relationship between the cancer and neurovascular bundles?

What is my estimated chance of erectile recovery with the proposed operation?

What erectile rehabilitation options will be available after surgery?

Should I consider sperm banking before treatment?

These conversations are particularly important because the decision to remove a neurovascular bundle is generally irreversible.

The important message

A non-nerve-sparing robotic-assisted radical prostatectomy is not an inferior version of nerve-sparing surgery.

In the right patient, it is a deliberate cancer-control strategy.

When prostate cancer is close to or suspected of involving the tissues surrounding the prostate, preserving the erectile nerves too aggressively may risk leaving cancer behind.

Modern robotic surgery allows the operation to be tailored to the individual patient. Some men can undergo bilateral nerve preservation, others may benefit from preservation on only one side, while patients with more extensive disease may require a wider non-nerve-sparing excision.

The consequences for erectile function are important and should be understood before surgery.

Once the neurovascular nerves have been removed, the procedure cannot be reversed.

However, loss of spontaneous erections does not mean the end of sexual intimacy. Vacuum devices, penile injection therapy and penile prostheses can provide effective options when natural erections are no longer possible.

Ultimately, the aim is to achieve the best possible balance between two important goals:

Effective treatment of the prostate cancer and preservation of quality of life.

A note for patients

Every prostate cancer is different. MRI findings, biopsy results, PSA, cancer grade, age, general health, pre-existing erectile function and personal priorities all influence the appropriate surgical approach.

A detailed discussion with your urologist before robotic prostatectomy is essential so that you understand whether nerve sparing is appropriate, what degree of nerve preservation may be possible and what this means for cancer control, continence and sexual function.

This information is intended for general patient education and does not replace individual medical advice. Treatment recommendations should be based on your individual prostate cancer characteristics, imaging, pathology, general health and discussion with your treating urologist.

Focal Therapy for Prostate Cancer: Treating the Cancer, Preserving the Prostate

August 26, 2026/0 Comments/in Blog Post, Prostate Surgery/by drjo

For many years, treatment of localised prostate cancer largely involved choosing between active surveillance and treatment of the whole prostate gland with surgery or radiotherapy.

Modern multiparametric MRI, targeted transperineal biopsy and increasingly accurate image-guided treatment have opened a third pathway for carefully selected men: focal therapy.

Rather than treating or removing the entire prostate, focal therapy aims to identify the clinically significant cancer and destroy that area together with an appropriate safety margin, while leaving as much normal prostate tissue as possible.

A useful analogy is treating the troublesome patch rather than replacing the entire lawn.

The attraction is obvious: if the cancer can be controlled without treating the whole prostate, it may be possible to reduce the risks of urinary incontinence, erectile dysfunction and other quality-of-life effects associated with radical treatment.

However, focal therapy is not suitable for every prostate cancer, and it comes with an important trade-off: long-term cancer-control evidence is less mature than it is for radical prostatectomy and radiotherapy. Current European guidance therefore remains cautious, recommending focal therapy within clinical trials or well-designed prospective registries until stronger long-term comparative evidence becomes available.

What is focal therapy?

Focal therapy treats a selected region of the prostate containing clinically significant cancer rather than treating the entire gland.

Depending on the size and location of the tumour, treatment may involve:

Focal ablation of an individual lesion
Hemi-ablation, treating approximately one side of the prostate
Quadrant or zonal ablation
A wider “hockey-stick” ablation where disease distribution requires a larger treatment field

The treatment zone normally includes both the visible tumour and a planned margin around it.

The challenge is that prostate cancer is frequently multifocal. The largest or most biologically significant lesion is often referred to as the index lesion, but smaller cancer deposits may exist elsewhere in the gland.

For this reason, careful imaging, biopsy and follow-up are fundamental to a successful focal therapy program.

Who may be suitable for focal therapy?

The ideal candidate is generally a man with localised, clinically significant prostate cancer that can be accurately identified and safely targeted.

Potential candidates may include men with:

Disease confined to the prostate
A clearly identifiable lesion on multiparametric MRI
Cancer confirmed by targeted and systematic or mapping transperineal biopsy
Favourable intermediate-risk disease, commonly ISUP Grade Group 2 / Gleason 3+4, in an appropriate anatomical distribution
Selected higher-volume Grade Group 1 disease where active surveillance is considered unsuitable or unacceptable
Occasionally carefully selected Grade Group 3 disease in experienced centres, although the evidence is less established
A lesion that can be treated with an adequate margin without unacceptable injury to the urethra, sphincter, rectum or neurovascular structures
A strong preference to minimise the potential urinary and sexual consequences of whole-gland treatment

The decision should ideally follow review of the MRI, biopsy pathology, PSA, PSA density, prostate volume, tumour location and overall risk profile, rather than simply asking whether a particular machine can reach the tumour.

Who is generally NOT a good candidate?

Focal treatment becomes less attractive when there is:

Extensive multifocal clinically significant cancer
Significant bilateral disease
High-volume high-grade cancer
Extracapsular extension
Seminal vesicle invasion
Lymph-node involvement
Metastatic disease
Cancer that cannot be reliably seen or mapped
Disease immediately adjacent to structures that cannot safely be included in the treatment margin
A patient preference for the treatment with the longest-established oncological follow-up

Some men with very low-risk disease may also be better served by active surveillance rather than focal treatment, avoiding treatment altogether until there is evidence that treatment is actually necessary.

How do we determine whether focal treatment is appropriate?

Successful focal therapy begins with accurate cancer mapping.

Assessment will usually include:

Multiparametric MRI

MRI identifies suspicious lesions and helps establish their size, location and relationship to the urethra, capsule, sphincter and neurovascular bundles.

Transperineal prostate biopsy

MRI alone is not enough.

Targeted biopsy confirms the grade and extent of the MRI-visible lesion, while systematic or mapping biopsies help determine whether significant cancer exists elsewhere in the prostate.

PSA and PSA density

PSA remains useful, although interpretation after focal therapy differs from interpretation following radical prostatectomy because normal prostate tissue remains behind.

PSMA PET/CT

PSMA PET may be useful in selected patients, particularly those with higher-risk characteristics or when there is concern about disease outside the proposed treatment area.

What focal therapy options are available?

Several technologies can destroy a selected area of prostate tissue.

These include:

Irreversible Electroporation: NanoKnife

NanoKnife® is a system used to perform irreversible electroporation, or IRE.

Several fine needle electrodes are inserted through the perineum around the tumour under imaging guidance. Very short, high-voltage electrical pulses are passed between the electrodes.

Rather than primarily heating or freezing the tissue, the electrical field creates irreversible disruption of cell membranes, resulting in cell death.

IRE is therefore principally considered a non-thermal ablative technology.

Focal Laser Ablation

A laser fibre is placed directly into the target lesion and laser energy produces controlled thermal destruction of cancerous tissue.

ProFocal-Rx® is an Australian-developed focal laser technology designed specifically for targeted prostate treatment.

High-Intensity Focused Ultrasound

HIFU focuses ultrasound energy within the prostate, heating and destroying the targeted tissue without requiring needles to be placed directly throughout the treatment zone.

Cryotherapy

Needles are placed into the prostate and tissue is repeatedly frozen and thawed, producing cellular destruction.

Other technologies

Photodynamic therapy, radiofrequency ablation, focal brachytherapy and other energy-based approaches have also been investigated.

The Prostate Cancer Foundation of Australia notes that focal therapies including IRE/NanoKnife, laser ablation, HIFU and other technologies have been investigated or used in Australia, although availability varies.

NanoKnife versus ProFocal Laser Therapy

Both technologies attempt to achieve the same broad objective: destroy the cancer while preserving as much normal prostate and surrounding function as possible.

They achieve this in very different ways.

	NanoKnife / IRE	ProFocal-Rx Laser
Energy	High-voltage electrical pulses	Laser energy
Mechanism	Irreversible electroporation	Thermal coagulative ablation
Thermal treatment	Principally non-thermal	Yes
Access	Transperineal needles/electrodes	Transperineal laser applicator
Treatment planning	Electrode geometry surrounds treatment zone	Laser applicator positioned within/adjacent to target
MRI/TRUS planning	Yes	Yes
Tissue effect	Cell membrane disruption	Controlled heating and tissue necrosis
Treatment margin	Created by electrical field between electrodes	Created by laser ablation zone
Near neurovascular structures	Potential theoretical advantage of non-thermal mechanism	Requires careful thermal planning
Anaesthesia	General anaesthesia with profound muscle relaxation generally required	General anaesthesia typically used
Cardiac synchronisation	Required with IRE	Not required in the same manner
Repeat treatment	Possible in selected cases	Potentially possible
Long-term oncological evidence	Growing medium-term evidence	Earlier-stage clinical evidence
Australian regulatory status	IRE devices are represented on the ARTG; specific device/indication should be checked	ProFocal is currently not included on the ARTG

NanoKnife: potential advantages

The major attraction of IRE is that it does not rely primarily upon heating or freezing the prostate.

The electrical field disrupts cell membranes while potentially allowing relative preservation of extracellular structures. This makes IRE particularly interesting when treating cancers close to delicate structures.

Potential advantages include:

Precise treatment planning
No ionising radiation
No prostate removal
Preservation of untreated prostate tissue
Low reported rates of significant urinary incontinence
Potentially better preservation of erectile function compared with whole-gland treatment
Ability to consider repeat focal treatment in selected patients
Radical surgery or radiotherapy may remain possible if subsequent clinically significant cancer develops

Australian and international experience with IRE is considerably more mature than that of many newer focal technologies, although long-term comparative data against radical prostatectomy and radiotherapy are still developing. Published reviews cited by the AUA report residual or recurrent clinically significant cancer after focal ablation across all technologies, reinforcing the need for surveillance rather than considering focal therapy a “treat it and forget it” procedure.

NanoKnife: disadvantages and potential complications

IRE is still an invasive procedure.

Potential complications include:

Temporary urinary frequency and urgency
Dysuria
Haematuria
Perineal bruising or discomfort
Urinary retention
Temporary catheter requirement
Urinary tract infection
Prostatitis
Urethral injury or stricture
Erectile dysfunction
Ejaculatory changes
Rare urinary incontinence
Incomplete tumour ablation
Residual cancer within the treated field
Development or recognition of cancer elsewhere in the prostate
Need for repeat focal treatment
Subsequent need for radical prostatectomy or radiotherapy

Because IRE uses high-voltage electrical pulses, treatment requires appropriate anaesthesia, muscle relaxation and cardiac synchronisation.

ProFocal-Rx: focal laser therapy

ProFocal-Rx is a targeted laser ablation system developed in Australia.

A treatment applicator is placed transperineally into the prostate tumour. Laser energy is then delivered into the planned treatment area, producing controlled thermal destruction.

Early Australian studies have evaluated the feasibility and safety of this approach, including clinical trials of targeted treatment for MRI-localised prostate cancer.

Potential attractions include:

Highly localised treatment
Direct placement of the treatment fibre into the tumour
Relatively small treatment volumes
Preservation of surrounding prostate tissue
Short treatment and recovery pathways
Potential preservation of urinary continence
Potential preservation of erectile and ejaculatory function

However, ProFocal remains a newer technology with substantially less long-term oncological follow-up than radical prostatectomy, radiotherapy and even some other focal therapy platforms.

ProFocal: potential risks and limitations

Because laser treatment is thermal, careful treatment planning is required to prevent unintended heat injury.

Possible complications include:

Urinary frequency or urgency
Dysuria
Haematuria
Temporary urinary retention
Infection
Perineal discomfort
Urethral thermal injury
Erectile dysfunction
Ejaculatory changes
Rectal injury, although uncommon with appropriate treatment planning
Incomplete ablation
Residual clinically significant cancer
Cancer developing or being detected elsewhere in the prostate
Need for repeat treatment
Need for subsequent radical prostatectomy or radiotherapy

An important additional consideration is simply the maturity of the evidence. Early results can be encouraging without necessarily predicting cancer control at 10, 15 or 20 years.

What is the TGA status in Australia?

This point deserves particular clarity.

The Australian Register of Therapeutic Goods (ARTG) is the TGA’s public register of therapeutic products that can legally be supplied in Australia, subject to applicable exemptions and special-access pathways.

IRE / NanoKnife

Irreversible electroporation technology is available in Australia and is being used clinically for selected prostate cancers. The Medical Services Advisory Committee currently has an application assessing IRE using the NanoKnife system for prostate tumour tissue, including a proposed Medicare Benefits Schedule item. That MSAC application remains under assessment rather than representing an established Medicare item.

It is important not to confuse TGA/ARTG regulatory status with Medicare funding or with endorsement of focal therapy as oncologically equivalent to prostatectomy or radiotherapy. These are separate questions.

ProFocal-Rx

As of August 2026, the manufacturer’s Australian website specifically states that:

ProFocal is not included on the TGA’s ARTG in Australia.

TGA documents also demonstrate previous Australian patient access to ProFocal-Rx through the Special Access Scheme, which is a pathway for accessing an unapproved therapeutic good in particular circumstances and is not the same as general ARTG inclusion.

This distinction is important when discussing ProFocal with Australian patients.

Regulatory status can change, so the current ARTG should always be checked when treatment is being considered.

Does focal therapy cure prostate cancer?

It can achieve local control of appropriately selected prostate cancers, but the word “cure” needs to be used carefully.

Unlike radical prostatectomy, focal therapy deliberately leaves much of the prostate behind.

There are therefore two important potential sites of future cancer:

In-field recurrence
Cancer persists or recurs within the treated area.

Out-of-field cancer
Clinically significant cancer is subsequently detected elsewhere in the untreated prostate.

Neither necessarily means that focal therapy was inappropriate, but patients need to understand from the outset that continued prostate cancer surveillance is part of the treatment strategy.

The AUA’s salvage guideline notes clinically significant cancer following focal treatment across different modalities and emphasises that recurrence remains an important consideration after focal ablation.

Follow-up after focal therapy

Focal therapy does not end prostate cancer surveillance.

Follow-up typically involves a combination of:

Regular PSA testing
Clinical review
Multiparametric MRI
Repeat targeted and systematic biopsy
Additional imaging where clinically indicated

A common strategy is to establish a new PSA baseline after treatment and combine PSA behaviour with MRI and scheduled biopsy rather than relying on PSA alone.

This is important because the remaining normal prostate continues to produce PSA. Unlike after radical prostatectomy, the PSA is therefore not expected to become undetectable.

What happens if the cancer returns?

One of the advantages of focal treatment is that further treatment options usually remain available.

Depending upon the location, grade and extent of recurrent disease, options may include:

Continued surveillance for insignificant disease
Repeat focal therapy
Radical prostatectomy
External-beam radiotherapy
Other appropriate salvage treatment

Patients should nevertheless understand that salvage surgery after previous focal therapy may be technically more challenging because of fibrosis and altered tissue planes.

For clinically significant recurrence following focal ablation, AUA salvage guidance recommends that men considering definitive salvage treatment be offered whole-gland treatment with radical prostatectomy or radiotherapy.

Focal therapy versus radical treatment

Focal therapy occupies an increasingly interesting middle ground.

Active surveillance aims to avoid treatment until treatment becomes necessary.

Focal therapy aims to treat the clinically significant cancer while preserving the remainder of the prostate.

Radical prostatectomy or radiotherapy aims to treat the entire prostate and therefore both known and potentially occult cancer within the gland.

There is no universally “best” choice.

The appropriate treatment depends upon:

Cancer grade
Cancer volume
MRI findings
Biopsy distribution
PSA and PSA density
Age and life expectancy
Baseline urinary function
Baseline erectile function
Other medical conditions
Individual attitude towards cancer risk
Willingness to undergo continued MRI and biopsy surveillance
Personal priorities regarding continence and sexual function

The key question: are we treating the right cancer?

The success of focal therapy depends less on the glamour of the machine and more on patient selection, accurate imaging, meticulous biopsy mapping, treatment planning and rigorous follow-up.

NanoKnife, laser, HIFU and cryotherapy are different tools. The most important step occurs before any of them are switched on: establishing exactly where the clinically significant cancer is and whether disease elsewhere in the prostate has been adequately excluded.

For the appropriately selected man, focal therapy offers an attractive possibility:

Treat the cancer that needs treatment while preserving as much of the prostate, urinary function and sexual function as possible.

For other men, active surveillance, radical prostatectomy or radiotherapy will remain the safer oncological strategy.

Important perspective

Focal therapy is an exciting and rapidly evolving field, but it should not be presented as a universally equivalent replacement for established prostate cancer treatments.

Current evidence suggests good functional outcomes in appropriately selected patients, while definitive long-term comparative oncological evidence remains incomplete. European guidelines consequently continue to recommend focal therapy within clinical trials or prospective registries.

The decision is therefore best made after a detailed discussion with a urologist experienced in prostate MRI, transperineal biopsy, focal therapy and established radical treatment options.

Australian regulatory note

At the time of writing in August 2026, ProFocal-Rx is not included on the Australian ARTG, while IRE/NanoKnife technology is available in Australia and IRE for prostate cancer is currently undergoing an MSAC assessment relating to proposed Medicare funding. Regulatory status and funding arrangements may change and should be confirmed before treatment.

This information is intended for general patient education and does not replace individual medical advice. Suitability for focal therapy requires assessment of the patient’s pathology, imaging, prostate anatomy, overall health and personal treatment priorities.

Active Surveillance for Prostate Cancer

August 21, 2026/0 Comments/in Blog Post, Prostate Surgery/by drjo

Being diagnosed with prostate cancer does not always mean that treatment needs to start immediately.

Many prostate cancers grow very slowly and may never cause symptoms or threaten a man’s life. For carefully selected men, active surveillance allows the cancer to be closely monitored while avoiding, or at least delaying, treatments such as surgery or radiation therapy.

Importantly, active surveillance does not mean ignoring the cancer. It is a structured programme of PSA testing, clinical review, prostate MRI and, when appropriate, repeat prostate biopsy. If there are signs that the cancer is becoming more significant, treatment can be recommended while the disease is still potentially curable.

Current international guidelines consider active surveillance the preferred or standard management approach for most suitable men with low-risk localised prostate cancer, and it may also be considered in carefully selected men with favourable intermediate-risk disease.

What Is Active Surveillance?

Active surveillance is a management strategy for prostate cancer in which curative treatment is deliberately postponed while the cancer is carefully monitored.

The aim is simple:

Avoid unnecessary treatment and its potential side effects, without compromising the opportunity for cure if the cancer changes.

This is particularly relevant because prostate cancer behaves very differently from one man to another. Some cancers are aggressive and require treatment, while others may remain small and slow-growing for many years.

Australian patient guidance describes active surveillance as close monitoring of low-risk prostate cancer that is not causing symptoms, with treatment initiated if investigations indicate that the cancer is becoming more aggressive.

Who Qualifies for Active Surveillance?

Active surveillance is most commonly recommended for men with low-risk prostate cancer.

Typical features include:

Cancer confined to the prostate
Grade Group 1 / Gleason score 3+3=6
PSA generally less than 10 ng/mL
Clinical stage T1 to T2a
Relatively small volume of cancer on prostate biopsy
Favourable findings on multiparametric MRI
A PSA density that supports low-volume disease
No clinical or imaging evidence suggesting more aggressive cancer

The AUA/ASTRO risk classification defines low-risk disease as PSA below 10 ng/mL, Grade Group 1 and clinical stage T1–T2a. For these patients, active surveillance is recommended as the preferred management strategy.

However, no single number determines suitability. Age, general health, family history, MRI findings, PSA density, biopsy findings, life expectancy and personal preferences all contribute to the decision.

Can Men With Gleason 3+4 / Grade Group 2 Cancer Have Active Surveillance?

Sometimes.

Active surveillance is increasingly considered for carefully selected men with favourable intermediate-risk prostate cancer, particularly when there is only a small amount of Gleason pattern 4 disease.

The 2026 European Association of Urology guidelines support active surveillance for selected men with favourable Grade Group 2 cancer. Features favouring surveillance include a small amount of pattern 4 disease, PSA below 10 ng/mL, limited tumour volume on biopsy and favourable imaging.

Similarly, AUA/ASTRO guidance suggests that favourable intermediate-risk patients with low PSA density, low tumour volume and a low percentage of Gleason pattern 4 disease may be considered for active surveillance.

These men require careful counselling because their risk of progression is higher than for men with Grade Group 1 disease.

Active surveillance is generally not appropriate for Grade Group 3 or higher-risk prostate cancer in men otherwise suitable for curative treatment.

What Happens Before Starting Active Surveillance?

The first step is making sure that the cancer really is suitable for surveillance.

Assessment may include:

PSA and PSA Density

PSA is considered together with prostate volume to calculate the PSA density.

A relatively low PSA density, commonly around less than 0.15 ng/mL/cc, provides additional reassurance in men being considered for surveillance, although it should not be interpreted as an absolute cut-off in isolation.

Multiparametric MRI of the Prostate

A high-quality multiparametric MRI (mpMRI) provides important information about:

The location of the tumour
Tumour size
Suspicious areas within the prostate
Possible extension outside the prostate
Areas that should be targeted during biopsy

MRI has become an important part of modern active surveillance, but MRI alone does not completely replace prostate biopsy.

Review or Confirmation of the Biopsy

The initial biopsy determines the Grade Group, Gleason score and volume of cancer.

Depending on how the original diagnosis was made, a confirmatory biopsy may be recommended. MRI-targeted biopsies can specifically sample suspicious lesions, while systematic or regional biopsies assess other areas of the prostate.

How Is Active Surveillance Performed?

Active surveillance is an ongoing programme rather than a single test.

The exact protocol varies according to the patient’s age, cancer characteristics, previous investigations and the treating urologist or institution.

A typical programme may include:

PSA Testing

PSA is usually measured approximately every 3–6 months initially, although intervals may become longer in men with very stable disease.

Current EAU guidance recommends PSA testing at least every six months, while Australian Cancer Council information describes PSA testing every 3–6 months.

The trend in PSA is usually more informative than one isolated reading.

An unexpected rise does not automatically mean that the cancer has progressed. PSA can fluctuate because of benign prostate enlargement, inflammation, infection and other factors.

For this reason, an unexpected PSA rise will often be repeated before further decisions are made.

Clinical Review

Regular appointments allow your urologist to review:

PSA changes
Urinary symptoms
General health
Examination findings
MRI results
Whether further investigation is required

A digital rectal examination may form part of surveillance, although its frequency can be individualised.

Repeat Prostate MRI

Repeat mpMRI may be performed periodically or earlier if PSA or other findings become concerning.

MRI allows comparison with previous scans to determine whether a lesion is:

Stable
Increasing in size
Becoming more suspicious
Showing features suggesting progression

Importantly, a change on MRI will often lead to a repeat biopsy rather than automatically triggering treatment. The EAU recommends confirming suspected histological progression before changing treatment strategy where appropriate.

Repeat Prostate Biopsy

Repeat biopsy remains an important component of active surveillance.

The frequency varies according to individual risk, previous MRI and biopsy findings and the surveillance protocol being followed.

The biopsy may involve:

Targeted biopsy of an MRI abnormality
Systematic sampling
A combination of targeted and regional/systematic biopsies

Modern surveillance programmes increasingly tailor biopsy frequency according to the individual’s risk rather than applying exactly the same schedule to every patient.

What Are We Looking for During Surveillance?

The purpose of surveillance is to identify reclassification or progression before the cancer becomes difficult to cure.

Your urologist will be looking for several possible warning signs.

These include:

Increasing cancer grade

For example, a cancer initially classified as Grade Group 1 may subsequently demonstrate a significant amount of Gleason pattern 4 disease.

Increasing cancer volume

More biopsy samples may contain cancer, or individual samples may contain a greater amount of cancer.

Changes on MRI

An existing lesion may enlarge or become more suspicious, or a new lesion may appear.

Persistent PSA changes

A progressively increasing PSA, particularly when accompanied by increasing PSA density or concerning MRI findings, may trigger further investigation.

Clinical progression

Changes on examination or other investigations may suggest that the cancer is no longer behaving as expected.

When Should Active Surveillance Stop?

Active surveillance should generally continue for as long as the cancer remains suitable for surveillance and curative treatment remains relevant.

The decision to move to treatment should ideally be based on the overall picture rather than PSA alone.

Treatment may be recommended when there is:

Significant upgrading of the cancer on repeat biopsy
Increasing amounts of higher-grade cancer
Significant increase in tumour volume
Concerning progression on MRI confirmed by appropriate investigation
Evidence suggesting progression beyond the original low-risk category
A change in the patient’s preference after informed discussion

AUA/ASTRO guidance recommends that significantly higher-volume or higher-grade disease on surveillance biopsy should prompt discussion about definitive therapy.

What Happens If the Cancer Progresses?

The important concept behind active surveillance is that treatment has been postponed, not abandoned.

If investigations demonstrate clinically significant progression, curative treatment can be considered.

Depending on the man’s age, general health, cancer characteristics and preferences, options may include:

Radical Prostatectomy

Surgical removal of the prostate, increasingly performed using robotic-assisted radical prostatectomy.

Focal therapy

Nanoknife electroporation

ProFocal laser ablation

Radiation Therapy

Options may include:

External beam radiation therapy
Stereotactic radiation therapy in appropriate patients
Brachytherapy in selected cases
Radiation combined with hormonal therapy where clinically indicated

Other Selected Treatments

In carefully selected circumstances, other approaches may be discussed. The evidence for focal ablative therapies remains less mature than that for established treatments such as surgery and radiation therapy, and suitability needs individual assessment.

What Are the Benefits of Active Surveillance?

For appropriately selected men, the major advantage is avoiding treatment that may never have been necessary.

Avoiding or Delaying Treatment Side Effects

Radical treatment can potentially cause:

Urinary incontinence
Erectile dysfunction
Ejaculatory changes
Urinary symptoms
Bowel symptoms following some forms of radiation therapy

Active surveillance allows men to maintain their existing urinary, sexual and bowel function for longer.

Maintaining Quality of Life

Many men can continue normal work, exercise, travel and sexual activity without the recovery period or functional consequences associated with immediate treatment.

Avoiding Overtreatment

Some low-risk prostate cancers may never become clinically significant during a man’s lifetime.

Treating every prostate cancer immediately would therefore expose some men to treatment complications without providing a meaningful survival advantage.

Treatment Remains Available

Active surveillance preserves the opportunity for curative treatment if the cancer subsequently demonstrates significant progression.

Long-term outcomes from well-conducted active surveillance programmes are reassuring. The EAU reports 10-year prostate cancer-specific survival rates of approximately 98–100% in active surveillance cohorts, although outcomes depend on appropriate patient selection and follow-up.

What Are the Risks of Active Surveillance?

Active surveillance is not completely risk-free.

The Cancer May Progress

Some cancers initially thought to be low risk will subsequently demonstrate more aggressive features.

In fact, a significant proportion of men are eventually reclassified during long-term surveillance and may proceed to treatment.

The Initial Biopsy May Underestimate the Cancer

A prostate biopsy samples only part of the prostate.

Occasionally, higher-grade cancer may already be present but was not captured during the original biopsy. Modern MRI and targeted biopsy techniques help reduce this risk but cannot eliminate it completely.

Small Risk of Losing the Optimal Window for Treatment

This is one of the main reasons that regular follow-up is essential.

In appropriately selected men who comply with structured surveillance, the risk is low, but surveillance must be active rather than passive.

Repeat Investigations

Active surveillance may involve:

Repeated blood tests
MRI scans
Urology appointments
Repeat prostate biopsies

Biopsies can cause discomfort, bleeding and infection, although contemporary transperineal biopsy techniques can substantially reduce the risk of serious infection.

Psychological Impact

Some men find living with untreated cancer surprisingly easy. Others find it difficult.

Anxiety may occur around:

PSA tests
MRI scans
Repeat biopsies
Waiting for results
Concern that the cancer may be progressing

For some men, the psychological burden becomes an important factor when deciding whether to remain on surveillance.

Active Surveillance Is Not the Same as Watchful Waiting

These terms are sometimes confused, but they describe different approaches.

Active surveillance is generally used for men with potentially curable prostate cancer. The cancer is actively monitored, with the intention of offering curative treatment if clinically significant progression occurs.

Watchful waiting is more commonly used in older men or men with significant other medical conditions where prostate cancer is unlikely to affect life expectancy. Monitoring is less intensive, and treatment is generally introduced to control symptoms rather than with the intention of cure.

Does Active Surveillance Mean Doing Nothing?

No.

This is perhaps the most important misconception about active surveillance.

A better description might be:

“Treatment if and when it becomes necessary.”

The cancer is being monitored carefully so that unnecessary treatment can be avoided while retaining the opportunity to intervene if its behaviour changes.

For the right patient, this can provide an excellent balance between cancer control and preservation of quality of life.

The Bottom Line

Active surveillance has become an established standard of care for appropriately selected men with low-risk prostate cancer and can also be considered for some men with carefully selected favourable intermediate-risk disease.

The decision should take into account:

PSA and PSA density
Grade Group and Gleason score
Amount of cancer found on biopsy
MRI findings
Clinical stage
Age and life expectancy
General health
Family and genetic risk factors
Personal preferences

Most importantly, active surveillance requires a partnership between the patient and his urologist.

The goal is not simply to avoid treatment.

The goal is to avoid treatment that is unnecessary, while identifying the point at which treatment becomes worthwhile.

This information is intended for general education and does not replace individual medical advice. Recommendations for prostate cancer management should be based on a detailed assessment of the individual patient, pathology, PSA results, imaging, general health and personal preferences.

PSA Screening for Prostate Cancer in Australia: Should You Have a PSA Test?

August 21, 2026/0 Comments/in Blog Post/by drjo

Prostate cancer is one of the most commonly diagnosed cancers in Australian men. One of the difficulties with prostate cancer is that early prostate cancer usually causes no symptoms. By the time symptoms develop, some cancers may already have progressed beyond the prostate.

A simple blood test called the prostate-specific antigen (PSA) test can help identify men who may be at increased risk of prostate cancer. However, PSA testing is not a perfect cancer test and deciding whether to have regular PSA testing involves balancing the potential benefits of early diagnosis against the risks of unnecessary investigation and treatment.

In Australia, there is currently no national population-based prostate cancer screening program. Instead, PSA testing is based on an informed discussion between a man and his doctor, taking into account age, family history, overall health, life expectancy and personal preferences.

What is PSA?

PSA, or prostate-specific antigen, is a protein produced by prostate cells. A small amount normally enters the bloodstream and can be measured with a simple blood test.

An elevated PSA does not automatically mean that you have prostate cancer.

PSA can rise because of:

prostate cancer
benign enlargement of the prostate (BPH)
inflammation or infection of the prostate
urinary infection
recent ejaculation or sexual activity
recent instrumentation of the urinary tract
manipulation of the prostate.

Conversely, some men with prostate cancer can have a PSA within the expected range. PSA is therefore best considered a marker of prostate activity and prostate cancer risk rather than a test that diagnoses cancer.

Who Should Consider PSA Testing in Australia?

Current Australian guidance supports informed, individualized PSA testing rather than universal population screening.

For men at average risk who have been informed about the potential benefits and harms and decide to undergo regular testing, current RACGP guidance recommends offering PSA testing every two years between the ages of 50 and 69 years.

Men with a significant family history may be advised to start earlier. Depending on the strength of the family history, testing may begin from approximately 40–45 years of age and continue every two years to age 69.

A stronger family history includes having a father, brother or multiple close relatives diagnosed with prostate cancer, particularly when prostate cancer occurred at a younger age.

Other factors, including ancestry, genetic predisposition and an individual’s general health and life expectancy, may also influence the decision about when to begin testing.

Importantly, these recommendations apply to men without symptoms. Men with symptoms or clinical findings that raise concern about prostate cancer require individual assessment rather than simply entering a screening program.

What Does an Elevated PSA Mean?

An elevated PSA is not a diagnosis of prostate cancer.

For men aged 50–69 undergoing early detection testing, a PSA above 3.0 ng/mL generally prompts further assessment under current Australian guidance. An abnormal result will often be repeated because PSA levels can fluctuate and temporary elevations are common.

Depending on the PSA level, age, prostate size, family history and other risk factors, further assessment may include:

Repeat PSA → assessment of PSA trend and other risk factors → specialist review → prostate MRI → possible prostate biopsy

Modern prostate cancer assessment has changed substantially. An abnormal PSA no longer necessarily means proceeding directly to a prostate biopsy. Multiparametric MRI (mpMRI) can help identify suspicious areas within the prostate and assist the urologist in deciding whether biopsy is necessary.

The Potential Benefits of PSA Screening

The principal advantage of PSA testing is straightforward:

It may detect a significant prostate cancer while it is still curable.

Aggressive prostate cancer can spread to lymph nodes, bones and other organs. Once metastatic prostate cancer develops, treatment is generally aimed at controlling rather than curing the disease.

Regular PSA testing provides an opportunity to identify some clinically important cancers years before they would otherwise become apparent.

Large screening trials have produced differing results, which is one reason PSA screening remains controversial. European screening data have demonstrated a reduction in prostate cancer mortality associated with PSA-based screening, while other trials have shown less convincing mortality benefits.

For an individual man, therefore, the potential benefit is significant: early detection may identify an aggressive cancer at a stage when curative treatment remains possible.

What Are the Downsides of PSA Screening?

The difficulty is that prostate cancer is not one disease.

Some prostate cancers are aggressive and potentially life-threatening. Others grow extremely slowly and may never cause symptoms during a man’s lifetime.

PSA testing can detect both.

False-positive PSA results

An elevated PSA may lead to anxiety, repeat blood tests, MRI scans and sometimes biopsy even when no cancer is ultimately found.

Overdiagnosis

PSA testing can identify a prostate cancer that would never have caused illness or shortened the man’s life.

This is known as overdiagnosis.

Overtreatment

If an insignificant cancer is diagnosed and subsequently treated, the man can potentially experience treatment complications without gaining a meaningful survival benefit.

Potential consequences of prostate cancer treatment include:

erectile dysfunction
urinary incontinence
urinary symptoms
ejaculatory changes
bowel symptoms following some forms of radiotherapy.

This is one of the major reasons Australia does not currently have a universal PSA population-screening program.

Importantly, however, diagnosing prostate cancer does not automatically mean treating it.

Many men with low-risk prostate cancer are now managed with active surveillance, involving PSA monitoring, MRI and selective repeat biopsy. Treatment is reserved for evidence that the cancer is becoming more significant.

What Are the Implications of Not Having PSA Screening?

Choosing not to undergo PSA testing is also a legitimate decision, particularly after considering the benefits and disadvantages.

The advantage is avoiding the potential cascade of:

PSA testing → abnormal result → anxiety → MRI → biopsy → diagnosis of an insignificant cancer → possible unnecessary treatment.

However, there is another side to this decision.

Because early prostate cancer frequently produces no symptoms, a man who does not undergo PSA testing may remain unaware that he has prostate cancer.

For most men who never develop clinically significant disease, this causes no harm.

For a smaller group who develop aggressive prostate cancer, however, the first indication of the disease may occur after the cancer has grown substantially or spread beyond the prostate.

At that stage, the opportunity for curative treatment may have been reduced or lost.

The decision is therefore not simply:

“Do I want to know whether I have prostate cancer?”

A more useful question is:

“Given my age, health, family history and personal priorities, do the potential benefits of finding a significant prostate cancer early outweigh the potential harms of investigating and possibly diagnosing a cancer that may never affect me?”

This is why shared decision-making with your GP or urologist is important.

What About a Digital Rectal Examination?

The digital rectal examination, or DRE, involves a doctor gently inserting a gloved, lubricated finger into the rectum to examine the back surface of the prostate.

The doctor assesses the prostate for abnormalities such as:

unusual hardness
nodules
asymmetry
irregularity
loss of the normal contour of the gland.

Historically, DRE was routinely combined with PSA testing for prostate cancer screening.

This has changed.

DRE is no longer recommended as a routine screening test in asymptomatic men

Current Australian guidance states that DRE should not routinely be added to PSA testing for early detection in asymptomatic men in primary care.

There are several reasons.

A finger can examine only part of the prostate. Small cancers may not be palpable, and cancers in areas of the prostate that cannot be reached during examination can be missed. A normal DRE therefore does not exclude prostate cancer.

Conversely, benign prostate enlargement and other abnormalities can sometimes produce an abnormal examination.

Does DRE Still Have a Role?

Yes.

Not recommending DRE as a routine screening test does not mean that the examination has become obsolete.

A urologist may perform a DRE when assessing a man with:

an elevated or rising PSA
urinary symptoms
suspected prostate disease
an abnormal MRI
concern about locally advanced prostate cancer
other pelvic or rectal symptoms.

Occasionally, a prostate cancer may produce a distinctly hard or irregular prostate even when the PSA is not dramatically elevated. An abnormal DRE can therefore remain clinically important and may prompt further investigation. Cancer Council Australia notes that urologists will commonly perform DRE as part of prostate assessment even though GPs no longer routinely use it for screening asymptomatic men.

The key distinction is:

DRE has a role in clinical examination and investigation, but it is not recommended as a routine population-screening test in an otherwise well man undergoing PSA testing.

PSA Screening Is About Risk, Not Just a Number

One of the most important changes in modern prostate cancer detection is moving away from treating PSA as simply “normal” or “abnormal.”

A PSA result should be interpreted in context.

Your doctor or urologist may consider:

your age + PSA level + change in PSA over time + family history + prostate size + symptoms + examination findings + MRI findings + overall health

Together, these provide a much more meaningful assessment of prostate cancer risk than a single PSA result.

Should I Have a PSA Test?

There is no single answer that is appropriate for every man.

For a healthy man in the appropriate age group, particularly someone with a family history of prostate cancer, the potential benefit of identifying an aggressive cancer while it remains curable may be important.

For an older man with substantial medical problems or limited life expectancy, the likelihood that PSA screening will provide meaningful benefit becomes considerably smaller. Current Australian guidance advises against PSA testing in men whose life expectancy is likely to be less than approximately seven years because a mortality benefit from early detection is unlikely to occur within that period.

The decision should therefore be individual rather than automatic.

The Bottom Line

PSA testing can save lives by detecting clinically significant prostate cancer at an earlier and potentially curable stage, but it can also detect cancers that would never have caused harm.

Australia therefore does not currently operate a universal PSA screening program. Instead, men are encouraged to make an informed decision about PSA testing after discussing their individual risk and the potential benefits and harms with their doctor.

For men who choose screening, current Australian guidance generally supports PSA testing every two years from age 50–69 for men at average risk, with earlier testing considered for men with a significant family history.

A digital rectal examination is no longer recommended as a routine addition to PSA screening in asymptomatic men, but it remains an important component of specialist prostate assessment in selected circumstances.

Concerned about your prostate cancer risk?

If you are considering PSA testing, have a family history of prostate cancer, have noticed a change in your PSA, or have urinary symptoms, discuss your individual risk with your GP or urologist.

Early detection should not simply be about finding more prostate cancers. The goal is to identify the cancers that matter, at a time when something useful can still be done about them.

This information is intended for general education and does not replace individual medical advice. Recommendations may differ according to your age, family history, medical conditions and previous PSA results.

Further information

Australian patient information and guidance are available from Cancer Council Australia: Prostate cancer screening and early detection and the RACGP Guidelines for preventive activities in general practice.

Living with an indwelling urethral catheter

November 23, 2025/0 Comments/in Bladder Surgery, Blog Post, Prostate Surgery, Urethral Surgery/by drjo

An indwelling urethral catheter is a soft tube passed through the urethra into the bladder. A small balloon holds it in place and urine drains into a bag. It may be needed for a few days after an operation or for longer when the bladder cannot empty safely. The reason for the catheter and a plan for review should be clear to the patient and the people helping with their care.[1, 2]

Why might a catheter be needed?

Common reasons include acute urinary retention, an obstruction to urine flow, temporary drainage after surgery, and selected cases of chronic retention when other options are unsuitable. In hospital, a catheter may be used to monitor urine output in a critically ill person or manage bleeding and clots. It can occasionally support comfort at the end of life. A urethral catheter is generally not the first response to urinary leakage alone.[1]

When practical, the team should discuss whether the catheter can be removed after a trial of void, whether intermittent self-catheterisation is possible, or whether a suprapubic catheter may be more suitable for longer-term drainage. The best choice depends on bladder function, dexterity, the underlying condition and the person’s wishes.[1, 3]

What might it feel like, and what can go wrong?

Some people notice discomfort or a sense of needing to pass urine after insertion. Bladder spasms can cause cramping or urine to leak around the tube. Leakage can also mean that the catheter is kinked or blocked, so it should be checked rather than simply treated as incontinence. Other possible problems include blood in the urine after insertion or a change, skin irritation, accidental pulling or displacement, blockage from debris or encrustation, and infection.[2, 3]

A long-term urethral catheter can also cause pressure or trauma at the urethral opening; persistent soreness or a change in its appearance deserves review. Bladder stones and repeated blockages are further reasons to reassess the drainage plan. The longer a catheter remains, the more opportunity there is for bacteria to colonise it, so it should stay in place only while needed.[3, 4]

How often should a long-term catheter be changed?

There is no single safe change interval for every catheter and every patient. The plan depends on the catheter material and manufacturer’s instructions, local nursing policy, comfort, drainage, and whether it repeatedly blocks or becomes encrusted. Some community protocols plan changes approximately every four to eight weeks, but an individual plan may differ. The interval should not exceed the relevant product’s recommended duration.[1, 3]

Changing a catheter more frequently just to prevent infection has not been shown to help. A catheter may instead need an earlier change if it is blocked, damaged, displaced, causing problems, or as part of managing a symptomatic infection. People with a history of difficult insertion, urethral injury or bleeding should have a specific plan for who can safely perform the change.[1, 3]

At each review, it is worth asking: Is the catheter still necessary? Could a trial without it or another drainage method be considered?[1]

Day-to-day care at home

Keep the drainage bag below bladder level, avoid kinks in the tubing, and secure the catheter so it does not pull. Wash your hands before and after handling the bag. Follow the nurse’s instructions for emptying it and for cleaning the area where the catheter enters the body. Ordinary hygiene is usually enough; do not disconnect the closed drainage system, flush the catheter or take preventive antibiotics unless your treating team has given a specific instruction.[3, 5]

Drink according to your usual health advice. If you have a fluid restriction for heart or kidney disease, follow that plan rather than trying to drink extra to “flush” the catheter. Ask your nurse which supplies to keep at home and whom to call after hours if drainage stops.[2]

Bacteria in urine: when are antibiotics needed?

With a catheter in place, bacteria commonly grow on the catheter surface. After a month, bacteriuria is found in nearly everyone with a long-term catheter. A positive urine culture without symptoms usually reflects colonisation, not an infection requiring antibiotics. Routine screening or treatment of asymptomatic bacteriuria is generally discouraged because antibiotics can cause side effects and encourage resistant bacteria. Exceptions include pregnancy and certain invasive urological procedures, where the treating team will advise on testing and treatment.[4, 6]

Seek clinical assessment for possible infection if you develop fever, rigors, new pelvic or flank pain, feel distinctly unwell, or have other new symptoms that could indicate infection. In a frail person, a new change in function or confusion warrants assessment of several possible causes rather than automatically assuming a UTI. Cloudy or strong-smelling urine, sediment, or a positive dipstick on its own does not usually justify antibiotics.[4, 6, 7]

When a symptomatic catheter-associated UTI is suspected, a clinician should assess you and arrange a properly collected urine specimen if indicated—not from the drainage bag. Treatment is chosen in light of symptoms, culture results, allergies and local guidance. If the catheter has been in place for more than two weeks and still needs to remain, changing it as part of treatment is commonly recommended. Routine antibiotics at every scheduled catheter change are not recommended.[7, 8]

When to get help promptly

Contact your nurse or doctor promptly if urine stops draining, the catheter falls out, you have significant pain or new bleeding, or urine is leaking around the catheter with little in the bag. Check for a kink or a full bag, but do not forcefully flush or reinsert a catheter yourself unless specifically trained and instructed. Seek urgent medical care if drainage has stopped and you have a painful or swollen lower abdomen, or if you have fever, shaking chills or feel seriously unwell.[2]

Catheter support in Bundaberg

Some people can have catheter assessment and planned changes at home through a community nursing service. Ozcare and BlueCare provide home nursing in the Bundaberg area; whether a nurse can provide catheter care for an individual depends on referral, staffing, clinical needs, service area and funding arrangements. Ask the provider directly about availability and costs before relying on a visit.[9, 10]

For my Bundaberg patients, Sandra Ilett, a continence nurse with Community Nurse Service, is another local contact for bladder and catheter-related care. Sandra and her colleague Carla Kerr have also seen patients at the nurse-led clinic at The Friendlies Medical Suites. Patients can discuss a suitable referral and whether a home visit or clinic appointment is available. Community Nurse Service: (07) 4126 2002.[11] This mention recognises local nursing support; it is not a claim that one service is preferable for every patient.

A written catheter plan should record the reason for drainage, catheter details, the planned review or change, who will provide care, and whom to call if problems arise. Community nurses, the GP and urology team can then coordinate care across visits.

This article provides general information. Follow your individual catheter plan and seek clinical advice for new symptoms or a catheter that is not draining.