The single most important decision in prostate cancer treatment is not which treatment to have — it is who performs it. Surgical volume, institutional experience, and a surgeon willing to discuss their own outcomes data are the most important factors to investigate.
You have been diagnosed with prostate cancer. You have been referred to a urologist. Perhaps your GP has referred you to a general urologist at the nearest hospital. Perhaps a friend has recommended someone. Perhaps you have been looking online.
The decisions you make in the next few weeks — specifically, who you choose to treat you — will have a greater impact on your functional and oncological outcome than almost any other factor. This is not said to create anxiety. It is said because it is true, and because patients who understand this are better equipped to make an informed choice.
1. Why the surgeon matters more than the platform
A great deal of energy is spent debating "robotic versus open," "surgery versus radiation," "da Vinci versus laparoscopic." These are meaningful questions — but they are secondary to a more fundamental one: who is performing the operation?
The published evidence is unambiguous. Surgical outcomes for radical prostatectomy — cancer control (positive margin rates), urinary continence recovery, and erectile function preservation — correlate strongly with surgeon volume. High-volume surgeons operating in high-volume centres consistently outperform low-volume surgeons regardless of the technology used.
A surgeon performing 150 radical prostatectomies per year at a specialist uro-oncology centre will achieve better continence rates, lower positive margin rates, and better nerve-sparing outcomes than a surgeon performing 20 per year at a general hospital — even if both are using the same robotic system. The technology is consistent. The skill is not.
2. Annual surgical volume — what to ask
Volume matters because prostate surgery is a technically demanding operation with a significant learning curve. Studies suggest meaningful improvement in outcomes continues through 150–200 cases. Ask directly:
- "How many radical prostatectomies do you perform per year?" The answer should ideally be 50 or above, and ideally over 100 for the most demanding nerve-sparing and high-risk cases.
- "How many have you performed in total?" Career volume also matters — an experienced surgeon who has done 1000+ cases brings pattern recognition and intraoperative judgement that accumulates only with time.
- "Is prostate surgery your primary subspecialty?" A surgeon who does 60 prostatectomies alongside 200 other urological operations per year is different from one for whom it is the primary clinical focus.
3. Outcomes data — what to look for
A surgeon confident in their results will share them. Reasonable questions to ask include:
Positive surgical margin rate
What percentage of your patients had cancer cells at the cut edge of the specimen? For pT2 (organ-confined) disease, a positive margin rate above 10–15% is a concern. For pT3 disease, margins are expected to be higher but should still be discussed.
Continence rate at 3 and 12 months
What percentage of your patients are pad-free (or using 1 safety pad) at 3 months? At 12 months? Rates below 70% pad-free at 12 months should prompt questions. High-volume centres report rates above 85–90% at 12 months.
Nerve-sparing rate and erectile recovery
In patients with suitable low-risk disease and good preoperative function, what percentage achieve adequate erectile function at 12–18 months? This is the most variable outcome and the hardest to predict, but a surgeon should be able to discuss realistic expectations.
Biochemical recurrence-free survival
What percentage of your patients are PSA-undetectable at 5 and 10 years? This is the ultimate oncological outcome measure and should be compared against published benchmarks for your tumour stage and grade.
Published outcomes at individual centres should be interpreted carefully. Case mix matters — a surgeon who primarily treats high-risk disease will have higher complication rates than one treating low-risk cases. Ask for outcomes stratified by tumour stage, not overall averages.
4. The importance of subspecialisation
Uro-oncology — the subspecialty focused specifically on urological cancers — has become its own discipline. A surgeon who has completed dedicated fellowship training in robotic uro-oncology, or who has been trained at a high-volume prostate cancer centre, brings a level of focused expertise that general urologists cannot replicate.
Questions to determine subspecialisation:
- Did you complete a dedicated uro-oncology or robotic surgery fellowship after your urology training?
- Do you attend multidisciplinary team (MDT) meetings for prostate cancer — with radiation oncologists, medical oncologists, and pathologists?
- Are you involved in prostate cancer research or clinical trials?
- Do you perform high-risk prostatectomies — including salvage surgery and cases following prior radiation?
5. Getting the most from your consultation
The first consultation with a urologist is not a passive event — it is an interview. Come prepared:
6. When to seek a second opinion
A second opinion is not a sign of distrust — it is an exercise of your autonomy as a patient. You should strongly consider a second opinion if:
- You have been diagnosed with high-risk or locally advanced disease
- You are being offered a less common or experimental treatment
- You are uncertain about the recommendation you have received
- Your surgeon does not discuss functional outcomes or their own results data
- You feel the consultation was rushed or your questions were not answered
At international centres of excellence — MD Anderson, Memorial Sloan Kettering, the Royal Marsden — second opinions before major cancer surgery are encouraged, not resisted. A confident surgeon welcomes the patient who has done their research. A surgeon who discourages you from seeking one is worth reconsidering.
- How many radical prostatectomies do you perform per year — and in total?
- What is your positive margin rate for pT2 disease?
- What is your pad-free continence rate at 3 months and 12 months?
- Do you discuss all treatment options — surgery, radiation, and active surveillance — before recommending?
- Will you be performing my surgery yourself — or will a trainee be operating under supervision?
- Are you part of a multidisciplinary team that reviews prostate cancer cases?
This article provides general guidance on choosing a surgeon for prostate cancer treatment. The right surgeon for you depends on your specific diagnosis, location, and personal circumstances. Take time to make an informed decision.