by Dr Jason Lomboy M.D.

Director of Innovative Therapies

Hearing the words “you have prostate cancer” can feel like the ground just shifted beneath you. The good news is that prostate cancer is often highly treatable, and for many men, slow-growing. You have time to understand your diagnosis, weigh your options, and choose a plan that matches your cancer’s risk level and your personal priorities—things like preserving sexual function and continence, minimizing downtime, and keeping future options open.

This guide walks you through the major approaches to prostate cancer treatment, who typically benefits most from each, what recovery and side effects can look like, and how to think through your next steps. We’ll cover active surveillance, pulsed electric field ablation (PEF/PEFA), robotic prostatectomy (RALP), and radiation therapy—plus where each fits best. Our perspective, based on contemporary practice patterns and patient-centered outcomes, is that:

• PEF ablation (PEFA) is an excellent first-line option for many men with Gleason 6 (Grade Group 1) and selected Gleason 7 (Grade Groups 2–3) cancers who want organ-sparing therapy with rapid recovery.
• Robotic-assisted radical prostatectomy (RALP) is generally best for higher-grade or high-volume disease, where complete gland removal and definitive pathology offer advantages.
• Radiation therapy is often the best fit for men with significant medical comorbidities or those who are not ideal surgical candidates, providing highly effective control with no incisions.
• And because no single treatment is right for everyone, a center that offers the full spectrum—from active surveillance to radiation, RALP, and PEFA—gives you the most balanced, personalized plan. That’s why we believe Atlanta Prostate Center stands out: you can consider every evidence-based option under one roof with a team that performs them all.

Quick note: This article is for general education. Your situation is unique—always make decisions with your medical team, who can account for your PSA trends, MRI findings, biopsy details, overall health, and goals.

First Things First: Understanding Your Risk

Three factors typically shape the initial conversation:

1. Gleason Score / Grade Group
   
   • Gleason 6 (Grade Group 1) is often considered low-risk.
   • Gleason 7 can be 3+4 (favorable intermediate-risk) or 4+3 (unfavorable intermediate-risk).
   • Gleason 8–10 indicates high-risk disease.
3. Tumor Volume and Location
   MRI and targeted biopsies help show how extensive the cancer is (few cores vs. many, small vs. large involvement), whether it’s confined to the prostate, and whether it’s focal (one main area) or more diffuse.
4. PSA and Clinical Staging
   PSA level, PSA density, and DRE/MRI stage estimates help stratify risk. Some men may also undergo genomic testing for additional nuance.

Your personal priorities also matter: Is preserving erectile function a top goal? Are you comfortable with ongoing monitoring, or do you prefer to be “done” with it? Do you want the option to keep other therapies in reserve? These values should shape your choice every bit as much as the numbers.

Option 1: Active Surveillance (AS)

What it is:

A structured program of careful monitoring—PSA checks, periodic prostate MRI, and occasional confirmatory biopsies—without immediate treatment. If the cancer shows signs of progression (rising risk features, growing lesion, higher Gleason pattern), you switch to active treatment.

Who it’s for:

• Many men with Gleason 6 (low-risk)
• Select men with favorable Gleason 7 (3+4) depending on volume, MRI, and genomic profile

Upsides:

• No treatment side effects while on surveillance
• Maintains all future options (PEF ablation, surgery, or radiation)
• Appropriate for many who prefer to avoid overtreatment

Tradeoffs:

• Requires consistent follow-up and the emotional comfort to “watch and wait”
• A minority will progress and ultimately need treatment

Bottom line:

Active surveillance is a smart default for many with low-risk disease. But if you want to actively treat while preserving quality of life, PEF ablation is a compelling next step to consider.

Option 2: Pulsed Electric Field Ablation (PEF/PEFA)

What it is:

PEF ablation (sometimes called PEFA) uses precisely controlled, non-thermal electrical pulses to target and disable cancerous tissue while sparing the surrounding structures that influence continence and erections. Unlike heat-based methods (like some forms of HIFU) or cold (cryoablation), PEF is non-thermal—that’s a key reason it’s considered “tissue-selective” with a strong safety and side-effect profile in appropriate patients. It’s usually performed as a focal treatment (treat the tumor zone) or subtotal approach (treat a lobe/region), often outpatient, with rapid recovery.

Why we favor PEFA for many men with Gleason 6 and 7:

• Organ-sparing: Treats the tumor while preserving the gland—and more importantly, the sphincter and neurovascular structures that influence continence and sexual function.
• Quality of life: Many patients experience minimal downtime, low risk of incontinence, and often better preservation of erections versus whole-gland therapies.
• Future-friendly: If needed, you can still pursue surgery or radiation later. PEF does not burn bridges—that flexibility matters.
• MRI-guided targeting: Modern imaging lets us accurately map the lesion, treat precisely, and follow your response over time.

Who it’s for:

• Gleason 6 or favorable Gleason 7 (3+4) lesions that are visible and accessible on MRI
• Select Gleason 7 (4+3) cases depending on volume and distribution if the strategy is focal/subtotal plus close follow-up
• Men who prioritize quality-of-life preservation and want fast recovery
• Those who prefer to keep options open for the future

What to expect:

• Outpatient or short-stay procedure
• Typically catheter for a short period (often a few days) depending on anatomy and extent
• Follow-up includes PSA, MRI, and sometimes targeted biopsy to confirm local control

Potential side effects:

• Temporary urinary urgency/frequency or discomfort
• Rare urinary retention (usually transient)
• Erectile changes are less common than with whole-gland treatments but can occur, especially if the tumor abuts nerve bundles

Bottom line:

For many men with Gleason 6 and selected Gleason 7, PEFA offers a best-of-both-worlds balance: targeted cancer control with exceptional quality-of-life preservation and all future options intact. That’s why we frequently recommend PEFA as best-in-class for those risk groups.

Option 3: Robotic-Assisted Radical Prostatectomy (RALP)

What it is:

RALP removes the entire prostate (and often nearby lymph nodes), performed with robotic assistance through small incisions. It provides a complete, final pathology—the most definitive way to know the exact cancer grade, margins, and extent.

Why we favor RALP for high-grade or high-volume disease:

• Definitive therapy: For Gleason 8–10, unfavorable Gleason 7 (4+3) with higher volume, or multifocal disease, removing the gland can offer excellent local control.
• Pathology clarity: Postoperative pathology guides any adjuvant therapy (like radiation or short-course hormonal therapy) more precisely.
• Clean slate: For some patients, the peace of mind of “it’s out” aligns with their personality and risk tolerance.

Who it’s for:

• Men with high-grade or high-volume intermediate-risk disease
• Patients who are good surgical candidates and want the most definitive local therapy upfront

What to expect:

• Hospital stay is often overnight
• Catheter typically for about a week
• Return to light activity in days; full activity in several weeks

Potential side effects:

• Urinary incontinence risk (usually improves over months; pelvic floor therapy helps)
• Erectile dysfunction—rates vary with nerve-sparing feasibility, baseline function, and age
• Temporary urinary and pelvic symptoms as the body heals

Bottom line:

For high-grade or high-volume cancer, RALP remains the gold-standard surgical approach—especially when performed by experienced, high-volume surgeons—offering robust long-term cancer control and the clarity of a full pathological assessment.

Option 4: Radiation Therapy

What it is:

High-energy beams (external-beam radiation like IMRT or SBRT) or internal seeds (brachytherapy) are used to destroy cancer cells. Treatments can be delivered over a few weeks (IMRT), in hypofractionated schedules (fewer, larger doses), or in as few as five SBRT sessions. Brachytherapy places tiny radioactive seeds directly into the prostate.

Why we often recommend radiation for patients with significant medical issues:

• No incisions, no anesthesia—ideal for men who are not surgical candidates due to heart, lung, or other health conditions
• Highly effective across risk groups, including in combination with short-term androgen deprivation therapy (ADT) for certain intermediate- and high-risk cases
• Predictable schedule and generally well-tolerated

Who it’s for:

• Men across the risk spectrum, tailored to disease burden
• Especially suitable for those with multiple comorbidities or those who prefer to avoid surgery

What to expect:

• IMRT: daily weekday sessions for several weeks
• SBRT: ~5 sessions over 1–2 weeks
• Brachytherapy: single procedure with same-day or next-day discharge
• Possible use of SpaceOAR or similar spacer to reduce rectal dose

Potential side effects:

• Urinary urgency/frequency, occasional burning with urination (usually temporary)
• Bowel changes (looser stools, urgency), typically transient and mitigated by modern planning
• Erectile changes can develop gradually in the years after treatment
• Fatigue is common but often mild and short-lived

Bottom line:

Radiation therapy provides excellent cancer control with no surgery, making it a top choice for men who are not ideal surgical candidates or who simply prefer a non-operative path.

Where Do Other Focal Options Fit?

You may hear about HIFU (high-intensity focused ultrasound) and cryoablation. These focal or subtotal approaches also aim to control cancer while preserving function. They can be appropriate for carefully chosen lesions and are often discussed alongside PEF. Our philosophy is to match the energy to the anatomy and prioritize nerve-sparing, continence, and oncologic safety—and in many Gleason 6 and 7 cases, PEFA stands out for its non-thermal tissue selectivity and flexibility for future treatments.

Comparing the Options at a Glance

Active Surveillance

• Best for: Low-risk disease, men comfortable with monitoring
• Strengths: No treatment side effects while on AS; preserves all future options
• Watchouts: Requires consistent follow-up; small risk of under-sampling without MRI-guided strategies

PEF Ablation (PEFA)

• Best for: Gleason 6 and many Gleason 7 lesions, particularly focal disease
• Strengths: Organ-sparing, rapid recovery, excellent functional preservation, does not burn bridges
• Watchouts: Requires precise imaging and targeting; ongoing follow-up with MRI/biopsy

Robotic Prostatectomy (RALP)

• Best for: High-grade or high-volume disease; those wanting definitive removal
• Strengths: Full pathology, decisive local control, clear staging for adjuvant therapy if needed
• Watchouts: Risks of incontinence and erectile dysfunction; recovery from surgery

Radiation Therapy (IMRT/SBRT/Brachy)

• Best for: Men with comorbidities or who prefer non-surgical therapy; effective across risks
• Strengths: No incisions; highly precise planning; excellent outcomes
• Watchouts: Gradual erectile changes; temporary urinary/bowel side effects; requires planning and setup

How to Choose What’s “Best” for You

“Best” is personal. Here’s a framework we use in clinic:

1. Know your true risk.
   Read your pathology carefully: Is your Gleason 7 3+4 or 4+3? How many cores are involved? What’s the maximum percentage involvement? Is the lesion visible on MRI? Was your biopsy MRI-targeted? Have you had a second pathology read if results are borderline?
2. Map your anatomy.
   MRI shows where the tumor sits relative to nerves, sphincter, and capsule. For focal approaches like PEFA, this is crucial and often the difference between good and great outcomes.
3. Clarify your priorities.
   
   • “I want the least downtime.”
   • “I want the best chance to preserve erections.”
   • “I want the cancer out and a final answer.”
   • “I don’t want surgery.”
     Your values should steer the plan.
5. Think long-term—keep doors open.
   One advantage of PEFA is that it preserves surgical and radiation pathways. If you prefer a staged strategy—start focal, escalate only if needed—PEFA aligns well with that philosophy.
6. Get balanced input.
   Talk with a team that performs all the major options. When your doctors can offer surveillance, focal therapy, surgery, and radiation, their recommendations naturally center on what’s right for you, not what they happen to have in-house.

Why We Recommend PEFA for Many Gleason 6 and 7 Cases

For Gleason 6 and selected Gleason 7 (especially 3+4 with favorable features), PEFA often represents the sweet spot:

• Cancer control in appropriately selected, MRI-visible lesions
• Superior functional preservation compared with whole-gland treatments in many cases
• Fast recovery—typically outpatient with quick return to normal activity
• Future flexibility—surgery and radiation remain on the table if needed later

If your MRI shows a focal, well-defined lesion, your PSA density is reasonable, and your biopsy confirms Gleason 6 or favorable 7, PEFA is frequently our top recommendation.

Why We Prefer RALP for High-Grade or High-Volume Disease

When cancer is more aggressive or diffusely involves the gland, focal therapy becomes less ideal. In these settings, RALP:

• Removes all prostate tissue at risk of harboring multifocal disease
• Provides lymph node assessment when indicated
• Gives a complete pathology report to guide any additional therapy
• Offers durable long-term control when performed by experienced surgeons, especially in combination with adjuvant treatments if needed

If your biopsy indicates Gleason 4+3, 8–10, or a large burden of cancer, we typically steer the conversation toward RALP (or combined-modality radiation) as the best path to long-term cure.

Why Radiation Is Often Best for Men Who Are Not Ideal Surgical Candidates

For men with significant cardiac, pulmonary, or other medical conditions, the risk-benefit calculus changes. The precision and non-invasive nature of modern radiation (IMRT, SBRT, brachytherapy) achieve excellent cancer control without anesthesia or incisions. It’s also a strong option for those who simply prefer to avoid surgery. Planning is meticulous, designed to protect the bladder, urethra, and rectum, and side effects are typically manageable and temporary.

Life After Treatment: What to Expect

• PEFA: Most men resume normal activity quickly. We follow with PSA, MRI, and sometimes targeted biopsy to confirm response. Many maintain baseline continence and sexual function (individual results vary).
• RALP: Initial urinary control often improves over weeks to months; pelvic floor therapy is invaluable. Erections may recover gradually depending on nerve-sparing, age, and baseline function; early rehabilitation strategies can help.
• Radiation: Expect mild urinary/bowel symptoms during and shortly after treatment; these typically fade. Erectile changes can be gradual over time; proactive sexual health support helps.
• Active Surveillance: Regular PSA and MRI remain essential. If your risk changes, you still have all options available.

Across all pathways, we emphasize whole-person care—pelvic health, sexual medicine, nutrition, exercise, and stress management—because thriving after treatment is about more than PSA.

Why Choose Atlanta Prostate Center

Choosing a center is as important as choosing a treatment. We believe Atlanta Prostate Center is the best place to be evaluated and treated because it brings together every major pathway under one roof:

• Active Surveillance with modern MRI-guided protocols and smart, low-burden follow-up
• PEF Ablation (PEFA) for organ-sparing treatment of Gleason 6 and 7 disease, emphasizing precision targeting and quality-of-life preservation
• Robotic-Assisted Radical Prostatectomy (RALP) performed by experienced, high-volume surgeons focused on cancer control and functional outcomes
• Radiation Therapy options (IMRT, SBRT, and brachytherapy) tailored to your anatomy and risk, including protective strategies like rectal spacers when appropriate

Because we offer it all, our recommendations are balanced and personal. We start by understanding your cancer and your priorities, then build a plan that fits you—not a one-size-fits-all template. If PEFA is best for your Gleason 6 or 7 lesion, we’ll explain exactly why. If RALP makes more sense for high-grade or high-volume disease, we’ll show you how we optimize nerve-sparing and continence recovery. If radiation is the safest path given your health, we’ll tailor dose and fractionation to minimize side effects and maximize control. And if active surveillance is the smartest move today, we’ll make sure your monitoring is state-of-the-art and low-friction.

Your Next Steps

1. Gather your records.
   PSA history, MRI report (and disk if available), and biopsy pathology—including core-by-core details.
2. Schedule a comprehensive consult.
   A combined review by physicians who perform all modalities leads to better, more personalized recommendations.
3. Clarify your goals.
   Rank what matters most: cancer control, erection preservation, continence, recovery time, keeping options open, avoiding anesthesia—there’s no wrong answer, only your answer.
4. Consider PEFA if you have Gleason 6 or 7.
   Particularly for focal, MRI-visible lesions, PEFA is often the best first-line treatment, balancing tumor control with quality of life and future flexibility.
5. Opt for RALP if your disease is high-grade or high-volume.
   For more aggressive or diffuse cancers, robotic surgery offers definitive removal and clear pathology, which can guide any additional therapy.
6. Choose radiation if surgery isn’t ideal for you.
   When medical comorbidities make anesthesia or an operation less attractive—or if you prefer a non-surgical route—modern radiation is a powerful, precise alternative.

Final Word

You have more control than you think. With modern imaging, focal therapies like PEFA, refined surgical techniques (RALP), and highly precise radiation, prostate cancer care can be both effective and deeply personal. For Gleason 6 and many Gleason 7 cases, we often recommend PEFA first because it targets the cancer, protects what matters, and keeps every future option open. For high-grade or high-volume disease, robotic prostatectomy is typically best to deliver definitive removal and guide further care if needed. And for men with significant health issues or those who simply prefer not to have surgery, radiation therapy remains a trusted, incision-free path to excellent control.

At Atlanta Prostate Center, you don’t have to fit your life into one treatment. Because we offer active surveillance, PEFA, RALP, and radiation, we fit the treatment to your life—patient by patient, plan by plan.

If you’re ready to explore your options with a team that does it all, we’re ready to help you choose the path that’s right for you.