Prostate cancer surgery at Apollo Hospital, Bhat, Gandhinagar · Consultation at Gota OPD, Ahmedabad
Intermediate risk is one label covering two different men. Favourable intermediate-risk prostate cancer — grade group 2, low volume, a reassuring MRI — can sometimes still be watched. Unfavourable intermediate-risk disease needs treatment now, and that treatment is either radical prostatectomy with a pelvic lymph node dissection, or radiotherapy with a few months of androgen deprivation therapy. Both control the cancer. What separates them, and what separates one operation from another, is how much continence and sexual function can honestly be preserved — and that is decided by your MRI and your biopsy map, side by side, before anyone picks up an instrument.
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Dr Swati Shah
MS, DrNB (Surgical Oncology)
Prostate Cancer Surgeon · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
Shah’s Gastro, Cancer & Robotic Surgery Centre. Trained at high-volume cancer units, full surgical-oncology qualification, and a practice built on uro-oncology rather than general urology. Rated 4.99 from 85 Google reviews at the Gota clinic and 5.0 from 28 at Apollo, Bhat.
Intermediate risk means the cancer is confined to the prostate but is no longer the quietest kind. In the EAU 2026 stratification a man sits in this group if his PSA is between ten and twenty, or his biopsy is ISUP grade group 2 or 3, or the gland feels involved on one side on examination. Any one of those three is enough. It does not mean the cancer has spread, and it does not by itself mean the prostate must come out.
Dr Swati Shah sees men arrive at the Gota OPD holding a report with the words “intermediate risk” on it and believing a decision has already been made for them. It has not. The label is a starting position, and the first job of the consultation is to find out which half of it you are in.
Three things are needed before that can be answered honestly, and one of them is almost always missing when a man arrives from elsewhere: a multiparametric MRI of the prostate reported by PI-RADS, done before the biopsy rather than after it; the PSA density, which is the PSA divided by the MRI-measured volume of the gland; and a biopsy that sampled both the MRI target and the rest of the prostate systematically, reported with the grade group, the number of cores involved, the maximum involvement in any one core, and — critically — whether cribriform or intraductal patterns are present.
| Favourable intermediate risk | Unfavourable intermediate risk | |
|---|---|---|
| Grade | ISUP grade group 2 only | Grade group 3, or grade group 2 with adverse features |
| Volume | Low — few cores, limited involvement in each | Extensive core involvement, or both lobes |
| Histology | No cribriform, no intraductal pattern | Cribriform or intraductal pattern present |
| PSA density | Low | High |
| What is on the table | Active surveillance in selected men; surgery; radiotherapy | Radical prostatectomy with pelvic node dissection, or radiotherapy with androgen deprivation therapy for four to six months |
| PSMA-PET before treatment | Not indicated | Where the result would change the plan |
Cribriform and intraductal patterns matter more than most men are told. They behave worse than their grade group suggests, they are reported inconsistently, and their presence takes active surveillance off the table even when every other number looks favourable. If your histology report does not mention them either way, ask for it to be reviewed before you choose anything.
The nerves that carry erection run in two bundles along the back corners of the prostate, close enough to the capsule that sparing them and removing all the cancer are sometimes the same manoeuvre and sometimes opposite ones. Dr Swati Shah decides nerve-sparing side by side, not as one yes-or-no answer for the whole operation, and the decision on each side rests on three findings.
The first is whether the MRI shows the tumour reaching or breaching the capsule on that side. Extracapsular extension on the right does not say anything about the left. The second is how heavily that side was involved on biopsy — a single short core at the apex is a different proposition from four cores of grade group 3 filling the base. The third is what is felt and seen at operation, because tissue that is tethered to the prostate at the moment of dissection overrules a reassuring scan.
That is why many men with intermediate-risk disease have a full nerve-sparing dissection on one side and a deliberately wide one on the other. It is not a compromise and it is not indecision. It is the only way to give the side that can be saved its greatest chance without giving the cancer a route out of the specimen on the other.
A positive surgical margin means cancer was left at the cut edge. It usually means radiotherapy afterwards, and radiotherapy after surgery compounds the very urinary and sexual problems the nerve-sparing was meant to prevent. A man who keeps his erections and loses his cure has not been given a good operation.
So the rule in this unit is stated before surgery, not afterwards: where the tumour is against the capsule on a given side, that side is taken wide. You will be told before the operation which side is at risk and what the likely trade is, and if the pathology afterwards changes that picture you will be told that too, with what it means for the next step.
Whether the pelvic lymph nodes are removed is a separate question from the nerves. It is decided by a nomogram that combines PSA, grade group, stage and core involvement to estimate the chance that cancer has reached the nodes. Where that estimate rises above roughly one in twenty, an extended dissection is done — external iliac, obturator and internal iliac stations, and where indicated the presacral and common iliac ones. Most unfavourable intermediate-risk disease meets that threshold. Most favourable disease does not.
A limited dissection that takes only the obturator packet is worse than no dissection at all in one specific way: it under-stages, and a man is then told his nodes were clear when they were never properly sampled. Extended dissection carries its own cost, chiefly lymphocele and leg or genital swelling, and those are explained at consent rather than discovered later.
For localised intermediate-risk prostate cancer, surgery and radiotherapy give equivalent cancer control. A man who chooses radiotherapy has not chosen the lesser option. What differs is the shape of the side effects over time: surgery gives immediate urinary leakage that improves over months, and erections that recover slowly and often incompletely over one to two years. Radiotherapy gives little immediate change, then irritative urinary and bowel symptoms that appear over the following years, and a slower erectile decline.
For unfavourable intermediate-risk disease, radiotherapy is given with androgen deprivation therapy for four to six months, and that hormone course has its own consequences — fatigue, weight gain, bone loss, mood change and metabolic effects — which are part of the comparison and are frequently left out of it.
Dr Swati Shah’s position, and the unit’s practice, is that this comparison is not made by a surgeon alone. Every man in whom the choice is genuinely balanced is discussed at the tumour board and, wherever possible, hears both options from a radiation oncologist and a surgeon in the same conversation. That is a benefit to you, not a description of anyone’s standing.
Yes, in selected men with favourable intermediate-risk disease — grade group 2, low volume, favourable MRI, low PSA density, and no cribriform or intraductal pattern. This changed in the current guidelines and it is the point most often missed in reports written from older templates.
Surveillance is not neglect. It is PSA every six months, a digital rectal examination each year, an MRI at twelve to eighteen months, a confirmatory biopsy inside the first year and then a biopsy every two to four years or sooner if anything changes. The trigger to treat is grade progression on biopsy or progression on imaging, not a single rising PSA reading. The men who come to harm on surveillance are almost always the ones who stop attending, which is why the protocol is written down and the appointments are booked rather than suggested.
| When | What to expect |
|---|---|
| Four weeks before surgery | Pelvic floor muscle training starts — supervised, not from a leaflet. This is the single highest-yield thing you can do for your own continence, and starting it after the catheter comes out is starting it late |
| Day 1 to 2 | Home, with the catheter, after being taught how to care for it |
| Seven to ten days | Catheter removed in OPD. Pelvic floor exercises restart the same day, supervised. Pads issued, with an honest count of how many to expect |
| Two weeks | Wound check, histology discussion, pad count recorded, erectile function score repeated, and penile rehabilitation started where the nerves were spared |
| Six to eight weeks | First PSA. Not earlier — it has to fall to undetectable and an early test only frightens people |
| Three, six, twelve and twenty-four months | Pad count and erectile function score recorded as numbers at each visit |
| Twelve months | The decision point. Most men are dry or on a single small pad by now. If leakage persists, formal testing and then a sling or an artificial urinary sphincter — you are not told to keep waiting |
Erections recover slowly. With both nerve bundles spared in a man who was fully potent beforehand, a substantial proportion regain erections adequate for intercourse, and that recovery takes twelve to twenty-four months and is often partial. Where the nerves could not be spared, spontaneous erections do not return and tablets, injections or an implant will be needed. Your own figures are given to you at the consent discussion, adjusted for your age, your gland, your grade and whether nerve-sparing was possible.
Some consequences of radical prostatectomy are not risks to be weighed. They are certainties, and Indian men are systematically under-counselled on them.
Dr Swati Shah counsels on these personally and, with your agreement, with your wife or partner present. The complication rates — bleeding needing transfusion, infection, clots, injury to the rectum or ureter, a narrowing at the join that needs a further procedure, urine leak, lymphocele, a positive margin and the chance of needing radiotherapy — are named in full at that discussion with your own numbers, rather than published here as averages that describe nobody.
What moves the estimate is the operation chosen, whether an extended lymph node dissection is done, the approach used, the room category and the length of stay. Apollo Hospital, Bhat, is empanelled with most major insurers and with cashless TPAs; pre-authorisation is arranged by the hospital’s insurance desk before admission and the office will tell you what documents it needs.
Two costs are commonly missed. A PSMA-PET scan, where it is indicated, is self-funded, and its price is quoted to you at the time it is ordered rather than at the billing counter. And the things that decide your function afterwards — supervised pelvic floor physiotherapy, and penile rehabilitation medication — run for months and are budgeted from the start rather than dropped when the surgical bill is settled.
★★★★★
“Dr. Swati Shah performed my prostate surgery, and I am truly grateful for her care and expertise. It has been 3 years since the operation, and I recently visited for a follow-up. I am doing well now and living a normal, healthy life. Thank you so much, doctor, for your excellent treatment and support.”
Kiran Parikh, March 2026
★★★★★
“I’m so grateful to Dr. Swati Shah for her care during prostate cancer treatment. She was professional, caring, and very patient in answering all my questions. Her thorough approach and confidence gave me peace of mind. Excellent surgeon and wonderful person!”
DIVYA PARMAR, January 2026
★★★★★
“Dr. Swati Shah operated on my father for prostate cancer. The surgery was successful and his recovery is going well. She explained everything clearly and treated us with great care and patience. Very thankful to her and her team. Highly recommended.”
Dhruv Maheta, January 2026
A patient of Dr Swati Shah’s, after prostate biopsy — the step that produces the map every later decision is made from.
No. Favourable intermediate-risk disease can sometimes be watched, and where treatment is needed, radiotherapy with a short course of hormone therapy controls the cancer as well as surgery does. The prostate comes out when that is the option that suits your disease and your priorities, not automatically.
Erections are near-absent immediately after surgery in every man. Where both nerve bundles were spared and you were fully potent before, a substantial proportion of men recover erections adequate for intercourse over twelve to twenty-four months, often partially, and rehabilitation from two to four weeks after surgery improves the odds. Where the nerves could not be spared, treatment with tablets, injections or an implant is how erections are restored. Ejaculation stops permanently either way.
Weeks to a few months for most men. The great majority are using no pad or one small pad by twelve months. Starting pelvic floor training four weeks before the operation, rather than after the catheter comes out, is what shortens this most.
Only if you have unfavourable intermediate-risk disease and the result would change the plan. It is not indicated in favourable intermediate-risk disease, and a conventional bone scan with CT remains an acceptable alternative where the cost is a barrier — treatment is not delayed while money is arranged.
Yes, and where the choice is genuinely balanced it is the unit's practice to arrange exactly that, after the case is discussed at the tumour board. You should hear both options from people who practise them.
Training and experience
Robotic prostatectomy since 2013. Uro-oncology training under Dr Sudhir Rawal at Rajiv Gandhi Cancer Institute, New Delhi, during a 3-year DrNB in Surgical Oncology; MBBS and MS (General Surgery), Maulana Azad Medical College.
Consultation at Gota. Surgery at Apollo, Bhat, Gandhinagar.
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