The synthesis of an ageing population and increased prostate cancer detection has forced urologists to rethink the dogma of localised prostate cancer treatment. In some ways, this has been facilitated by less invasive treatment options, including LDR and HDR brachytherapy, and laparoscopic and robotic radical prostatectomy. Historically, we have been  guilty of over-treatment of low risk prostate cancer,  and the temptation to over-treat is greater if less morbid treatments are available. We have moved through an era of intensive and unchecked PSA testing, with increased detection in older, sicker men. Thankfully, active surveillance has provided some balance to the equation, and there is now talk of uncoupling diagnosis from treatment.

 The 'guidelines' we follow are that if a man has less than a 10-year life expectancy, PSA testing should not be performed, and if it is performed and prostate cancer discovered, we should not treat. This doesn't allow for the range of prostate cancer clinical behaviour, the tools we have to predict this are blunt, and this approach is simplistic.

At the other end of the spectrum, there is a drive for more aggressive treatment of high-risk prostate cancer, including a shift from systemic-only treatment in oligometastatic disease, to intent-to-cure treatment of the prostate cancer and its metastasis.

The peri-operative impact of radical prostatectomy has certainly been lessened by less invasive methods, and this inevitably means older patients with more co-morbidities can be safely treated by this method. The main long-term implication is that of incontinence and conflicting data exist for the results in older men.

The problems seem simple: to treat or not, and if we treat, with what? We don't yet have the answers.