OPTIONS: Active Surveillance or TULSA-PRO? How to Decide in 2026
When your urologist said "active surveillance," it may have sounded like relief: no surgery, no radiation, just watching.
For many men, that's exactly the right plan. For others, the real reason they chose it was to avoid side effects they weren't ready to accept.
If that's you, the question you may be quietly asking is whether there's anything between waiting and the treatments you were trying to avoid.
This article explains when active surveillance is the recommended approach, when it's one option among several, and where the TULSA Procedure (TULSA-PRO), an MRI-guided treatment that aims to preserve urinary and sexual function, may fit.
Integrative Urology offers the TULSA Procedure, but we also discuss all options including active surveillance. In this article, we try to be plain about when surveillance is the better fit, and about TULSA-PRO's own risks and costs.
The short answer
Active surveillance is a well-supported way to manage lower-risk prostate cancer, and for many men it remains the recommended approach. Some men choose it mainly to avoid the side effects of surgery or radiation, even when their cancer could reasonably be treated.
For some of those men, TULSA-PRO is an option that treats the cancer while aiming to preserve urinary and sexual function. It has its own risks, still requires ongoing monitoring and is not covered by most insurances, so the right choice depends on your cancer, how thoroughly it has been staged and what you most want to protect.
Why do so many men choose active surveillance?
Most men choose active surveillance to avoid the side effects of treatment they may not need yet, or may never need. Many prostate cancers grow slowly, and guidelines recognize that treating every one right away can expose men to risks to urinary and sexual function without a clear benefit.[1]
Surveillance is a scheduled plan of PSA tests, MRI scans and repeat biopsies, with treatment discussed if the cancer shows signs of changing.[1] The approach was championed by Dr. Laurence Klotz, a Toronto urologist who popularized the term "active surveillance."[2]
Dr. Klotz later led the pivotal clinical trial of TULSA-PRO, which is covered below.[4]
What you may have read
Active surveillance means doing nothing about your cancer.
What the evidence shows
Surveillance is an active plan of regular testing, including biopsies, designed to catch meaningful change early while sparing men treatment they don't need.
Is active surveillance the right fit for my cancer?
For low-risk prostate cancer, usually yes. The joint AUA/ASTRO guideline recommends active surveillance as the preferred approach for low-risk disease.[1]
For favorable intermediate-risk cancer, the same guideline asks doctors to discuss active surveillance, radiation and surgery as options, rather than naming one as preferred.[1] This is where the decision becomes personal, and where your priorities matter as much as your pathology report.
What does the long-term evidence on monitoring show?
One of the largest randomized trial comparing monitoring with surgery and radiation is the UK ProtecT trial.
After a median of 15 years, the risk of dying from prostate cancer was low in every group and not significantly different between them.[3]
ProtecT trial: 1,643 men with PSA-detected localized prostate cancer, median 15 years of follow-up [3]
- 3.1%, 2.2%, 2.9% of men died of prostate cancer in the monitoring, surgery and radiation groups, a difference that was not statistically significant.
- 9.4% vs. about 5% of men developed metastatic disease in the monitoring group, compared with the surgery and radiation groups.
- 61% of men in the monitoring group went on to have surgery or radiation during follow-up.
- 24% of men in the monitoring group had avoided both radical treatment and long-term hormone therapy at 15 years.
ProtecT's monitoring relied mainly on PSA testing, which is less intensive than today's surveillance with routine MRI and confirmatory biopsies.
The trial also included some men who would now be classed as intermediate or high risk.
Taken together, these results describe a tradeoff rather than a right answer. Monitoring spared many men treatment and its side effects, with a higher chance of the cancer progressing. Treatment lowered that chance but brought side effects sooner. Neither result means surveillance is unsafe for a man who is well matched to it and closely followed.
What if avoiding side effects is the main reason I'm waiting?
Then it helps to be clear with yourself, and with your doctor, about why you're on surveillance.
Some men are on surveillance because it's the best fit for their cancer. If your cancer is low risk and your workup has been thorough, surveillance is likely the right place to be, and nothing in this article should talk you out of it.
Other men chose surveillance mainly because the side effects of surgery or radiation felt like too high a price, even though their cancer could reasonably be treated. That's a legitimate choice. It's also worth knowing that treatments designed around preserving urinary and sexual function now exist, so the decision may not be limited to waiting or accepting those side effects.
Either way, the first question is the one Dr. Hong asks every man: how do we know the cancer is confined to the prostate? Surveillance and every local treatment depend on a thorough workup, including a quality MRI and an accurate biopsy.
Where does TULSA-PRO fit for men on surveillance?
TULSA-PRO may be worth discussing if your cancer could reasonably be treated and preserving function is your priority. It is an FDA-cleared, incision-free, radiation-free procedure for ablating prostate tissue.[5]
A thin device placed through the urethra directs ultrasound energy into the prostate while you lie inside an MRI scanner. The MRI measures tissue temperature as treatment happens, and the procedure is designed to spare the urethra and the urinary sphincter.[4]
There's an important caveat. The AUA/ASTRO guideline notes that high-quality data comparing ablation with surgery, radiation and active surveillance are still lacking for unfavorable intermediate-risk and higher cancers.[1] That's one reason a careful conversation about your specific case matters more than any single study.
TACT pivotal trial: 115 men with favorable to intermediate-risk cancer, 13 centers, whole-gland treatment, 12 months [4]
- 96% of men met the trial's primary goal of reducing PSA by at least 75 percent.
- 65% of men who had a 12-month biopsy showed no evidence of cancer. The remaining men had some cancer detected on biopsy.
- 69 of 92 men who had erections before treatment maintained or regained them at 12 months, as measured by a standard questionnaire.
TACT treated the whole gland in men with grade group 1 or 2 cancer. It did not compare TULSA-PRO with surveillance or any other treatment, and results from partial-gland treatment or other patient groups may differ.
Does TULSA-PRO end the monitoring?
No. After TULSA-PRO you'll still have regular PSA tests and follow-up imaging, and some men need additional treatment later. If you're thinking about leaving surveillance mainly to escape the waiting, it's worth knowing that treatment changes what you're watching for, but it doesn't end the watching.
PSA also behaves differently than it does after surgery.
Surgery removes the prostate, so PSA usually falls close to zero. TULSA-PRO leaves some healthy prostate tissue in place, and that tissue keeps making PSA, so many men settle at a new, lower baseline. As Dr. Hong explains to his patients, the pattern over time matters more than any single number.
If more treatment is ever needed, your doctor can walk you through which options remain open for your situation.
How do active surveillance and TULSA-PRO compare?
The two approaches ask for different commitments. This table sets them side by side without ranking them.
| Question | Active surveillance | TULSA-PRO |
|---|---|---|
| What it involves | A scheduled plan of PSA tests, MRI scans and repeat biopsies | A single outpatient, MRI-guided procedure to ablate prostate tissue |
| Where guidelines place it* | Recommended for low-risk cancer; one option to discuss for favorable intermediate risk | An option for selected men; high-quality comparative data are still limited for unfavorable intermediate-risk or higher |
| Side effects | None from treatment; periodic biopsies carry their own small risks | Possible changes to urinary and sexual function |
| Monitoring | Ongoing, by design | Ongoing PSA tests and imaging after treatment |
| If results change | Treatment is discussed | Additional treatment is possible |
| Insurance | Standard tests, generally covered depending on your plan | Generally not covered; self-pay |
*Per the AUA/ASTRO guideline on clinically localized prostate cancer.[1]
What does each option cost?
Active surveillance is built from standard tests, including PSA blood work, MRI and biopsies, which insurance generally covers. What you pay out of pocket depends on your plan.
TULSA-PRO is generally not covered by insurance, and costs range from $30,000 to $50,000+ at most centers nationwide. TULSA-PRO at Integrative Urology is self-pay.
How does Dr. Hong think about active surveillance?
Dr. Hong personally evaluates every man who asks about TULSA-PRO, including men on surveillance who want a second perspective. Here's how he approaches the question, in his own words.
Which men on surveillance should stay on it, and which should talk about treatment?
Active surveillance can be a good option for those who are unsure of what to do. Tread water and make a careful choice because once you commit to surgery, radiation or even TULSA-PRO for that matter, you can't take that decision back.
Now if that hits in an uncomfortable place psychologically, you're not alone. Many men elect to be treated while on active surveillance, not always just because the cancer is getting worse.
What changes lead him to bring up treatment?
Usually it's a biopsy result that shows worsening prostate cancer. The biopsy could have been triggered by a rising PSA test, new or concerning MRI findings, or just part of the surveillance protocol. Sometimes, men just don't want to live with fear of cancer getting worse or keep getting testing and biopsies year after year.
What does he tell a man who wants to leave surveillance because of the worry?
Don't jump out of the frying pan into the fire. Make sure you understand why you're leaving surveillance and what changed since starting your surveillance plan. Then consider your treatment options and consider whether you would regret your treatment choice if you had a permanent side effect of treatment. Your answer depends on risk and reward. The risk of not treating vs. the risk of treating. More certainty vs. less certainty.
Then talk to your loved ones and provider honestly about what's important to you and what you're trying to avoid. If it's still clear as mud, give us a call. We can help you see the situation clearly.
Common questions about active surveillance and TULSA-PRO
Is active surveillance safe?
For men with lower-risk prostate cancer who are carefully selected and closely followed, long-term studies show a low risk of dying from prostate cancer. A large randomized trial found no significant difference in prostate cancer deaths between surveillance, surgery and radiation after 15 years. Surveillance did carry a higher chance of the cancer progressing and metastatic disease, which is why this study needs longer follow-up and regular follow-up matters on surveillance.
Can I stop active surveillance and choose treatment later?
Yes. Many men on surveillance eventually choose treatment, possibly because their results change or because their priorities do. Which options make sense at that point depends on how the cancer has changed, so a fresh review of your records is the right first step.
If my cancer is low risk, should I choose TULSA-PRO instead of surveillance?
For most men with low-risk cancer, guidelines recommend active surveillance as the preferred approach, and many are well served by staying on it. Treating low-risk cancer means accepting side effect risks for the benefit of getting off surveillance. A thorough review of your records is the best way to know which group you're in.
What are the side effects of TULSA-PRO?
Possible side effects include changes to erectile function and urinary symptoms, particularly in the first months after treatment. In the pivotal TACT trial, 69 of 92 men (75%) who had erections before treatment maintained or regained them at 12 months. Individual results vary, and your risks depend on your anatomy and your treatment plan.
Will I still need PSA tests after TULSA-PRO?
Yes. Monitoring continues after TULSA-PRO, with regular PSA tests and follow-up imaging. Because some healthy prostate tissue remains, PSA usually settles at a new baseline rather than dropping to zero, and your doctor watches the pattern over time.
Is TULSA-PRO covered by insurance?
TULSA-PRO is generally self-pay and not covered by insurance. Active surveillance relies on standard tests that insurance usually covers, depending on your plan.
Bring your questions
If you're on active surveillance and wondering whether it's still the right plan, the candidacy assessment is a simple first step, and Dr. Hong's care team will follow up by phone. You'll get an honest answer, including if surveillance is where you should stay.
Take the candidacy assessmentReferences
Numbers in this post come from the sources below, current as of 10/12/2026.
- Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically localized prostate cancer: AUA/ASTRO guideline, part I: introduction, risk assessment, staging, and risk-based management. J Urol. 2022;208(1):10-18. PubMed 35536144
- Choo, R., Klotz, L., Danjoux, C., et al. Feasibility study: Watchful waiting for localized low to intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression. The Journal of Urology 2002, 167(4), 1664–1669. https://doi.org/10.1016/s0022-5347(05)65174-9
- Hamdy FC, Donovan JL, Lane JA, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2023;388(17):1547-1558. doi:10.1056/NEJMoa2214122
- Klotz L, Pavlovich CP, Chin J, et al. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate cancer. J Urol. 2021;205(3):769-779. doi:10.1097/JU.0000000000001362
- U.S. Food and Drug Administration. 510(k) premarket notification K191200, TULSA-PRO system. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K191200
- Profound Medical announcement of 200 independently performed TULSA procedures, reported by BioTuesdays, November 18, 2025. https://www.globenewswire.com/news-release/2025/11/18/3190496/33471/en/profound-medical-celebrates-the-hong-center-s-200th-independent-tulsa-procedure-for-prostate-disease.html
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