Clinical Edge

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Radical prostatectomy vs deferred treatment for localized prostate cancer

Key clinical point: Radical prostatectomy improves oncological outcomes in men with localized prostate cancer vs. watchful waiting or active surveillance, but also markedly increases rates of urinary incontinence and erectile dysfunction.

Major finding: Radical prostatectomy vs. watchful waiting probably reduced the risk for all-cause mortality (hazard ratio [HR], 0.79), cancer-related death (HR, 0.57), progression (HR, 0.43), and metastasis (HR, 0.56). Radical prostatectomy may considerably increase the rate of urinary incontinence (risk ratio [RR], 3.97) and erectile dysfunction (RR, 2.67). Radical prostatectomy vs. active monitoring showed no differences in all-cause mortality (HR, 0.93) or cancer-specific mortality (HR, 0.63) and reduced the risk for progression (HR, 0.39) and metastasis (RR, 0.39).

Study details: Meta-analysis of 4 studies including 2,635 patients with localized prostate cancer.

Disclosures: This study received no external funding. The authors declared no conflicts of interest.


“The optimal strategy for the management of early stage prostate cancer continues to be somewhat elusive. Vernooji et al. conducted a meta-analysis and review of trials of prostatectomy versus either watchful waiting or active monitoring. For the 3 studies evaluating watchful waiting versus prostatectomy, the authors concluded that prostatectomy probably reduces the risk of dying from any reason. Conversely, for the trial comparing surgery versus active monitoring, they concluded there is probably no difference between the two groups with respect to dying from any reason.

For all 4 studies, the overall quality of life between the two approaches is probably similar; however, the surgery groups did likely have more issues with sexual function and urinary incontinence. It is evident that these randomized trials are only the beginning and more nuanced studies will be needed to better identify patients where the risks of surgery vastly outweigh the benefits and vice versa.”

Mark Klein, MD


Vernooij RWM et al. Cochrane Database Syst Rev. 2020 Jun 4. doi:10.1002/14651858.CD006590.pub3.