Active surveillance (AS) is the preferred management for individuals with low-risk prostate cancer (PCa), but its role in intermediate-risk (IR) disease remains underreported. Given growing interest and published data, we performed an updated systematic review and meta-analysis to evaluate AS outcomes in selected patients with Gleason Grade Group (GG) 1-2 IR PCa.
A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD420251138532). PubMed/MEDLINE, Embase, and Web of Science databases were searched for studies published up to September 2025 reporting outcomes of AS in IR PCa. Primary outcomes were AS discontinuation-free survival and GG ≥3 upgrade-free survival.
In total, 18 studies, including 3783 selected patients with IR PCa, were analyzed. Pooled AS discontinuation-free survival rates were 70% (95% confidence interval [CI] 62-78) at 3 years, 63% (95% CI 58-68) at 5 years, and 53% (95% CI 38-67) at 10 years. In analyses restricted to GG 2 cohorts, corresponding pooled estimates were 72% at 3 years, 56% at 5 years, and 40% at 10 years. GG ≥3 upgrade-free survival was 84% (95% CI 76-92) at 3 years and 78% (95% CI 65-91) at 5 years in all cohorts and 92% (95% CI 86-98) and 87% (95% CI 78-95) at 3 and 5 years in cohorts screened using multiparametric magnetic resonance imaging. No significant difference in AS discontinuation was observed between biopsy GG 1 and 2 (hazard ratio 1.08; 95% CI 0.86-1.35). Limitations include moderate risk of bias and heterogeneity across AS protocols.
Although long-term data are lacking, particularly regarding robust oncological outcomes, growing evidence suggests that AS appears oncologically safe in well-selected patients. Magnetic resonance imaging will play a key role in the appropriate selection and follow-up of patients.
BJU international. 2026 Jul 26 [Epub ahead of print]
Alessandro Uleri, Ludovica Cella, Thibaut Long-Depaquit, Federica Sordelli, Alba Farré, Victor Caballero, Josep Comet, Pawel Rajwa, Romain Diamand, Bertrand Tombal, Morgan Roupret, Veeru Kasivisvanathan, Michael S Leapman, Guillaume Ploussard, Michael Baboudjian
Department of Urology, Josep Trueta University Hospital, Girona, Spain., Department of Urology, Humanitas Clinical and Research Institute IRCCS, Milan, Italy., Department of Urology, APHM, North Academic Hospital, Marseille, France., Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria., Department of Urology, Jules Bordet Institute, Hôpital Universitaire de Bruxelles, Brussels, Belgium., Institut de Recherche Clinique, Cliniques Universitaires Saint Luc, Brussels, Belgium., Department of Urology, GRC 5 Predictive Onco-Uro, Pitié Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France., Yale School of Medicine, New Haven, CT, USA., Department of Urology, La Croix du Sud Hôpital, Quint Fonsegrives, France.