Clinically Localized Prostate Cancer: Active Surveillance, Surgery and Follow-up

Publication Date: May 10, 2022
Last Updated: May 11, 2022

Principles of Active Surveillance

Patients managed with active surveillance should be monitored with serial prostatespecific antigen (PSA) values and repeat prostate biopsy. (Expert Opinion, )

In patients selecting active surveillance, clinicians should utilize multiparametric magnetic resonance imaging (mpMRI) to augment risk stratification, but this should not replace periodic surveillance biopsy. (Expert Opinion, )

Principles of Surgery

In patients electing radical prostatectomy, nerve-sparing, when oncologically appropriate, should be performed. (Moderate, B)

Clinicians should inform patients that pelvic lymphadenectomy provides staging information, which may guide future management, but does not have consistently documented improvement in metastasis-free, cancer-specific, or overall survival. (Moderate, B)

Clinicians should use nomograms to select patients for lymphadenectomy. The potential benefit of identifying lymph node positive disease should be balanced with the risk of complications. (Clinical Principle, )

Clinicians performing pelvic lymphadenectomy should perform an extended dissection, which improves staging accuracy compared to a limited dissection. (Moderate, B)

Clinicians should complete a radical prostatectomy if suspicious regional nodes are encountered intraoperatively. (Moderate, C)

Clinicians should risk stratify patients with positive lymph nodes identified at radical prostatectomy based on pathologic variables and postoperative PSA. (Expert Opinion, )

Clinicians may offer patients with positive lymph nodes identified at radical prostatectomy and an undetectable post-operative PSA adjuvant therapy or observation. (Conditional, C)

Clinicians should not routinely recommend adjuvant radiation therapy after radical prostatectomy. (Strong, A)

Follow-up after Treatment

Clinicians should monitor patients with prostate cancer post therapy with PSA and symptom assessment. (Clinical Principle, )

Clinicians should support patients with prostate cancer through continued symptom management and encouraging engagement with professional or community-based resources. (Clinical Principle, )

Recommendation Grading


  • CI: Confidence Interval
  • DRE: Digital Rectal Examination
  • HR: Prostate Imaging-reporting And Data System
  • MRI: Magnetic Resonance Imaging
  • PI-RADS: Prostate Imaging-reporting And Data System
  • PLND: Pelvic Lymph Node Dissection
  • PSA: Prostate Imaging-reporting And Data System
  • QOL: Prostate Imaging-reporting And Data System
  • SDM: Prostate Imaging-reporting And Data System
  • mpMRI: Multi-parametric Magnetic Resonance Imaging



Clinically Localized Prostate Cancer: Active Surveillance, Surgery and Follow-up

Authoring Organizations

Publication Month/Year

May 10, 2022

Last Updated Month/Year

May 25, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Document Objectives

The summary presented herein represents Part II of the three-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, discussing principles of active surveillance and surgery as well as follow-up for patients after primary treatment. Please refer to Parts I and III for discussion of risk assessment, staging, and risk-based management (Part I), and principles of radiation and future directions (Part III). 

This guideline aims to inform clinicians treating patients with clinically localized prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to further improve care for these men.

Target Patient Population

Patients with clinically localized prostate cancer

Target Provider Population

Urologists, radiation oncologists, surgical oncologists and other allied providers caring for patients with prostate cancer

Inclusion Criteria

Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services, Operating and recovery room

Intended Users

Radiology technologist, nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D011467 - Prostate, D011471 - Prostatic Neoplasms


prostate cancer, surveillance, surgery

Source Citation

Eastham JA, Auffenberg GB, Barocas DA, Chou R, Crispino T, Davis JW, Eggener S, Horwitz EM, Kane CJ, Kirkby E, Lin DW, McBride SM, Morgans AK, Pierorazio PM, Rodrigues G, Wong WW, Boorjian SA. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline, Part II: Principles of Active Surveillance, Principles of Surgery and Follow-up. J Urol. 2022 May 10:101097JU0000000000002758. doi: 10.1097/JU.0000000000002758. Epub ahead of print. PMID: 35536148.

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
August 1, 2021
Literature Search End Date
September 1, 2021