Prostatectomy or SBRT: which treatment better preserves quality of life?

By Lila Rouland | Published on November 20, 2025 | 3 min read


In men with localized prostate cancer at low or intermediate risk, two curative treatments are now standard options: radical prostatectomy and stereotactic body radiotherapy (SBRT). While surgery is often regarded as the more radical approach, radiotherapy is considered less invasive, but its side effects—particularly bowel toxicity—raise questions.  

The PACE-A study is the first phase 3 randomized trial directly comparing patient-reported quality of life outcomes (PROs) after these two approaches. Its objective: to assess, two years after treatment, the specific impact on urinary continence, bowel function, and sexual function to better inform therapeutic decision-making.  

Cross-over findings: less incontinence and sexual dysfunction after SBRT, but more bowel symptoms  

Methodology and participant profile 

Between 2012 and 2022, 123 men with low- or intermediate-risk localized prostate cancer (94% intermediate risk per NCCN criteria) were randomized (1:1) to receive either laparoscopic radical prostatectomy (n=60) or SBRT in 5 fractions (n=63). No patient received hormonal therapy. The 24-month results were based on validated patient questionnaires (EPIC-26, IIEF-5, IPSS, Vaizey) completed at multiple time points.  

Urinary function: radiotherapy better preserves continence 

Two years after treatment, 50% of surgically treated patients reported using at least one urinary protection pad per day, compared with only 6.5% in the SBRT group (p < 0.001). The estimated difference was 43 percentage points, unfavorable to prostatectomy. Continence scores (EPIC-26) reflected the same pattern, with a median of 77.3 after surgery versus 100 after SBRT (p = 0.003).  

Bowel function: a weak point of SBRT 

Bowel discomfort, assessed by the “bowel” domain of EPIC-26, was significantly more pronounced after SBRT (median: 87.5) than after surgery (median: 100), with a mean difference of 8.9 points (p < 0.001). Nearly 45% of patients receiving SBRT experienced a clinically significant decline in bowel scores, compared with only 14% following surgery.  

Sexual function: surgery remains more detrimental 

At two years, sexual function scores (EPIC-26) were markedly lower in postoperative patients: a median of 18 compared with 62.5 after SBRT (p < 0.001). Erectile dysfunction was also more frequent and severe: 63% of prostatectomy patients had grade ≥2 erectile dysfunction versus 18% after radiotherapy (p < 0.001).  

Clinician-reported toxicities: low in both groups 

Grade ≥2 genitourinary and gastrointestinal toxicities were rare and similar between groups, but proved less sensitive than patient-reported data. This discrepancy highlights the need to systematically include PROs in treatment evaluation.   Quality of life at the core of therapeutic decision-making  The PACE-A trial provides level 1 evidence supporting better preservation of continence and sexual function with SBRT, at the cost of a modest decline in bowel function. Radical surgery, although effective oncologically, more frequently results in persistent urinary incontinence and significant erectile dysfunction.  

These findings should guide clinicians toward a more individualized approach, taking into account patient preference and functional risk profiles. SBRT, well tolerated and effective, may therefore be favored in men who are active or particularly concerned about preserving urinary and sexual quality of life. Conversely, patients with pre-existing digestive conditions or increased bowel sensitivity may benefit more from a surgical approach.  

Longer-term studies with larger sample sizes will help confirm these trends and better identify optimal candidates for each treatment modality.   

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