Long‐Term Clinical Outcomes of Radical Prostatectomy Versus Image‐Guided and Intensity‐Modulated Radiation Therapy for Prostate Cancer: A Retrospective and Comparative Study

<b>Background and Objective:</b> The optimal definitive treatment for localized prostate cancer (PCa)-radical prostatectomy (RP) or intensity-modulated radiation therapy with image guidance (IMRTG) remains controversial. This study compares the long-term clinical outcomes of RP and IMRTG in patients with PCa. <b>Methods:</b> We retrospectively analyzed 884 consecutive PCa patients over 25 years. Among them, 610 (69%) underwent RP, while 274 (31%) received IMRTG starting in 2011. The primary objective was to comprehensively assess both treatment modalities. <b>Results:</b> The median age was 68 years in the RP cohort and 73 years in the IMRTG cohort. The median operation time for RP was 4.11 h, with nerve-sparing procedures performed in 45% of cases. Median blood loss was 310 mL, the urinary incontinence rate was 13%, and the median hospital stay was 14 days. In the RP cohort, 46 complications (28%) occurred, including a Grade 4 rectal injury and a Grade 4 wound insufficiency. In the IMRTG cohort, over 80% of patients experienced radiation-induced urological complications, with 11% reporting Grade 2 adverse effects. During a median follow-up of 98 months, there were 79 all-cause deaths and 7 PCa-specific deaths. The 15-year overall survival (OS) rates were 80.9% for RP and 58.3% for IMRTG; however, this difference was not significant in the multivariate analysis, likely due to a higher proportion of high-risk disease in the IMRTG cohort. Approximately 45% of all deaths were attributed to malignant tumors. <b>Conclusions:</b> This long-term retrospective study provides valuable insights into the comparative effects of RP and IMRTG on OS in PCa patients. Both treatments are associated with distinct adverse events, complications, and impacts on urinary continence and sexual function, highlighting the importance of individualized clinical decision-making.