Context There is ongoing uncertainty about the optimal management of patients with localised prostate cancer.

Objective To evaluate the comparative efficacy and safety of different treatments for patients with localised prostate cancer.

Design Systematic review with Bayesian network meta-analysis to estimate comparative ORs, and a score (0–100%) that, for a given outcome, reflects average rank order of superiority of each treatment compared against all others, using the Surface Under the Cumulative RAnking curve (SUCRA) statistic.

Data sources Electronic searches of MEDLINE without language restriction.

Study selection Randomised trials comparing the efficacy and safety of different primary treatments (48 papers from 21 randomised trials included 7350 men).

Data extraction 2 reviewers independently extracted data and assessed risk of bias.

Results Comparative efficacy and safety evidence was available for prostatectomy, external beam radiotherapy (different types and regimens), observational management and cryotherapy, but not high-intensity focused ultrasound. There was no evidence of superiority for any of the compared treatments in respect of all-cause mortality after 5 years. Cryotherapy was associated with less gastrointestinal and genitourinary toxicity than radiotherapy (SUCRA: 99% and 77% for gastrointestinal and genitourinary toxicity, respectively).

Conclusions The limited available evidence suggests that different treatments may be optimal for different efficacy and safety outcomes. These findings highlight the importance of informed patient choice and shared decision-making about treatment modality and acceptable trade-offs between different outcomes. More trial evidence is required to reduce uncertainty. Network meta-analysis may be useful to optimise the power of evidence synthesis studies once data from new randomised controlled studies in this field are published in the future.