Pathological Outcomes Following Radical Prostatectomy for Low-Risk Prostate Cancer

Introduction There is an increasing view that the standard of care for men diagnosed with low-risk prostate cancer (LRPC) should be conservative, whether it be with active surveillance (AS) or watchful waiting. The introduction of imaging such as prostate magnetic resonance imaging (MRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) has provided additional tools to predict the likelihood of occult clinically significant prostate cancer (PC) prior to biopsy and may also play a role in predicting missed clinically significant prostate cancer when prostate biopsies are either negative or only find low-grade PC. The New South Wales Prostate Cancer Outcomes Registry (NSW-PCOR) lists radical prostatectomy (RP) for LRPC as a performance metric for participant urologists, to whom such data is provided through Quality Reports. Given that factors beyond a diagnosis of LRPC may influence a decision for RP, a high level of pathological upgrade is anticipated in men with LRPC undergoing surgery in contemporary practice. The aim of this study was to evaluate the final pathological outcomes of men with LRPC who had undergone an RP and what factors played a role in the decision to undergo surgery. Methods The NSW-PCOR Quality Reports were analyzed from inception, and 10 patients who had undergone RP for LRPC were identified. Data, including biopsy histopathology, RP histopathology, and indications for RP, were extracted from clinical records. Clinically significant PC was defined as a Gleason score of ≤3 + 4 or the presence of extraprostatic extension or seminal vesicle invasion. Results It was found that seven out of 10 men had clinically significant PC on their RP histopathology. For eight men, preoperative imaging with prostate MRI or PSMA PET/CT had suggested a mismatch between imaging and biopsy pathology of low-grade PC. Of these eight men, seven were found to have clinically significant PC on RP. Other reasons for RP being performed included young age at diagnosis and the request for intervention related to patient anxiety. Conclusion In this contemporary cohort of men undergoing RP for LRPC, clinically significant disease was correctly predicted for all but one, where imaging had prompted intervention. Caution needs to be applied both in instances of reliance on imaging to predict occult clinically significant PC, as well as in the appropriateness of assigning conservative management purely on the basis of PC risk stratification.