Shifting risk profile in radical prostatectomy over 18 years: A bicentric French study of 8,358 patients

Area of Science:

• Urology
• Oncology
• Surgical Pathology

Background:

• Radical prostatectomy (RP) practice has evolved due to active surveillance (AS) guidelines for low-risk prostate cancer and the 2014 International Society of Urological Pathology (ISUP) Gleason reclassification.
• This study examines the temporal changes in patient characteristics undergoing RP over 18 years at two French high-volume centers.

Purpose of the Study:

• To describe the evolution of clinical and pathological features of patients undergoing RP.
• To analyze trends in patient risk stratification and disease characteristics over an 18-year period.

Main Methods:

• Retrospective analysis of 8,358 consecutive RPs performed between 2007 and 2025.
• Patients were stratified by D'Amico risk classification across three distinct time periods: 2007-2012, 2013-2018, and 2019-2025.

Main Results:

• A significant decline in low-risk patients (4.5% to 0.6%) and an increase in high-risk patients (9.5% to 21.7%) were observed.
• Biopsy Gleason score ≤6 decreased substantially (48.0% to 4.2%), while pathological stage ≥pT3 and lymph node involvement (pN1) increased (30.5% to 47.3% and 1.0% to 5.4%, respectively).
• Median patient age increased, and these shifts accelerated post-2012-2014, coinciding with guideline revisions and ISUP reclassification.

Conclusions:

• A profound and sustained shift in the risk profile of patients undergoing RP has occurred over 18 years.
• The near-disappearance of low-risk cases and the rise in high-risk and advanced disease suggest successful implementation of guideline-concordant active surveillance.
• These findings highlight significant changes in prostate cancer management and patient selection for radical prostatectomy.