Radical Prostatectomy Without Prior Biopsy? Final Histopathology of Radical Prostatectomies in 103 Consecutive Biopsy-naïve Patients Who Underwent Radical Prostatectomy.

Abstract

Background and objective: Prostate biopsy for histological confirmation is the standard before radical prostatectomy (RP). However, some patients refuse biopsy despite highly suspicious imaging findings. This study aimed to evaluate final pathology, assess potential active surveillance (AS) eligibility, and exploratorily evaluate perioperative outcomes and short-term oncological biochemical recurrence (BCR)-free survival after biopsy-naïve RP (bnRP).

Methods: We retrospectively analyzed a single-center cohort of patients who underwent bnRP with pT2-pT3 disease between 2019 and 2026. Final pathology was assessed, and potential AS eligibility was approximated using European Association of Urology-based low-risk and favorable intermediate-risk categories. Perioperative outcomes and short-term BCR-free survival were exploratorily compared between patients who underwent bnRP and those who underwent biopsy-confirmed RP (bcRP) using Kaplan-Meier estimation, log-rank testing, and a univariable Cox proportional hazards model.

Key findings and limitations: In 103 consecutive bnRP specimens, prostate cancer was confirmed in all patients. Overall, 94% had clinically significant prostate cancer (csPCa). Compared with 3081 consecutive patients who underwent bcRP, patients who underwent bnRP had fewer low-grade tumors and more locally advanced disease. Overall, 5.8% of the biopsy-naïve patients had International Society of Urological Pathology grade group 1 disease, but only one patient fulfilled the stricter AS approximation criteria. However, in total, 18% of the biopsy-naïve patients fulfilled broader AS criteria and might have warranted formal AS assessment. Exploratory analysis revealed no significant difference in short-term BCR-free survival between patients who underwent bnRP and those who underwent bcRP.

Conclusions and clinical implications: In our single-center observational analysis of carefully selected patients, bnRP seemed safe and was associated with a high likelihood of csPCa. Nevertheless, the retrospective approximation of AS eligibility highlights that bnRP should be performed cautiously. Exploratory perioperative and short-term oncological analyses need prospective validation.