Changing times: trends in risk classification, tumor upstaging, and positive surgical margins after radical prostatectomy - results from a contemporary National Cancer Database study.

Purpose: Recent advancements in screening, prostate MRI, robotic surgery, and active surveillance have influenced the profile of patients undergoing radical prostatectomy (RP). We sought to examine their impact on trends in clinicodemographic, risk classification, and adverse pathology in men undergoing surgery.

Methods: We queried the National Cancer Database for clinicodemographic, risk group, and pathology data in men undergoing upfront RP between 2006 and 2020. Patients were categorized by NCCN risk groups, and trends were assessed among 2006-2010, 2011-2015, and 2016-2020 periods. Endpoints included rates of pT3, positive surgical margins (PSM), pathologic upstaging, and Gleason grade group (GG) upgrading.

Results: 610,762 patients were included. There were significant increases in African Americans (9.8-14.1%), comorbidities (2.1-5.2% with Charlson scores > 1), and robot-assisted RP (78-84%). Over the three time periods, high-risk cases increased from 15 to 20 to 27%, and intermediate-risk from 54 to 51 to 60%. Overall rates of pT3 rose from 20 to 38%, and PSM from 20 to 27% (p < 0.001). Pathologic upstaging increased in low (6-15%), intermediate (20-33%), and high-risk groups (42-58%) -p < 0.001. Gleason upgrading rose in low-risk (45-59%, p < 0.001), with slight reductions in the intermediate and high-risk groups.

Conclusions: Recent trends in RP indicate a shift towards more advanced disease, evidenced by increasing rates of pT3, PSM, and pathologic upstaging across all NCCN risk groups. These findings emphasize the need for a careful balance in applying fascia and nerve-sparing techniques to avoid compromising oncological safety.