Evaluating the impact of radical prostatectomy and pathological upgrading on prognosis in non-clinically significant prostate cancer

Amidst growing medical concern about the risks of overtreatment in non-clinically significant prostate cancer (ncsPCa), this study aims to evaluate the impact of radical prostatectomy (RP) on the prognosis of ncsPCa patients, with a focus on the effects of post-RP International Society of Urological Pathology (ISUP) grading upgrades. Analyzing 20,600 ncsPCa patients diagnosed via prostate biopsy from 2010 to 2015 using the SEER database, we comprehensively assessed the effects of RP treatment and subsequent ISUP grade upgrades on patient outcomes through competing risk regression, Cox regression, propensity score matching (PSM), and Kaplan-Meier survival curves. The study reveals significant improvements in overall survival rates and prostate cancer-specific mortality for patients undergoing RP compared to those who did not, indicating a markedly better prognosis (HR = 0.54, 95 %CI = 0.43–0.68, P < 0.001; HR = 0.20, 95 %CI = 0.08–0.53, P = 0.001). Further analyses using PSM confirmed the effectiveness of RP treatment in enhancing overall survival rates and reducing prostate cancer-specific mortality risks, with statistically significant differences (P < 0.01). Moreover, the potential impact of postoperative ISUP grading upgrades on long-term prognosis was found to be insignificant. This study demonstrates that RP significantly improves the prognosis of ncsPCa patients, including better overall survival rates and lower prostate cancer-specific mortality, without adverse effects from postoperative ISUP upgrades. These findings support considering RP as a viable option in treatment strategies for ncsPCa patients. Future research should further explore how to optimize treatment decisions for ncsPCa patients to ensure effective disease management while mitigating the risk of overtreatment. • In the context of re-evaluating treatment strategies for low-risk prostate cancer, this study validates the efficacy of radical prostatectomy (RP) in patients with non-clinically significant prostate cancer (ncsPCa), providing important guidance for clinical practice. • This research systematically assesses the impact of post-RP ISUP upgrading on the prognosis of ncsPCa patients for the first time, finding no negative effect on long-term survival rates and specific mortality risks, offering new evidence for the safety of RP treatment. • It proposes future research directions, suggesting the development of more precise patient selection criteria and treatment management protocols. This aims to maximize treatment effectiveness and quality of life while avoiding overtreatment, further advancing the field of ncsPCa treatment.