Biochemical Recurrence in High-Risk Localized Prostate Cancer: A Comparison of Laparoscopic Prostatectomy and External Radiotherapy

<i>Background</i>: This retrospective study evaluated and compared oncological outcomes in patients with localized prostate cancer treated either by laparoscopic radical prostatectomy (LRP) or by external beam radiotherapy (EBRT) combined with androgen deprivation therapy (ADT). The primary aim was to identify predictors of biochemical recurrence (BCR) and to assess recurrence-free survival. <i>Subjects and methods</i>: A total of 107 patients diagnosed with localized prostate cancer and treated between 2016 and 2023 were included in the analysis. Of these, 61 patients underwent LRP, and 46 patients received EBRT+ADT. The median follow-up period was 60 months for the LRP group (IQR 24-72) and 66 months for the EBRT group (IQR 49.5-72). Biochemical recurrence (BCR) was defined as a PSA level > 0.2 ng/mL after LRP or an increase > 2 ng/mL above nadir following EBRT. Kaplan-Meier survival curves, log-rank tests, Pearson's chi-square, and Cox regression models were used to evaluate outcomes and identify predictors of recurrence, with significance set at <i>p</i> < 0.05. <i>Results</i>: Biochemical recurrence occurred in 21 (34.4%) of LRP patients and 10 (21.7%) of EBRT patients. The five-year BCR-free survival was 40 (65.6%) patients in the LRP group and 33 (71.7%) for EBRT, with a trend toward improved outcomes in the EBRT group that approached statistical significance (log-rank <i>p</i> = 0.089). Median time to recurrence was 30 months for LRP (IQR 12.75-60) and 48 months for EBRT (IQR 30-60). Predictive analysis revealed that in the LRP group, higher ISUP grade at biopsy (<i>p</i> = 0.001), advanced pathological stage (<i>p</i> < 0.001), positive surgical margins (<i>p</i> < 0.001), and intermediate initial PSA levels (10-20 ng/mL; <i>p</i> = 0.080) were associated with increased risk of BCR. No independent predictors of recurrence were identified in the EBRT group. <i>Conclusions</i>: Both LRP and EBRT+ADT provide effective cancer control with similar five-year BCR-free survival. However, LRP was associated with a higher recurrence rate, particularly among patients with intermediate-risk features such as iPSA 10-20 ng/mL, high ISUP grade, advanced pathological stage, or positive surgical margins. These findings highlight the need for risk-adapted follow-up and timely salvage treatment in high-risk LRP patients to improve long-term outcomes.