Long‐Term Oncological Outcomes of Robot‐Assisted Radical Prostatectomy for Clinically Localized Grade Groups 4 and 5 Prostate Cancers Diagnosed on Prostate Biopsy

ABSTRACT Objectives This study aimed to investigate the long‐term oncological outcomes of Grade Group (GG) 4 and 5 Prostate Cancer (PCa) diagnosed by prostate biopsy who underwent robotic‐assisted radical prostatectomy (RARP). Methods We retrospectively reviewed our database for those who had clinically localized GG 4 and 5 PCa discovered on prostate biopsy who underwent RARP before January 1, 2018. Demographic and clinical data was collected. Primary outcomes included overall survival (OS) and PCa‐specific survival (CSS). Secondary outcomes covered biochemical recurrence‐free survival (BCR‐FS), need for adjuvant or salvage radiotherapy (aRT/sRT), and final specimen pathological features. Kaplan‐Meier analyses assessed 5‐, 10‐, and 15‐year OS and BCR‐FS. Results 98 patients met our inclusion criteria, with a median age of 63.7 years (IQR: 59.7–69.3) and a median preoperative PSA level of 6.9 ng/mL (IQR: 4.9–10.9). Most patients were GG 4 (77.6%), and 22.4% were GG 5. Pathology at prostatectomy revealed the following ISUP Grade Groups: 19 patients (19.4%) with Grade Group 2, 36 (36.7%) with Grade Group 3, 27 (27.6%) with Grade Group 4, and 16 (16.3%) with Grade Group 5. 64.2% had pT3 (or greater?) disease, 21.4% with pN+, and 22.4% with positive margins. 26.5% of patients received post‐RARP radiotherapy (14.3% adjuvant, 12.5% salvage). After a median follow‐up of 132 months, 12 deaths occurred (none from prostate cancer; CSS = 100%]). OS estimates were 95% at 5 years, 88% at 10 years, and 86% at 15 years. The estimated BCRFS rates were 90%, 80%, and 78% at 5, 10, and 15 years respectively. Conclusions In our cohort, RARP for clinically localized GG 4 and 5 PCa discovered on prostate biopsy achieved high OS, CSS, and BCFRS rates with mostly single‐modality treatment. RARP remains a valid first‐line treatment for clinically localized GG 4 and 5 PCa.