Offering active surveillance to patients with a Gleason score of 3+4 is a highly controversial topic. This study aims to investigate the incidence of pathological upgrading from biopsy with ISUP Grade Group 2 to prostatectomy and to identify the predictive factors associated with pathological upgrading in this Indian cohort.

Retrospective analysis was conducted on 153 patients at a single institution who underwent robot-assisted radical prostatectomy(RARP) between January 2019 and May 2024, following the detection of ISUP Grade Group 2 prostate cancer on biopsy. Univariate and multivariate logistic regression analyses were performed to identify the independent factors associated with GG 2 upgrading post-prostatectomy.

82 patients (53.59%) with GG2 had upgrading post-prostatectomy. Patient in upgradation group had higher PSA (median 14.6 vs. 11.2 ng/ml; p=0.006), higher PSA density (median 0.38 vs. 0.29 ng/ml2; p=0.03), higher Prostate Imaging-Reporting and Data System version 2 (p=0.03) on multiparametric MRI, greater percentage of Gleason 4 pattern on biopsy (median 37.5 vs. 30;p<0.001) and higher maximum standard uptake value (SUV max) (median 10.55 vs. 7.6;p=0.001) on Gallium-68-PSMA positron emission tomography/computer tomography (Ga-68-PSMA PET/ CT). On multivariate analysis, PSA (odds ratio(OR):1.09 (95% CI: 1.03-1.16); p=0.001), the percentage of Gleason 4 (OR: 1.03 (95% CI: 1.01 -1.05); p=0.001) and SUV max (OR: 1.11 (95% CI:1.04 -1.19); p=0.001) were significant predictors of ISUP GG2 upgrading.

A significant proportion of patients with ISUP GG2 prostate cancer on biopsy were upgraded after RARP. PSA, percentage of Gleason 4 pattern on biopsy and SUV max on PSMA PET/CT should be considered before offering active surveillance to these patients.