The impact of surgical downgrading on prostate cancer recurrence: systematic review and analysis of a multiethnic population

Denzel Zhu, William Shyr, Michelle Toker, Ethan Fram, Jinrong Cheng, Evan Z. Kovac, Ilir Agalliu, Ahmed Aboumohamed, Kara L. Watts

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objective: To perform a systematic review and a retrospective cohort analysis evaluating the rates of surgical downgrading of prostate cancer (PCa) from biopsy (PBx) to radical prostatectomy (RP), and their association with biochemical recurrence (BCR) in a multiethnic population. Methods: A systematic review of PubMed and other databases was performed. We included retrospective studies evaluating the relationship between surgical downgrading and BCR-free survival. Data regarding Gleason score (GL) downgrading were abstracted from the articles and categorized as follows: GL8-10 to GL7, GL7 to GL6, and GL 7(4 + 3) to GL7(3 + 4). We also performed a retrospective cohort review of patients who underwent RP at our institution from 2005 through 2020. Kaplan–Meier survival analysis and Cox proportional hazards models were used to compare BCR among downgraded versus non-downgraded men. Results: Systematic review yielded 137 abstracts; of these, 36 full-texts were reviewed, 8 of which were included in our systematic review. Despite substantial variability, all showed that GL at RP is one of the most important factors of BCR-free survival. A total of 1,484 men with PCa were analyzed from our institution. On multivariate analysis, GL7 to GL6 downgrading (HR = 0.50, p = 0.022) and GL8-10 to GL7 downgrading (HR = 0.42, p = 0.011) were associated with reduced risk of BCR when compared to men with GL7 and GL8-10 concordance, respectively. However, GL7(4 + 3) to GL7(3 + 4) downgrading was not significantly associated with reduced BCR (HR = 0.56, p = 0.12), when compared to GL7(4 + 3) concordance, although HR was similar. Conclusion: Surgical downgrading at RP was associated with a reduced risk of BCR compared to GL concordant disease, and these findings have been validated within our multiethnic population. Pathologic downgrading at the time of RP may be a more useful predictor of subsequent BCR in comparison to that associated with GL concordant pathology.

Original languageEnglish (US)
Pages (from-to)709-718
Number of pages10
JournalWorld Journal of Urology
Issue number3
StatePublished - Mar 2022


  • Biochemical recurrence
  • Hispanic
  • Multiethnic
  • Non-Hispanic black
  • Non-Hispanic white
  • Prostate biopsy
  • Prostate cancer
  • Radical prostatectomy
  • Surgical downgrading
  • Systematic review

ASJC Scopus subject areas

  • Urology


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