Understanding Your Radical Prostatectomy Pathology Report

by Jason Wasserman MD PhD FRCPC
March 18, 2026

A radical prostatectomy is a surgical procedure in which the entire prostate gland is removed, along with the seminal vesicles and, in many cases, nearby lymph nodes. It is one of the main treatments for prostate cancer that is confined to the prostate or has spread only to the immediately surrounding tissue. After the surgery, the removed tissue is sent to a pathology laboratory, where a pathologist examines it carefully under a microscope and writes a detailed report.

Understanding what your radical prostatectomy pathology report says can help you have more informed conversations with your doctor about what was found, what it means, and what comes next.

What is a radical prostatectomy?

A radical prostatectomy is surgery to remove the entire prostate gland. It is called “radical” because the whole gland is removed, not just part of it. The seminal vesicles — two small glands that sit just behind the prostate and contribute to semen production — are removed at the same time. Depending on your situation, your surgeon may also remove nearby pelvic lymph nodes to check for cancer spread. This part of the procedure is called a pelvic lymph node dissection.

The surgery can be performed in several ways, including open surgery, laparoscopic surgery, or robot-assisted surgery. The approach used does not change how the pathologist examines or reports the tissue.

What does the pathology laboratory do with the prostate after surgery?

After removal, the prostate gland is sent fresh to the pathology laboratory, where it is carefully processed before any microscopic examination takes place. Understanding this process helps explain why the report contains so much detailed information.

The pathologist assistant first examines and measures the prostate with the naked eye, describing its size, shape, and external appearance. This is called the gross examination. The outer surface of the prostate is painted with a special ink, often in two colors to distinguish the left and right sides, so that the margins — the edges of the removed tissue — can be precisely identified under the microscope.

The prostate is then sliced into thin sections, processed, embedded in wax, and sectioned into very thin slices, which are placed on glass slides. Special dyes are applied to highlight different structures within the tissue. The pathologist examines all of these slides systematically under the microscope, mapping out where cancer is found, how it looks, and whether it has reached or spread beyond the edges of the specimen.

What are the main sections of a radical prostatectomy pathology report?

A radical prostatectomy report is one of the most detailed pathology reports a patient will ever receive. Most reports follow a structured format, often called a synoptic report, which ensures all critical information is recorded consistently. The following sections explain what each part means.

The diagnosis

The diagnosis section states the type of cancer found. In the vast majority of cases, the diagnosis will be prostatic adenocarcinoma, also called acinar adenocarcinoma. This is the most common type of prostate cancer, arising from the gland cells of the prostate. Less commonly, other types of prostate cancer may be found, such as ductal adenocarcinoma or neuroendocrine carcinoma. Your report will specify which type or types are present.

Tumour location

The prostate is divided into several zones and regions. Your report will describe which parts of the prostate contain cancer. The most common locations are:

Peripheral zone. The outer part of the prostate, where most prostate cancers arise.
Transition zone. The inner part of the prostate, surrounding the urethra. Cancers here are less common but do occur.
Apex, mid-gland, and base. The prostate is also described from bottom to top as the apex (the tip, closest to the urethra), the mid-gland (the middle), and the base (the top, where the prostate meets the bladder).
Left and right sides. The report will note whether cancer is present on the left side, the right side, or both sides of the prostate.

Knowing where the cancer is located helps your doctor understand the surgical findings and plan any additional treatment if needed.

Tumour size and volume

After examining all the slides from the prostate, the pathologist estimates how much of the gland is involved by cancer. This is called tumour volume or tumour quantification. It is usually expressed as a percentage of the prostate replaced by cancer, and sometimes as a measurement in centimeters of the largest tumour focus.

Larger tumour volumes are generally associated with a higher risk of the cancer returning after surgery, although tumour volume is considered alongside the grade and stage when assessing overall risk.

Gleason grade and Grade Group

The Gleason grading system is the main way pathologists describe how aggressive prostate cancer looks under the microscope. It is based on how different the cancer cells and their arrangements look compared to normal prostate gland tissue. The more different they look from normal, the higher the grade and the more aggressive the cancer is considered to be.

Gleason grade

When examining the prostate, the pathologist identifies the different patterns of cancer present and assigns each a Gleason grade from 3 to 5. Grades 1 and 2 are no longer used in modern reporting.

Gleason grade 3. Cancer cells form small, well-defined glands that are recognizable as glands, although they look different from normal prostate glands. Grade 3 is the least aggressive pattern.
Gleason grade 4. Cancer cells form poorly defined, fused, or irregularly shaped glands, or grow in a cribriform pattern (a sieve-like arrangement with many holes). Grade 4 is more aggressive than grade 3.
Gleason grade 5. Cancer cells no longer form recognizable glands. They grow in solid sheets, cords, or as individual scattered cells. Grade 5 is the most aggressive pattern.

Gleason score

The Gleason score is calculated by adding together the two most common Gleason grade patterns seen in the prostate. The most predominant pattern is listed first, followed by the second most common. For example, a Gleason score of 3+4=7 means the most common pattern is grade 3, and the second most common is grade 4. A score of 4+3=7 means grade 4 is more predominant, even though the total score is the same number, and this carries a worse prognosis than 3+4=7.

If only one pattern is present throughout the entire prostate, the same grade is counted twice. For example, if cancer is entirely grade 3, the score is 3+3=6.

If a grade 5 pattern is present anywhere in the specimen, even in a small amount, the pathologist will note this because its presence can affect prognosis and treatment decisions, even when it is not the most predominant pattern.

Grade Group

The Grade Group system was introduced to make prostate cancer grading easier to understand. It groups Gleason scores into five categories, from least to most aggressive:

Grade Group 1. Gleason score 3+3=6. The least aggressive pattern. Cancer cells form reasonably well-defined glands.
Grade Group 2. Gleason score 3+4=7. Mostly well-defined glands with a smaller proportion of more irregular or fused glands.
Grade Group 3. Gleason score 4+3=7. Mostly irregular or fused glands with a smaller proportion of more well-defined glands. Considered more aggressive than Grade Group 2 despite the same total score.
Grade Group 4. Gleason score 4+4=8, or 3+5=8, or 5+3=8. Predominantly poor gland formation or no glands at all.
Grade Group 5. Gleason score 9 or 10. The most aggressive pattern, with little or no gland formation and frequently with individual scattered cancer cells.

Your Grade Group is one of the most important pieces of information in your report. Your doctor will use it alongside other findings to estimate your risk of cancer recurrence and guide decisions about further treatment.

Pathological stage (pTNM)

After surgery, the pathologist assigns a pathological stage, also written as pTNM. The “p” stands for pathological, meaning it is based on examination of the removed tissue, rather than imaging or clinical findings alone. The pTNM stage has three components.

Tumour stage (pT)

The pT stage describes how far the cancer has spread within or beyond the prostate itself. For prostate cancer after radical prostatectomy, the main pT stages are:

pT2. The cancer is confined within the prostate gland. It has not grown through the outer covering of the prostate (the prostatic capsule). This is often referred to as organ-confined disease.
pT3a. The cancer has grown through the outer covering of the prostate into the surrounding fatty tissue. This is called extraprostatic extension (EPE). It may also include cancer found at the surgical margin at the bladder neck.
pT3b. The cancer has spread into one or both of the seminal vesicles, the small glands that sit just behind the prostate.
pT4. The cancer has spread into nearby structures other than the seminal vesicles, such as the external sphincter, the rectum, the bladder wall, or the pelvic wall. pT4 disease is uncommon at the time of surgery.

In general, lower pT stages are associated with better outcomes after surgery. Extraprostatic extension (pT3a or higher) increases the risk of cancer recurrence and may prompt your doctor to recommend additional treatment such as radiation therapy.

Nodal stage (pN)

The pN stage describes whether cancer has been found in the lymph nodes removed during surgery. Not all patients have a pelvic lymph node dissection; your surgeon will have made this decision based on your preoperative risk assessment.

pN0. No cancer was found in any of the lymph nodes examined. This is a favorable finding.
pN1. Cancer was found in one or more lymph nodes. If lymph node involvement is present, your report will note how many lymph nodes were examined, how many contained cancer, and the size of the largest area of cancer (called a deposit or focus). Lymph node involvement increases the risk of cancer spreading to other parts of the body and usually prompts discussion about additional treatment.
pNX. Lymph nodes were not removed or were not submitted for examination.

Metastatic stage (pM)

The pM stage refers to distant metastasis, meaning cancer that has spread to parts of the body far from the prostate, such as the bones, lungs, or liver. This is not assessed by the pathology report itself, as it is determined by imaging and other tests. If distant metastasis has not been assessed, the report will note pMX. If imaging prior to or around the time of surgery showed no distant spread, it will be noted as pM0.

Extraprostatic extension

Extraprostatic extension (EPE) means that cancer cells have grown through the outer covering of the prostate and into the fatty tissue that surrounds it. The prostatic capsule is not a true capsule like a hard shell but rather a fibrous outer boundary. When cancer cells push through this boundary, it is called extraprostatic extension.

Your report may describe extraprostatic extension as:

Focal. A small amount of cancer is present just outside the prostate in only one or two areas.
Established (or non-focal). A larger or more widespread amount of cancer is present outside the prostate.

Focal extraprostatic extension carries a lower risk of recurrence than established extraprostatic extension. Your doctor will consider the extent of extraprostatic extension, along with margins and grade, when assessing your overall risk and deciding whether additional treatment is needed.

Seminal vesicle invasion

The seminal vesicles are two small glands that sit behind and above the prostate. They are removed together with the prostate during radical prostatectomy. If cancer cells have spread directly into the wall of one or both seminal vesicles, this is called seminal vesicle invasion.

Seminal vesicle invasion places the cancer in the pT3b stage and is associated with a higher risk of cancer recurring after surgery. Your doctor may recommend additional treatment, such as radiation to the prostate bed or hormone therapy, if seminal vesicle invasion is found.

Surgical margins

The surgical margin is the outer edge of the tissue removed during surgery. Before the prostate is examined under the microscope, the pathologist inks the outer surface so that the edges can be precisely identified. Margins are one of the most closely watched findings in a prostatectomy report, because they indicate whether the surgeon was able to remove all of the cancer.

Negative margins

A negative surgical margin means that no cancer cells were found at the inked outer edge of the removed prostate. This is the desired result. It means the cancer appears to have been fully removed with a rim of normal tissue around it. A negative margin does not guarantee that the cancer will not recur, because microscopic cancer cells may sometimes remain in the surrounding area even when the margin looks clear, but it is a favorable finding.

Positive margins

A positive surgical margin means that cancer cells were found at the inked outer edge of the specimen. This indicates that cancer cells were present right at the cut surface, which may mean that some cancer cells remain in the body at that location. The report will describe:

Location. Where the positive margin is found, such as the apex (the tip of the prostate), the posterior surface (near the rectum), the bladder neck, or another specific site.
Extent. How much of the margin is involved, sometimes described as focal (a very small area) or extensive (a larger area).
Grade at the margin. The Gleason grade of the cancer cells present at the margin, since high-grade cancer at a positive margin carries a greater risk of recurrence.

A positive margin increases the risk of PSA recurrence after surgery — meaning your PSA level may rise again after the operation, suggesting remaining cancer cells are still active. Your doctor will monitor your PSA closely after surgery and discuss whether radiation therapy to the prostate bed is appropriate.

Perineural invasion

Perineural invasion means that cancer cells have been found alongside or wrapped around a nerve fiber within the prostate. Nerves travel along specific pathways through and around the prostate, and cancer cells can sometimes travel along these pathways.

Perineural invasion is commonly seen in prostate cancer and its presence alone does not necessarily change treatment decisions after a radical prostatectomy. However, when perineural invasion is found at or near a positive surgical margin, or in combination with other high-risk features, it contributes to the overall picture that your doctor uses to guide follow-up care.

Lymphovascular invasion

Lymphovascular invasion means that cancer cells have been found inside the thin-walled channels of blood vessels or lymphatic vessels within the prostate tissue. Lymphatic vessels carry a fluid called lymph and connect to lymph nodes, where immune cells are concentrated. Blood vessels carry blood throughout the body.

When cancer cells enter these channels, they have a potential route to travel to lymph nodes or to distant organs such as the bones or lungs. Lymphovascular invasion is associated with a higher risk of cancer spread and recurrence and contributes to the overall risk assessment your doctor makes after surgery.

Intraductal carcinoma

Intraductal carcinoma of the prostate is a pattern in which cancer cells fill and expand the existing ducts and glands of the prostate without breaking through the surrounding tissue. Although it is technically contained within the ductal system, intraductal carcinoma is almost always found alongside high-grade invasive prostate cancer, and its presence is a marker of aggressive disease.

When intraductal carcinoma is identified in your radical prostatectomy specimen, it is noted in the report separately from the invasive cancer. It is not assigned its own Gleason grade, but its presence contributes to the overall assessment of aggressiveness and may influence treatment decisions.

Lymph nodes

If a pelvic lymph node dissection was performed, the lymph nodes that were removed will be examined separately. The pathologist counts the total number of lymph nodes found in the submitted tissue, examines each one under the microscope, and reports whether any contain cancer.

Your report will state the number of lymph nodes examined and the number that contain cancer. If cancer is found in a lymph node, the report will also note the size of the cancer deposit and whether the cancer has spread beyond the lymph node into the surrounding fatty tissue, which is called extranodal extension.

Finding cancer in pelvic lymph nodes (pN1) is associated with a higher risk of the cancer spreading to other parts of the body and typically prompts a discussion about additional systemic treatment.

Other findings that may appear in your report

The pathologist examines the entire prostate specimen and may note findings beyond the cancer itself. These additional findings are part of a thorough examination and provide a complete picture of the prostate.

High-grade prostatic intraepithelial neoplasia (HGPIN). This is a precancerous change in the prostate gland cells. It is very commonly found alongside prostate cancer in radical prostatectomy specimens and does not require separate treatment after surgery.
Benign prostatic hyperplasia (BPH). Non-cancerous enlargement of the prostate is extremely common in older men and is often found incidentally in the specimen. It does not affect the management of the cancer.
Inflammation. Inflammatory cells are sometimes found in the prostate tissue. This is usually incidental and does not affect cancer management.
Perineural invasion in the fat outside the prostate. If cancer cells are found tracking along nerves in the fatty tissue outside the prostate (rather than inside the gland itself), this is noted specifically, as it may indicate a higher risk of local recurrence.

What happens after the pathology report is finalized?

Once your surgeon and oncologist have reviewed the pathology report, they will discuss the findings with you and explain what they mean for your follow-up plan.

After a radical prostatectomy, your PSA level should fall to an undetectable level, usually below 0.1 ng/mL, within a few weeks of surgery. This is because the prostate, which produces PSA, has been removed. Your doctor will monitor your PSA at regular intervals after surgery. A PSA that begins to rise after surgery — called a biochemical recurrence or PSA recurrence — is often the earliest sign that cancer cells may still be present somewhere in the body. If your PSA rises, your doctor will discuss options including radiation therapy to the prostate bed, hormone therapy, or other treatments depending on the pattern of the rise and the pathology findings.

The pathology report findings that most strongly influence the risk of PSA recurrence after surgery are the Grade Group, the pT stage, the margin status, and whether lymph nodes contain cancer. Your doctor will use all of these together, along with your PSA trajectory after surgery, to guide your care.

Questions to ask your doctor

What is my Grade Group, and what does it mean for my risk of recurrence?
Was the cancer confined to the prostate, or did it extend beyond the prostate?
Were my surgical margins negative or positive, and if positive, where and how extensive?
Was seminal vesicle invasion found?
Were lymph nodes removed, and if so, did any contain cancer?
Based on my pathology report, what is my overall risk of cancer recurrence?
How often will my PSA be monitored after surgery, and what PSA level would concern you?
At what PSA level would you recommend considering additional treatment such as radiation therapy?
Are there any features in my report that suggest I might benefit from hormone therapy?
Should I be referred to a radiation oncologist to discuss whether radiation therapy is recommended?