Introduction: Preoperative needle biopsy-based risk classification for prostate cancer is the basis for treatment choice, especially in resource-limited settings like Cameroon. However, there is evidence that it underestimates the tumor risk when compared to postoperative whole-tumor pathology. We conducted a retrospective study in a single urological center in Douala to compare preoperative biopsy-based tumor parameters with postoperative findings from transperitoneal laparoscopic total prostatectomy, hypothesizing that preoperative assessment underestimates tumor risk.

Methods: We analyzed clinical records of 130 patients with prostate adenocarcinoma treated between 2015 and 2025 at a urological center in Douala, Cameroon. All patients underwent 12-core prostate biopsy under local anesthesia (lidocaine without adrenaline), with preoperative Gleason score, International Society of Urological Pathology (ISUP) grade group, and tumor risk category (low, intermediate, or high) recorded. Within one month, all patients underwent transperitoneal laparoscopic total prostatectomy, and postoperative histological parameters were recorded. McNemar’s chi-squared test assessed discordance between preoperative and postoperative risk classifications.

Results: The mean age of our participants was 60.99±6.06 years. Overall, there was a statistically significant difference between tumor risk determined via biopsy and risk determined via whole-sample histology. Biopsy-based risk assessment frequently underestimates true tumor risk compared to postoperative pathology from the prostatectomy specimen, confirming substantial discordance between the two sampling methods.

Conclusion: Preoperative biopsy-based tumor risk classification significantly underestimates true tumor risk in prostate adenocarcinoma. In low-resource settings where patients cannot afford repeat surgeries, clinicians must interpret biopsy risk categories cautiously and consider clinical and biological parameters to anticipate undergrading.