Changing Face of Radical Prostatectomy: A Nationwide Registry Study of Case-Mix, Surgical Evolution, and Outcomes

Background/Objectives: We aimed to evaluate temporal changes in patient selection, surgical practice, and postoperative outcomes of radical prostatectomy in Switzerland (2020–2025) using a national registry. Methods: Data from 7687 patients undergoing radical prostatectomy were extracted from a prospective national registry (January 2020–March 2025). Preoperative, operative, and postoperative variables were compared descriptively using the Mann–Whitney U test for continuous variables and the chi-square test for categorical variables. Temporal trends were assessed using locally estimated scatterplot smoothing. Multivariable logistic regression analyses were performed for positive surgical margins and PSA persistence. Results: Baseline patient characteristics remained stable over time. The use of MRI-targeted biopsy increased from 46% to 84% (p < 0.001). The proportion of low-risk diseases being treated decreased from 7.1% to 4.0% (p = 0.040). Minimally invasive surgery increased from 81% to 95% (p < 0.001); pelvic lymph node dissection declined from 83% to 63% (p < 0.001). Operative time (205 vs. 185 min, p = 0.002) and blood loss (300 vs. 200 mL, p < 0.001) decreased over time. Lymph node invasion decreased from 11% to 6.0% (p = 0.001), positive surgical margins from 27% to 22% (p = 0.044), and prostate-specific antigen persistence from 18.5% to 11.3% (p = 0.001). Severe postoperative complications decreased from 2.5% to 0.8% (p = 0.014). After multivariable adjustment, surgery performed in 2024 remained independently associated with lower rates of positive surgical margins (OR 0.73, 95% CI 0.57–0.93) and PSA persistence (OR 0.26, 95% CI 0.19–0.37) compared with 2020. Conclusions: Using the Swiss national registry, we demonstrate that radical prostatectomy has evolved toward more risk-adapted patient selection, near-universal minimally invasive surgery, and more selective pelvic lymph node dissection. Despite a shift away from low-risk disease, perioperative and early oncological outcomes improved, likely reflecting a combination of evolving diagnostic pathways, increasing surgical experience, and broader changes in perioperative management.