Background: Active surveillance (AS) is the recommended approach for managing Grade-Group1 (GG1) prostate cancer (PCa). Incorporating MRI at entry improve patient selection and outcomes.

Objective: To evaluate long-term oncological outcomes of patients receiving AS selected with MRI at entry.

Materials and Methods: Retrospective analysis of a single-center cohort of patients selected for AS from 2007 to 2022. Inclusion criteria were GG1 PCa with MRI prior to systematic and targeted biopsies. A per-protocol rebiopsy at one year has not been part of the AS inclusion criteria since 2015. Main outcome was cumulative incidence of: biopsy grade reclassification, AS discontinuation, active treatment, post active-treatment biochemical recurrence, metastasis, and mortality. Secondary outcome was the identification of risk factors for AS discontinuation.

Results: Cohort consists of 354 men. Median follow-up is 6.3 years (IQR:3.2-9.1). Median PSA was 6.3ng/ml (5.0 to 8.5). At 10 years post-diagnosis, the cumulative incidence was 29.6% (95%CI:23.3%-36.2%) for grade reclassification, 40.0% (95%CI:32.8%-47.0%) for AS discontinuation, 36.9% (95% CI: 30.0 to 43.7) for active treatment, 9.4% (95% CI: 3.7-18.4) for post active-treatment biochemical recurrence and 0.5% for metastatic progression (2 patients). No PCa-related deaths were observed. PIRADS score, and the number of positive biopsies at inclusion were identified as predictive factors for AS discontinuation.

Conclusion: In this cohort of AS patients with MRI at entry, 60% of men remained on AS at 10 years, with less than 1% developing metastatic disease and no PCa-related mortality. These results support AS management with MRI at entry and add to share decision-making with patients.