<b><i>Introduction:</i></b> In current study, we compared the accuracy of the PSA isoform p2PSA and its derivatives, the percentage of p2PSA to free PSA (%p2PSA) and the Prostate Health Index (PHI) in the detection of prostate cancer (PC) characteristics at the &#xFB01;nal pathology with respect to reference standards. <b><i>Materials and Methods:</i></b> This was an observational prospective study evaluating 43 consecutive PC patients treated with laparoscopic/robotic radical prostatectomy (RP). Logistic regression models were &#xFB01;tted to test the predictors of pT3 stage, pathologic Gleason score ≥8 or Gleason score upgrading, margin status, lymph node invasion, and the presence of high-risk disease (pT3 disease and/or Gleason score ≥8 and/or positive lymph node). The comparative base model included tPSA, clinical stage, biopsy Gleason score, and percentage of positive core. <b><i>Results:</i></b> Seventeen patients (39.5%) were affected by pT3 disease or had a pathologic Gleason score ≥8; positive margins were detected in 12 patients (27.9%), lymph node invasion was found in 2 patients (4.7%), and 15 patients (34.8%) harbored high-risk disease. In the univariate analysis, p2PSA, %p2PSA, and PHI were signi&#xFB01;cant predictors of pT3 disease, pathologic Gleason score, and the presence of high-risk disease (all p < 0.05), whereas only PHI was an independent predictor of pT3 disease, margin status, and presence of high-risk disease, increasing the accuracy of a base multivariable model by 6.3% (p < 0.05) and 4.2% (p < 0.05) for the prediction of pT3 and high-risk disease, respectively. <b><i>Conclusions:</i></b> p2PSA and its derivatives, primarily PHI, were signi&#xFB01;cant predictors of unfavorable PC characteristics as detected at the &#xFB01;nal pathology, thus improving the clinical performance of standard prognostic factors for aggressive disease.