Xpert Bladder Cancer (BC) is an mRNA-based urine assay for diagnosis and surveillance of urothelial carcinoma. Although previous meta-analyses have examined Xpert, none has evaluated its accuracy in both BC detection and non-muscle-invasive bladder cancer (NMIBC) surveillance, while also exploring its potential role in guiding repeat transurethral resection (re-TURBT) and in the diagnostic evaluation of upper tract urothelial carcinoma (UTUC). We systematically assessed the diagnostic accuracy of Xpert in all these clinical settings, integrating grade-specific analysis and formal evidence-certainty assessment. PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched to January 2026 (PROSPERO: CRD420251184275). Sensitivity and specificity were pooled using bivariate random-effects models; PPV and NPV using univariate models. Grade-specific sensitivity was pooled across 13 studies with tumour-grade-stratified data. Evidence certainty was assessed using GRADE-DTA. Publication bias was evaluated with Deeks' funnel plots. Twenty-six studies (8613 patients) were included. For Detection (k = 8, where k denotes the number of cohorts pooled), pooled sensitivity was 0.83 (95% CI 0.73-0.90) and specificity 0.77 (0.65-0.86); NPV was 0.96. For Monitor (k = 15), sensitivity was 0.71 (0.63-0.77) and specificity 0.78 (0.70-0.85); NPV was 0.91. Grade-specific pooling showed high-grade (HG) sensitivity of 0.89 (0.83-0.93) in Detection and 0.80 (0.71-0.87) in Monitor, versus 0.60 for low-grade (LG) in both settings; heterogeneity was not statistically significant for HG estimates. Re-TURBT (k = 2) and UTUC (k = 2) were exploratory, with encouraging NPV but limited by sparse events. Evidence certainty was low for sensitivity/NPV and very low for specificity/PPV. No publication bias was detected. Xpert demonstrates high sensitivity and NPV, particularly for HG disease, supporting its role as an adjunctive rule-out tool. Grade-adapted interpretation is warranted. Prospective validation with standardised grade-specific reporting is needed.

BACKGROUND AND OBJECTIVE:Targeted plus perilesional biopsies are recommended for men with prostate lesions visible on magnetic resonance imaging. However, available data are mainly retrospective, without predefined biopsy scheme protocols. The MRI-Integrated Regional and targeted Approach, recommendations, and Guidelines for prostate biopsies (MIRAGE) study is the first prospective European study designed to evaluate the outcomes when perilesional biopsies are incorporated deliberately into the biopsy protocol. METHODS:MIRAGE was a prospective, observational, multicenter study conducted across ten European centers between January and June 2025. We enrolled 912 men with a single Prostate Imaging Reporting and Data System (PI-RADS) ≥3 lesion. Targeted and perilesional biopsies were mandated, while distant biopsies (ie, cores taken beyond the perilesional zone) were left to the discretion of investigators. Detection rates of Gleason grade (GG) group ≥2 and 1 lesions were calculated separately for each scheme: targeted, perilesional, and distant biopsies. KEY FINDINGS AND LIMITATIONS:Targeted biopsy detected GG group ≥2 lesions in 380 men (41%). Compared with targeted biopsy alone, perilesional sampling increased GG group ≥2 lesion detection by +3.6% at the cost of +1% GG group 1 lesion detection. The greatest benefit of perilesional sampling was observed in biopsy-naïve men and those with PI-RADS 4-5 lesions. Conversely, in those with PI-RADS 3 or a prior negative biopsy, perilesional sampling yielded more cases of GG group 1 than of GG group ≥2. Distant sampling provided minimal incremental GG group ≥2 (contralateral: +1.6%; ipsilateral: +1.4%) but more GG group 1 (contralateral: +2.5%; ipsilateral: +2.9%) cases. CONCLUSIONS AND CLINICAL IMPLICATIONS:The MIRAGE study provides prospective evidence that, when a targeted plus perilesional biopsy strategy is applied, distant biopsies add minimal diagnostic benefit and should be omitted.

Background:Lower urinary tract symptoms (LUTS) and pain are clinically relevant problems after transurethral resection (TURBT) of nonmuscle-invasive bladder cancer. Although intravesical instillation of hyaluronic acid has already been proven to be a valid treatment for storage LUTS and pain in patients with inflammatory bladder syndrome, its efficacy in patients who undergo TURBT is unknown. This study aimed to present the results of a prospective, randomized, controlled, clinical pilot study on the safety and clinical performance of HydealCyst (Fidia Farmaceutici S.p.A., Italy), a device formulated to provide progressive, long-lasting intravesical release of hyaluronic acid. Materials and methods:Adults diagnosed with nonmuscle-invasive bladder cancer and scheduled for TURBT were included and underwent 4 visits up to 25 days after TURBT. Of the 47 patients who completed the investigation, 25 participants received 2 postoperative intravesical instillations with HydealCyst. The efficacy of HydealCyst on storage LUTS, pain, urinary symptoms, and patients' quality of life was evaluated using validated questionnaires. Results:Although the overall LUTS were similar in the 2 experimental groups, lower micturition frequency and fewer daytime micturitions were observed in patients treated with HydealCyst. These patients also showed a significant reduction in pain (p = 0.03) 3 days after catheter removal and better quality of life at the end of the study. The device was well tolerated, with no treatment-emergent adverse events of severe intensity. Conclusion:The results from this pilot study indicate a clinically meaningful improvement of symptoms after 2 instillations of HydealCyst, supporting this intervention as a potentially effective treatment for LUTS and pain after TURBT.

BACKGROUND AND OBJECTIVE:The transperineal (TP) route is recommended for prostate biopsy due to its superior safety profile. However, randomized evidence comparing the TP and the transrectal (TR) routes was generated through combined targeted and systematic biopsy frameworks, now challenged by lesion-focused strategies, defined as the combination of targeted (TB) and perilesional (PB) sampling without distant systematic cores. This study aimed to reassess the diagnostic performance of TP versus TR biopsy with the recommended TB + PB scheme. METHODS:This prospective multicenter, observational study was conducted across 10 European institutions between January 2025 and June 2025. We included 912 men with at least one magnetic resonance imaging (MRI)-visible lesion (Prostate Imaging-Reporting and Data System version 2.1 ≥3) who underwent either TP or TR MRI-targeted biopsy according to predefined TB + PB protocols. The primary outcome was the detection rate of clinically significant prostate cancer (csPC; Gleason Grade [GG] Group ≥2). KEY FINDINGS AND LIMITATIONS:TP biopsy detected more csPC than TR (48% vs 39%; OR [odds ratio]: 1.41, 95% CI [confidence interval]: 1.06-1.88; p = 0.017) without increasing the detection of insignificant PC (insPC) (18% vs 23%; p = 0.06). In multivariable mixed-effects analysis accounting for center-level clustering, the TP route remained independently associated with csPC detection (adjusted OR: 1.61, 95% CI: 1.17-2.23; p = 0.004). Limitations include limited power in selected subgroups and potential inter-center heterogeneity inherent to the observational design. CONCLUSIONS AND CLINICAL IMPLICATIONS:Within a standardized lesion-focused TB + PB framework, TP biopsy was independently associated with higher csPC detection without increasing insPC detection. This study focuses on diagnostic performance and does not provide direct comparative data on biopsy-related complications or patient-reported outcomes.

OBJECTIVES:To demonstrate the reliability and diagnostic accuracy of fluorescence confocal microscopy (FCM) analysis of surgical margins during minimally invasive radical prostatectomy (RP). PATIENTS AND METHODS:From January 2022 to February 2023, we enrolled 100 consecutive patients in this single-centre, prospective, non-randomised trial (C2021/32). The VivaScope® 2500M-G4 microscope (Mavig GmbH, Munich, Germany), a laser scanning microscope designed for rapid acquisition of high-resolution digital images, was employed. Following surgery, each posterolateral prostatic margin was analysed using FCM and reviewed by two expert urological pathologists. This study aimed to assess the accuracy of FCM in evaluating surgical margins during RP, comparing the diagnostic accuracy of FCM to final anatomical pathology (AP) and assessing the inter-rater agreement between two urological pathologists (Cohen's kappa agreement). RESULTS:A total of 100 patients (i.e., 200 surgical margins) were included. Overall, 37 margins in 33 patients were positive according to FCM. At final pathology, 38 specimens in 29 patients were positive. On a per-patient analysis sensitivity, specificity, positive predictive value, and negative predictive value of FCM were 65.5%, 80.2%, 57.5%, and 85.0%, respectively. On a per-margin analysis, they were 60.5%, 91.3%, 62.1%, and 90.7%, respectively. The inter-rater agreement was 0.64 and 0.61 for per-patient and per-margin analysis, respectively. CONCLUSIONS:Fluorescence confocal microscopy is a feasible technology to be employed during RP, offering a good diagnostic accuracy without distorting final AP.

Background/Objectives: The transperineal (TP) approach has progressively replaced the transrectal (TR) approach for prostate biopsy because of its improved safety profile. However, its impact on the detection of clinically significant prostate cancer (csPCa), particularly within modern lesion-focused biopsy strategies that combine targeted and perilesional sampling, remains uncertain. We aimed to evaluate the real-world diagnostic impact of transitioning from a TR systematic-based biopsy strategy to a TP lesion-focused approach. Methods: We conducted a retrospective single-centre study including consecutive men who underwent image-guided prostate biopsy between 2018 and 2025. Only patients with a single MRI-visible lesion (PI-RADS ≥ 3) were included. Two biopsy strategies were compared: TR systematic biopsy (TR-SBx), combining targeted and systematic cores, and TP lesion-focused biopsy (TP-LFx), combining targeted and perilesional cores. The primary outcome was the detection of csPCa (Gleason Grade Group ≥ 2). Secondary outcomes included detection of Gleason Grade Group 1 cancer and negative biopsies. Inverse probability of treatment weighting (IPTW) based on a propensity score was applied to adjust for baseline differences. Doubly robust weighted logistic regression models were used, with predefined subgroup and sensitivity analyses. Results: Among 1032 included patients, 931 underwent TR-SBx and 101 TP-LFx. After restriction to the region of common support, 528 patients were retained for IPTW analyses. In the IPTW-adjusted analysis, TP-LFx was associated with higher csPCa detection compared with TR-SBx (adjusted odds ratio [OR] 2.52, 95% confidence interval [CI] 1.40-4.52; p = 0.002) and with lower detection of Gleason Grade Group 1 cancer (OR 0.50, 95% CI 0.27-0.92; p = 0.03). Subgroup analyses suggested a stronger association in patients with prior negative biopsy and in anterior or apical lesions. Conclusions: In routine clinical practice, transitioning from a transrectal systematic-based biopsy strategy to a transperineal lesion-focused approach was associated with improved detection of csPCa and reduced overdiagnosis. These findings support the consideration of transperineal, lesion-focused MRI-guided biopsy strategies in contemporary prostate cancer diagnostics.

Background and Objective: Transurethral resection of bladder tumor (TURBT) is the standard for non-muscle-invasive bladder cancer (NMIBC), yet recurrence rates remain high. This study evaluates the safety, tolerability, and efficacy of neoadjuvant intravesical mitomycin C (neoMMC) before TURBT in reducing recurrence and improving surgical outcomes. Methods: This randomized phase III trial enrolled patients with primary or recurrent NMIBC. Participants were randomized 1:1 to a neoadjuvant group receiving two instillations of MMC (day -14 and -7) before TURBT, or a control group undergoing standard TURBT without neoadjuvant treatment. The primary endpoint was 12-month recurrence-free survival (RFS). Secondary endpoints included surgical quality (complete resection, cauterization only, absence of residual tumor) and safety. Exploratory endpoints included histopathologic response and time to recurrence. Key Findings and Limitations: Among 95 patients (48 neoMMC, 47 controls), baseline characteristics were balanced. After a median follow-up of 19.4 months, recurrences occurred in 9 StA and 4 NeoA patients, with one progression to MIBC in the NeoA arm. RFS did not differ significantly between groups at 12 or 18 months. Neoadjuvant MMC was well tolerated, with only grade 1-2 AEs. Exploratory microbiota analyses suggested that neoadjuvant MMC modulated urinary microbial diversity and was associated with a microbiota profile more similar to that observed in non-recurrent patients. Limitations include single-center design and relatively short follow-up. Conclusions and Clinical Implications: Neoadjuvant intravesical MMC before TURBT was feasible and well tolerated in patients with NMIBC, with no unexpected safety signals. In this prematurely terminated and underpowered trial, no significant improvement in RFS was observed. Larger adequately powered studies are needed to clarify the oncologic efficacy of this approach.

PURPOSE:While mitomycin C (MMC) is widely used for intravesical therapy, the optimal maintenance regimen for non-muscle invasive bladder cancer (NMIBC) remains unclear. This study assessed the impact of MMC maintenance on recurrence-free survival (RFS) in patients with intermediate-risk Ta NMIBC and aimed to identify the optimal number of instillations for improved outcomes. METHODS:We conducted a retrospective multicenter analysis of patients with Ta NMIBC treated with transurethral resection and adjuvant MMC across 13 Italian centers (2010-2023). Patients were grouped based on MMC maintenance duration: no maintenance, short-term (≤ 6 instillations), and long-term (> 6 instillations). Kaplan-Meier curves, Cox regression, and CART analysis were used to evaluate RFS and high-grade RFS (HG-RFS). RESULTS:Among 292 patients included, maintenance therapy significantly improved 2-year and 3-year RFS compared to no maintenance (78% vs. 55% and 67% vs. 30%, respectively; p < 0.001). CART analysis identified > 6 instillations as the threshold for optimal benefit. Long-term maintenance was associated with a lower risk of recurrence (HR 0.23 vs. no maintenance; HR 0.39 vs. short-term; both p < 0.001). No significant difference in HG-RFS was observed between no maintenance, long-term, and short-term groups. CONCLUSION:Long-term MMC maintenance (> 6 instillations) significantly prolongs RFS in patients with Ta NMIBC. These findings suggest that extended MMC regimens may improve patients' outcomes and should be considered in clinical practice. Prospective studies are needed to confirm these results and guide evidence-based treatment strategies.

OBJECTIVE:To identify the most environmentally sustainable urinary drainage strategies commonly used to manage bladder outlet obstruction and also to highlight actionable levers for reducing the footprint of urinary drainage in clinical practice. MATERIALS AND METHODS:We conducted a comparative life cycle assessment of three urinary drainage strategies (i.e., indwelling urinary catheter, clean intermittent self-catheterisation [CISC], and temporary urethral stent) over a 30-day period, in accordance with International Organization for Standardization (ISO) 14040 and ISO 14044 standards. Primary data were collected via device disassembly and manufacturer consultation, with secondary data from the Ecoinvent version 3.9 database (Ecoinvent, Zurich, Switzerland). Impacts were modelled using the Environmental Footprint 3.0 method across 13 categories. Sensitivity analyses tested care delivery parameters and reusable catheters for CISC. RESULTS:The mean climate change impact over 30 days was 96.5 kg CO2 equivalents (CO2-eq; 95% confidence interval [CI] 58.8-162) for indwelling catheterisation, 39.8 kg CO2-eq (95% CI 31.2-53.3) for disposable CISC catheters, and 16.1 kg CO2-eq (95% CI 8.4-29.2) for the stent. Indwelling catheterisation consistently showed the highest impact, CISC intermediate, and the stent the lowest. Relative to catheterisation, the stent reduced climate impact by 83%, fossil resource use by 83%, and water consumption by 92%. Reusable CISC catheters showed a comparable profile to the stent. Sensitivity analyses confirmed that home nurse travel, device replacement frequency, and patient autonomy substantially influenced overall impact. Limitations include the mono-country design. CONCLUSIONS:Device choice and care delivery models critically affect the environmental footprint of urinary drainage strategies. This study provides further strong arguments for promoting existing alternatives to the indwelling urinary catheter.

OBJECTIVE:Active surveillance (AS) is the preferred management for individuals with low-risk prostate cancer (PCa), but its role in intermediate-risk (IR) disease remains underreported. Given growing interest and published data, we performed an updated systematic review and meta-analysis to evaluate AS outcomes in selected patients with Gleason Grade Group (GG) 1-2 IR PCa. METHODS:A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD420251138532). PubMed/MEDLINE, Embase, and Web of Science databases were searched for studies published up to September 2025 reporting outcomes of AS in IR PCa. Primary outcomes were AS discontinuation-free survival and GG ≥3 upgrade-free survival. RESULTS:In total, 18 studies, including 3783 selected patients with IR PCa, were analyzed. Pooled AS discontinuation-free survival rates were 70% (95% confidence interval [CI] 62-78) at 3 years, 63% (95% CI 58-68) at 5 years, and 53% (95% CI 38-67) at 10 years. In analyses restricted to GG 2 cohorts, corresponding pooled estimates were 72% at 3 years, 56% at 5 years, and 40% at 10 years. GG ≥3 upgrade-free survival was 84% (95% CI 76-92) at 3 years and 78% (95% CI 65-91) at 5 years in all cohorts and 92% (95% CI 86-98) and 87% (95% CI 78-95) at 3 and 5 years in cohorts screened using multiparametric magnetic resonance imaging. No significant difference in AS discontinuation was observed between biopsy GG 1 and 2 (hazard ratio 1.08; 95% CI 0.86-1.35). Limitations include moderate risk of bias and heterogeneity across AS protocols. CONCLUSIONS:Although long-term data are lacking, particularly regarding robust oncological outcomes, growing evidence suggests that AS appears oncologically safe in well-selected patients. Magnetic resonance imaging will play a key role in the appropriate selection and follow-up of patients.

BACKGROUND AND OBJECTIVE:Current European Association of Urology guidelines universally recommend a second transurethral resection (ReTUR) for all T1 non-muscle-invasive bladder cancer (NMIBC) cases. However, ReTUR is an invasive and costly procedure that is often negative for residual disease, and may represent overtreatment in appropriately selected patients who have undergone complete initial TUR. Our aim was to report 2-yr oncological outcomes and confirm the safety of a novel, response-guided strategy with selective ReTUR for patients with T1 NMIBC. METHODS:The prospective, observational, multicenter HuNIRe trial enrolled patients with T1 NMIBC from 2020 to 2024. Patients with complete TUR underwent urine cytology at 3-4 wk and cystoscopy at 4-6 wk. ReTUR was performed only if cytology was positive (Paris system 3-6) or disease was detected on cystoscopy; otherwise, patients proceeded directly to bacillus Calmette-Guérin (BCG) induction therapy. The primary endpoints were 2-yr recurrence-free survival (RFS) and progression-free survival (PFS). Secondary endpoints included comparison of outcomes between the groups with and without ReTUR, and between the overall HuNIRe cohort and a retrospective cohort of patients with T1 NMIBC who underwent routine ReTUR. Kaplan-Meier estimates and the log-rank test were used for survival analysis. KEY FINDINGS AND LIMITATIONS:A total of 90 patients were prospectively enrolled. The protocol successfully avoided ReTUR in 71% (n = 64) of patients, who proceeded directly to BCG therapy. Only 29% (n = 26) of the patients required ReTUR according to early evaluation; importantly, no patient was upstaged to MIBC at ReTUR. After median follow-up of 26 mo, 2-yr survival rates for the entire cohort were 69% for RFS and 91% for PFS. There were no significant differences between the groups with and without ReTUR in RFS (p = 0.9) or PFS (p = 0.6). Oncological outcomes were also comparable between the HuNIRe cohort and a retrospective cohort that underwent routine ReTUR (2-yr RFS: 74% vs 74%; 2-yr PFS: 91% vs 92%). CONCLUSIONS AND CLINICAL IMPLICATIONS:Results from the HuNIRe trial confirm that a risk-adapted approach to ReTUR in selected patients with T1 NMIBC after complete initial TUR is feasible, although oncological outcomes should be interpreted with caution owing to the short follow-up. This strategy spared 71% of patients from ReTUR, and could support a tailored, response-guided approach rather than the blanket guideline recommendation for ReTUR.

BACKGROUND AND OBJECTIVE:Same-day discharge (SDD) after robot-assisted radical prostatectomy (RARP) is increasingly adopted as a standard of care. This systematic review and meta-analysis assess the safety and effectiveness of SDD compared with conventional inpatient (IP) management. METHODS:A literature search was conducted in accordance with PRISMA guidelines using PubMed/MEDLINE, Embase, Web of Science, and Scopus databases up to February 2025, including only comparative studies reporting on SDD versus IP RARP. The primary endpoint was postoperative complication rates. Secondary endpoints included 30-day readmission rates, unplanned postoperative visits, and patient-reported satisfaction. Subgroup analysis focused on studies involving single-port (SP) robotic platforms. KEY FINDINGS AND LIMITATIONS:Nineteen studies were included, encompassing 11 211 SDD and 114 999 IP cases. Overall complication rates were lower in the SDD group (odds ratio [OR]: 0.65, 95% confidence intervals [CI]: 0.50-0.84, p < 0.001). The pooled OR favored the outpatient group for both minor and major complications (OR: 0.52, 95% CI: 0.28-0.98, p = 0.042). No significant differences were found in 30-d readmissions (OR: 0.89, 95% CI: 0.77-1.02, p = 0.082), unplanned visits (odds OR: 0.61, 95% CI: 0.35-1.07, p = 0.081), or continence recovery. In the SP subgroup, no differences were observed in major complications (OR: 0.71, 95% CI: 0.39-1.29; p = 0.7) or readmission rates (OR: 1.88, 95% CI: 0.56-6.39, p = 0.3). The main limitation was the retrospective design of most studies. CONCLUSIONS AND CLINICAL IMPLICATIONS:The available evidence does not allow reliable causal comparisons between SDD and inpatient care after RARP; however, perioperative outcomes within SDD cohorts appear acceptable, supporting the feasibility of SDD in carefully selected patients.

Purpose of review Urothelial carcinoma demonstrates high prevalence and is characterized by significant clinical heterogeneity. As treatment options expand, therapeutic decisions become more complex, giving multidisciplinary teams (MDT) a crucial role. This review summarizes current evidence on the impact of a multidisciplinary approach on outcomes in urothelial carcinoma. Recent findings Most urothelial carcinoma data derive from bladder cancer studies, where MDT have a substantial impact on diagnostic accuracy, improved staging quality and treatment recommendations. MDT often implement treatment changes such as the addition of intravesical or systemic therapies and improve adherence to clinical guidelines. This is associated with improved patient outcomes, although data on the effect on patient survival remains limited. Summary The therapeutic landscape for urothelial carcinoma is rapidly evolving with the implementation of new therapeutic options, making multidisciplinary collaboration essential for personalized treatment strategy. MDT ensure optimal diagnostical pathways, establishment of comprehensive treatment strategies, and thus potential survival benefits.

BACKGROUND AND OBJECTIVE:Magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion guided biopsy is the cornerstone of prostate cancer (PC) diagnosis. While prior studies have focused on detection rates, the impact of fusion registration methods-elastic registration techniques (ERT) versus rigid registration techniques (RRT)-on International Society of Urological Pathology (ISUP) grade concordance remains underexplored. Our objectives were to assess the effect of ERT versus RRT on the concordance between targeted biopsy (TBx) and overall biopsies (OBx) for detection of (1) clinically significant PC (csPC; defined as ISUP grade ≥2) and (2) high-grade PC (hgPC; defined as ISUP grade ≥3) in biopsy-naïve men with confirmed PC. METHODS:Our multicenter retrospective study included 888 biopsy-naïve men with confirmed PC (prostate-specific antigen ≤20 ng/ml, cT1-2, Prostate Imaging-Reporting and Data System [PI-RADS] score 3-5) who underwent MRI-TRUS fusion guided biopsy using ERT (n = 479) or RRT (n = 409) at two high-volume institutions. After 1:1 propensity score matching (PSM) to control for confounding, a sample of 674 patients was included in the final analysis. The primary endpoint was the concordance of csPC detection between TBx and OBx. Secondary endpoints included concordance for hgPC detection (ISUP grade ≥3) between TBx and OBx, concordance for hgPC (ISUP grade ≥3) between systematic biopsy (SBx) and OBx, biopsy sampling metrics, and subgroup analyses for PI-RADS 3 lesions. Multivariable logistic binomial regression models adjusted for clinical and imaging covariates were tested. KEY FINDINGS AND LIMITATIONS:There was a significant difference in the frequency of csPC concordance between the ERT and RRT groups (60.2% vs 33.6%; p < 0.0001). Moreover, the ERT approach was associated with significantly higher odds of being classified as concordant csPC in comparison to RRT (adjusted odds ratio [aOR] 4.82, 95% confidence interval 2.82-8.24). ERT was also significantly associated with higher odds of hgPC concordance after adjusting for PSA density, clinical TNM stage and PI-RADS score (aOR 2,51, 95% confidence interval 1.51-4.16; corrected p = 0.0014). ERT reduced overgrading of ISUP grade 1 lesions (12.5% vs 39.2%; p < 0.001). Despite lower core volume and fewer positive cores, ERT achieved similar maximum cancer core length, suggesting superior spatial targeting. PI-RADS 3 subgroup analyses showed favorable trends for ERT, although the results were not statistically significant (p >0.05). CONCLUSIONS AND CLINICAL IMPLICATIONS:ERT was associated with better concordance for detection of both csPC and hgPC on TBx, supporting more accurate risk stratification while reducing detection of indolent cancer. While our findings indicate diagnostic advantages for ERT over RRT, prospective multicenter studies with centralized pathology review are warranted for external validation and evaluation of the downstream clinical impact.