Background/Objectives:Targeted High-Intensity Focused Ultrasound (HIFU) is an emerging treatment option for localized prostate cancer (PCa), aiming to balance oncological control with functional preservation. However, data on the feasibility and outcomes of salvage robotic-assisted radical prostatectomy (sRARP) after targeted HIFU remain limited. This study aimed to evaluate feasibility, functional and early oncological outcomes of sRARP in this specific setting. Methods:Among 112 men treated with targeted HIFU for localized prostate cancer, 15 underwent sRARP between June 2022 and June 2025. The primary outcome was surgical feasibility and safety, assessed by conversion rate, operative time, nerve-sparing approach, lymphadenectomy, positive surgical margins (PSM) at frozen section and final pathology, and intraoperative complications. Secondary outcomes included urinary continence (full or social continence at 1 year), erectile function (with or without phosphodiesterase type 5 inhibitors at 1 year), PSA levels at 45 days and one year after surgery, and postoperative complications. Results:All procedures were completed robotically without intraoperative complications or conversions. Bilateral nerve-sparing was performed in 13 patients (87%). PSM were found in three (20%) patients at frozen section and in two patients (13%) at final pathology; one patient (11%) had lymph node metastases. Early complications occurred in three patients (20%), with only one Clavien Dindo grade ≥3 event. At 1-year follow-up, one patient (8%) had PSA >0.2 ng/mL; nine patients (75%) were continent and six (50%) reported preserved erectile function. The median follow-up was 14 months (IQR 10.8-16.5; 95% CI). Conclusions:sRARP after targeted HIFU is feasible and safe, with favorable early oncological and functional outcomes. These findings suggest that targeted HIFU may be a viable option in selected patients, without compromising future curative strategies in case of recurrence.

BACKGROUND AND OBJECTIVE:Magnetic resonance imaging (MRI)-led active surveillance (AS) for prostate cancer uses prostate-specific antigen (PSA) and MRI for regular monitoring with biopsy only when indicated by changes in MRI or PSA density. METHODS:This clinical cohort, which started AS between February 2000 and July 2023, includes those with (1) Gleason score (GS) ≤3 + 4, (2) PSA <20 ng/ml, and (3) at least two MRI scans. The primary outcome was event-free survival (EFS) defined as histological upgrade to GS ≥4 + 3 or transition to treatment. Patients were risk stratified by baseline MRI visibility and Gleason pattern 4, and Kaplan-Meier curves were used to compare groups. KEY FINDINGS AND LIMITATIONS:The cohort consisted of 1150 patients with a median follow-up of 64 mo per person overall (quartiles: 32, 107). At baseline, of these 1150 patients, 412 (36%) had GS 3 + 4, 627 (55%) had an MRI-visible lesion, and 201 (17%) had MRI-visible Gleason 3 + 4 disease. The EFS rate at 5 yr was 91% (95% confidence interval: 88-94%) for nonvisible GS 3 + 3, 71% (65-78%) for MRI-visible GS 3 + 3, 70% (63-78%) for nonvisible GS 3 + 4, and 44% (35-54%) for MRI-visible GS 3 + 4. A total of 487 patients had follow-up biopsies, with 74 having more than one, and histological upgrade to GS ≥4 + 3 was uncommon, occurring in 67 patients. Progression to nodal or bone metastases occurred in ten patients and only in those who had declined the recommended follow-up MRI and/or biopsies. Thirty patients chose treatment despite having stable characteristics, and 31 were lost to follow-up. CONCLUSIONS AND CLINICAL IMPLICATIONS:MRI visibility and secondary Gleason pattern 4 at baseline are associated with progression to treatment and to primary Gleason pattern 4 during MRI-led AS.

OBJECTIVES:To improve sensitivity and inter-reader consistency of prostate cancer localisation on micro-ultrasonography (MUS) by developing a deep learning model for automatic cancer segmentation, and to compare model performance with that of expert urologists. PATIENTS AND METHODS:We performed an institutional review board-approved prospective collection of MUS images from patients undergoing magnetic resonance imaging (MRI)-ultrasonography fusion guided biopsy at a single institution. Patients underwent 14-core systematic biopsy and additional targeted sampling of suspicious MRI lesions. Biopsy pathology and MRI information were cross-referenced to annotate the locations of International Society of Urological Pathology Grade Group (GG) ≥2 clinically significant cancer on MUS images. We trained a no-new U-Net model - the Prostate Micro-Ultrasound Network (ProMUS-NET) - to localise GG ≥2 cancer on these image stacks in a fivefold cross-validation. Performance was compared vs that of six expert urologists in a matched sub-cohort. RESULTS:The artificial intelligence (AI) model achieved an area under the receiver-operating characteristic curve of 0.92 and detected more cancers than urologists (lesion-level sensitivity 73% vs 58%; patient-level sensitivity 77% vs 66%). AI lesion-level sensitivity for peripheral zone lesions was 86.2%. CONCLUSIONS:Our AI model identified prostate cancer lesions on MUS with high sensitivity and specificity. Further work is ongoing to improve margin overlap, to reduce false positives, and to perform external validation. AI-assisted prostate cancer detection on MUS has great potential to improve biopsy diagnosis by urologists.

Background/Objectives: This study evaluates and compares the diagnostic accuracy of [68Ga]Ga-PSMA-11 and [18F]F-PSMA-1007 for lymph node staging in patients with prostate cancer (PCa) scheduled for robot-assisted radical prostatectomy (RARP) and lymphadenectomy (LND). Methods: We retrospectively reviewed prospectively collected data on patients referred to our hospital from October 2020 to January 2023. We included all patients who underwent [68Ga]Ga-PSMA-11 or [18F]F-PSMA-1007 PET/CT for primary staging and subsequently had RARP with concomitant LND. The maximum standard uptake value (SUVmax) for lymph nodes (LNs) and the SUV node-to-background ratio were reported. Two different cut-off values for the SUV node-to-background ratio (i.e., ≥2 vs. <2 and ≥15.5 vs. <15.5) were used to evaluate the diagnostic performance of both tracers. The first cut-off was empirically chosen, while the second was based on Liu’s method. Results: A total of 156 patients were included (median age: 67 years). Among them, 83 underwent [68Ga]Ga-PSMA-11 and 73 underwent [18F]F-PSMA-1007 PET/CT. Suspicious lymph nodes were identified in 21 patients (13.5%). Pathological nodal involvement (pN1) was confirmed in 25 cases (16%). Of the 21 patients with suspicious pathological lymph nodes on PSMA PET/CT, 9 (42.9%) had positive nodes on the final pathology report. With an SUV node-to-background ratio cut-off of ≥2, [68Ga]Ga-PSMA-11 showed 37.5% sensitivity (SE) and 98.5% specificity(SP), while [18F]F-PSMA-1007 demonstrated 33.3% SE and 100% SP. Using the ≥15.5 cut-off, SE and SP were 31.3% and 100% for [68Ga]Ga-PSMA-11 and 11.1% and 100% for [18F]F-PSMA-1007, respectively. Conclusions: [18F]F-PSMA-1007 PET/CT showed, even if not statistically significantly, slightly lower SE and higher SP for nodal staging compared to [68Ga]Ga-PSMA-11 PET/CT, irrespective of the SUV ratio used.

INTRODUCTION:Multiparametric (mp) magnetic resonance imaging (MRI) is essential for prostate cancer (PCa) detection but is limited by availability, cost, and complexity. Micro-ultrasound (microUS) offers real-time, high-resolution imaging and may enhance clinically significant (cs) prostate cancer (PCa) detection when used with mpMRI. This study updates the diagnostic performance of microUS compared to mpMRI in a large prospective cohort. MATERIALS AND METHODS:We prospectively enrolled 1, 423 men with suspected PCa between October 2017 and April 2024. All patients underwent imaging with the ExactVu system, followed by both microUS-targeted and MRI-targeted biopsies. The primary outcome was the accuracy of detecting csPCa, defined as Gleason score ≥3 + 4 (International Society of Urological Pathology Grade Group ≥2), comparing microUS, mpMRI, and their combined use. RESULTS:CsPCa was diagnosed in 116 (36.3%) patients. MicroUS detected lesions in 1, 076 out of 1, 423 patients (76%) of patients, with a sensitivity of 85% and a negative predictive value of 79% for csPCa. Concordance between microUS and mpMRI findings was 96%. In total, 252 patients (18%) were diagnosed with PCa solely on targeted cores. Among these, 25 csPCa cases were identified exclusively by microUS-targeted and 4 by MRI-targeted biopsies. However, systematic biopsies still identified 22% of csPCa cases missed by both targeted approaches. CONCLUSION:MicroUS, especially when combined with mpMRI, significantly enhances csPCa detection. This combined imaging approach may reduce the need for systematic biopsies. Further advancements in microUS technology could refine its diagnostic utility.

The Prostate Imaging after Focal Ablation (PI-FAB) score has been recently proposed for scoring the appearance on multiparametric magnetic resonance imaging (mpMRI) of prostate cancer after focal therapy. The progressive implementation of prostate specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) into the management of prostate cancer has revolutionized the diagnostic work-up and inspired our proposal for a dedicated PSMA Focal Ablation Imaging (PSMA-FAB) scoring system. Based on pre- and post-treatment imaging, the classification is categorized into: PSMA-FAB 1 (continue monitoring); PSMA-FAB2 (assess PSA kinetics and MRI, with biopsy to be considered in case of suspicion); and PSMA-FAB 3 (recommend biopsy). Furthermore, a combined Focal-therapy Imaging Response Evaluation Score (FIRE-SCORE) embedding PI-FAB and PSMA-FAB scores is suggested to help patient’s management at follow up.

The presence of histologically defined prostate cancer (PCa) is common and rises with age. Nevertheless, histological evidence of PCa does not always lead to clinically evident or life-threatening disease, and we know that PSA-based population screening can find twice the prevalence of PCa than would present via clinical routes. The PROTECT study randomized men diagnosed through PSA screening, to surgery, radiotherapy, or active monitoring. At 15 years, PCa-related deaths ranged from 2.1