Andrea Mari

Objective: To evaluate patterns and imaging-based predictors of positive surgical margins (PSMs) in patients with high-risk prostate cancer (PCa) undergoing nerve-sparing (NS) robot-assisted radical prostatectomy (RARP). Materials and Methods: We retrospectively analyzed 1,235 consecutive patients with high-risk PCa treated with RARP between 2022 and 2024 at a high-volume tertiary referral center. Among them, 533 patients underwent preoperative multiparametric MRI (mpMRI) reviewed by two expert uro-radiologists and MRI–ultrasound fusion biopsy. A per-side analysis was performed to identify predictors of ipsilateral PSMs in cases where neurovascular bundle (NVB) preservation was attempted. Biochemical recurrence (BCR) was assessed, and multivariable logistic regression was used to determine independent predictors of PSMs. Results: Overall, 36.1% of patients underwent non–nerve-sparing surgery, 49.5% unilateral NS, and 14.4% bilateral NS. Nerve sparing was performed on 418 surgical sides, with ipsilateral PSMs detected in 90 (21.5%). Sides with and without PSMs showed comparable nerve-sparing techniques (intra- vs interfascial) and similar 3-year BCR-free survival rates (68% vs. 69%) at a median follow-up of 36 months, although earlier biochemical failure at lower PSA thresholds was more frequent in PSM-positive sides. On multivariable analysis, larger prostate volume, apical tumor location, peripheral zone involvement, greater lesion diameter, and extracapsular extension on mpMRI were independently associated with an increased risk of ipsilateral PSMs. Conclusions: Nerve-sparing RARP may be feasible in carefully selected high-risk PCa patients. The integration of mpMRI-based predictors can enhance patient selection, optimizing the balance between oncologic safety and functional preservation. Prospective studies are warranted to validate these findings and minimize selection bias.

Objective: To evaluate the early oncological outcomes of patients treated with robot-assisted radical prostatectomy for prostate cancer with multiple PIRADS lesions at baseline mpMRI in a tertiary referral center. Methods: Data of consecutive patients undergoing robot-assisted radical prostatectomy between 2020 and 2022 at a high-volume tertiary referral center were prospectively collected. mpMRI data was evaluated by two expert uro-radiologists at our center. All patients received an MRI–ultrasound fusion biopsy. Results: Overall, 286 patients with multiple PIRADS lesions treated with robot-assisted radical prostatectomy at a tertiary referral center were included. Unilateral and bilateral nerve-sparing were achieved in 63 (22.3%) and 124 (43.1%) patients, respectively. Median age was 69 years (IQR: 64–72), while median Charlson Comorbidity Index was 3 (IQR: 2–4). The presence of two PIRADS lesions was found in the 81.8% of cases, while 18.2% presented with three or more. Bilateral lesions were observed in 67.4% of cases. The dominant lesion was PIRADS 4 in 57.3% and PIRADS 5 in 32.3% of cases, with a median diameter of 12 mm (IQR: 10–17). Pathological upstaging to pT3 occurred in 61% of patients. Overall, 9.8% of cases exhibited positive surgical margins (PSMs), most of them single and limited in extent. Postoperative major complications were recorded in 6.3% of patients. At a median follow-up of 18 months (IQR: 6–29), biochemical recurrence (BCR) occurred in 8% of patients. Patients with PIRADS 5 lesions experienced shorter BCR-free survival compared to those with PIRADS 3–4. On multivariable Cox regression, PIRADS 5 independently predicted biochemical recurrence (HR: 2.52; 95% CI: 1.10–5.80; p = 0.029), after adjustment for age, number of lesions, and nerve-sparing status, with the performance of nerve-sparing not associated with an increased risk of recurrence, including in patients with multifocal disease. Conclusions: Nerve-Sparing Robot-Assisted Radical Prostatectomy in patients with multiple PIRADS lesions achieves encouraging short-term oncologic outcomes, with biochemical recurrence-free survival exceeding 84% at 3 years, despite high rates of multifocality and pathological upstaging.

Low-risk prostate cancer (PCa) has historically been overtreated, exposing men to unnecessary morbidity. Emerging evidence supports conservative management of low-risk PCa without immediate radical intervention. Contemporary data show a marked decline in surgical overtreatment, with the proportion of radical prostatectomies yielding only Grade Group 1 cancers falling from 32.4% in 2010 to 7.8% in 2020 in the US SEER registry. Long-term studies confirm that deferring treatment is safe for low-risk disease, with PCa-specific survival exceeding 95% at 15–25 years for cohorts managed with surveillance. Major guidelines now endorse active surveillance (AS) as the preferred management for low-risk PCa. An alternative risk stratification system that expands the low-risk category was shown to reclassify 45–83% more men as low risk without increasing 15-year PCa mortality. Focal therapy has emerged as a potential middle-ground strategy, though evidence is still limited. The paradigm for managing low-risk PCa has shifted toward conservatism, with AS firmly established as the standard of care. Continued efforts to refine risk stratification and evaluate focal therapy are needed to further optimize individualized care, minimize harm, and maintain excellent cancer-specific outcomes for low-risk PCa. This comprehensive review aims to create a practical, risk-adapted framework for managing patients on AS. We will: (i) summarize inclusion criteria and outcomes, (i) compare AS follow-up schedules across major institutions and guidelines, (iii) provide evidence-based criteria to de-intensify surveillance in men with sustained stability and (iv) clarify the role of focal therapy as an intermediate treatment option within the AS continuum.

Objective: To validate International Bladder Cancer Group (IBCG) definitions of Bacillus Calmette‐Guérin (BCG)‐unresponsive and BCG‐exposed non‐muscle‐invasive bladder cancer (NMIBC) and assess prognostic heterogeneity across various BCG‐failure types. Patients and Methods: From a multicentre international cohort of 3806 BCG‐treated patients, 591 who developed high‐grade NMIBC recurrence following BCG between 2003 and 2024 were included. Progression‐free survival (PFS) was the primary endpoint; cancer‐specific (CSM) and overall mortality (OM) were secondary endpoints. Cumulative incidence functions, competing‐risk models and multivariable Cox regression were used. Results: Patients with BCG‐unresponsive and BCG‐exposed disease showed similar PFS, CSM, and OM (all P > 0.05). When stratified into five subgroups, prognosis varied: 5‐year progression rates were 29% for BCG‐unresponsive, 32.5% for late relapse (between 6 and 24 months) after adequate BCG, 30% for BCG‐exposed with inadequate BCG (24 months since last BCG) ( P < 0.01). In multivariable analysis, BCG‐exposed after inadequate BCG (subdistribution hazard ratio [sHR] 3.42, 95% confidence interval [CI] 1.33–8.84), late relapse (sHR 3.74, 95% CI 1.59–8.78), and BCG‐unresponsive (sHR 2.34, 95% CI 1.00–5.44) were associated with higher progression risks compared to very late relapse. Limitations include retrospective design and treatment heterogeneity. Conclusions: Under IBCG definitions, BCG‐unresponsive and BCG‐exposed NMIBC have similarly poor outcomes. A refined classification reveals prognostic heterogeneity, with late relapses after adequate BCG demonstrating outcomes comparable to BCG‐unresponsive, and very late relapses conferring better prognosis.

Objective: To develop a data‐driven risk‐stratification model to identify high‐risk patients following radical cystectomy (RC) for bladder cancer and propose a risk‐adapted follow‐up (FU) schedule. Patients and Methods: We performed a retrospective analysis of an individual patient data registry comprising 3196 patients with clinical T stage (cT)2–T4 N0M0 bladder cancer who underwent RC at 16 European centres (1990–2024). All treatment decisions, including the use of neoadjuvant chemotherapy, adjuvant therapy, and the FU schedule, were made at the discretion of the treating physician in accordance with the patient's preference. A Classification and Regression Tree (CART) analysis, incorporating pathological T and N stages, lymphovascular invasion (LVI), and other features, was used to stratify patients into Low‐Risk and High‐Risk groups for recurrence. The primary endpoint was recurrence‐free survival (RFS). We used a landmark analysis to evaluate the conditional risk of recurrence at 1, 2, 3, 4, and 5 years after RC. Results: At a median FU of 81.8 months, 891 patients recurred. CART analysis identified a High‐Risk group (pathological T stage [pT]3–pT4, node‐positive disease, or pT2 with LVI) with significantly worse 5‐year RFS than the Low‐Risk group (37.8% vs 76.2%; P < 0.001). This stratification was strongly prognostic for recurrence (hazard ratio [HR] 4.29; 95% confidence interval 3.63–5.00), cancer‐specific survival (subdistribution HR 5.80), and overall survival (HR 3.04) (all P < 0.001). Landmark analysis confirmed that the elevated risk persisted up to 4 years; however, the conditional risk for event‐free patients converged after 5 years (HR 1.37; P = 0.3). Conclusions: This study establishes a simple, pathologically derived model (pT3–4/pN+/pT2 + LVI) that effectively stratifies post‐RC patients, enabling a risk‐adapted FU strategy. Prospective evaluation of this framework is required to confirm its clinical utility, safety, and cost‐effectiveness.

Objective: To evaluate the prognostic impact of T‐stage at re‐transurethral resection of bladder (TURB) and its utility for refining risk stratification across European Association of Urology 2021 (EAU21) risk groups in patients with T1 high‐grade (HG) non‐muscle‐invasive bladder cancer (NMIBC) treated with adequate Bacillus Calmette–Guérin (BCG). Patients and Methods: Retrospective multicentre study including patients with primary or secondary T1HG NMIBC treated with TURB, re‐TURB, and adequate BCG between 2007 and 2020 across 28 European academic centres. Patients were stratified according to re‐TURB pathological stage (T0, Ta, Tis, T1) and EAU21 risk groups. Kaplan–Meier, Cox regression, and competing‐risk methods were used to evaluate recurrence‐free survival (RFS), HG‐RFS, progression‐free survival (PFS), and cancer‐specific mortality (CSM). A mixture cure model estimated statistical cure fractions for the overall cohort. Results: Among 1403 patients, residual disease at re‐TURB was identified in 38.8%, including 17.7% with persistent T1. Residual T1 was consistently associated with worse outcomes. Compared with T0/Ta, persistent T1 at re‐TURB showed substantially lower 5‐year HG‐RFS and PFS, with high‐grade recurrence in over half of patients and 5‐year progression up to 48% in high‐ and very high‐risk groups. The 5‐year CSM rose from 6–7% (T0/Ta) to 23% (T1). On multivariable analysis, residual T1 was independently associated with worse HG‐RFS (hazard ratio 2.40), PFS (hazard ratio 3.10), and CSM (hazard ratio 3.00). Cure modelling showed lower cure fractions for residual T1 compared with T0/Ta. Conclusion: Residual T1 at re‐TURB is strongly associated with adverse long‐term oncological outcomes in BCG‐treated T1HG NMIBC and markedly reduces the likelihood of statistical cure. High‐ and very high‐risk patients with persistent T1 represent a biologically adverse subgroup in whom standard BCG may be insufficient.

Background: With the rapid advancement of artificial intelligence (AI), its applications in andrology are expanding across diagnostic assessment, preoperative planning, intraoperative assistance, and postoperative management. This narrative review aims to synthesize current evidence regarding AI applications across the spectrum of andrological surgery. Methods: A comprehensive literature search was conducted using the PubMed, Scopus and Web of Science databases to identify relevant studies published between January 2020 and October 2025. The search strategy utilized combinations of keywords including “artificial intelligence,” “andrology,” “erectile dysfunction,” “male infertility,” “microsurgery,” and “robotic-assisted surgery.” Original research and review articles published in English were selected based on their clinical relevance to surgical practice. Results: AI has shown promise in the evaluation and management of erectile dysfunction (ED), male infertility-related microsurgery, and complex reconstructive procedures. AI-based models can improve risk prediction and diagnosis of ED, standardize semen analysis, support individualized selection of surgical candidates for varicocele repair and other interventions, and augment microsurgery through enhanced visualization and decision support. In the postoperative phase, AI-driven tools are being explored for complication prediction, functional recovery monitoring, and long-term quality-of-life follow-up, enabling more patient-centered, continuous care. Conclusions: AI holds significant promise for advancing precision medicine in andrological surgery by enhancing objective assessment and intraoperative guidance. However, large-scale, standardized datasets and rigorous multi-institutional validation are needed. Establishing robust ethical and legal frameworks will be essential to ensure the safe and effective integration of AI into routine andrological care.