Michael Baboudjian

Background MRI-targeted biopsy (TBx) combined with ipsilateral systematic sampling is increasingly endorsed as an alternative to full bilateral systematic prostate biopsy (SBx). However, biopsy variables are constituent input to the nomograms guiding extended pelvic lymph node dissection (ePLND) and nerve-sparing surgery (NSS) decisions; the consequences of omitting contralateral SBx for nomogram-based surgical planning remain undefined. The COBRA study assessed the impact of contralateral SBx omission on Briganti 2019–derived lymph node invasion (LNI) estimates and on Gandaglia 2019–derived predictions of extracapsular extension (ECE), seminal vesicle invasion (SVI), and upgrading. Materials and Methods Multicentre retrospective cohort of 959 patients who underwent pre-biopsy MRI, combined TBx + SBx, and radical prostatectomy at six European centres (2018–2024). Patients were stratified by MRI lesion pattern into unifocal (n = 765), multifocal ipsilateral (n = 57), and bilateral (n = 137) cohorts. For each patient, nomogram estimates were computed with full bilateral systematic data (reference) versus ipsilateral-only inputs and compared as paired data. Results For ePLND planning, ipsilateral-only and full bilateral inputs were highly concordant across all lesion patterns (agreement 93–96%; κ 0.86–0.92), with comparable pN1 discrimination (unifocal AUC 0.70 vs 0.69; p = 0.3); candidate-selection discordance was minimal and, in the unifocal cohort, involved no pN1 disease. Conversely, ipsilateral-only inputs systematically overestimated ECE and SVI probabilities (median ECE 56.7% vs 60.1%; SVI 9.2% vs 11.1%) and reduced specificity, reclassifying many patients to higher risk without pathological confirmation, most notably for SVI (confirmed in only 4/112 upclassified patients). Conclusions Contralateral SBx omission does not meaningfully alter Briganti 2019–derived ePLND recommendations, with ipsilateral-only and full bilateral inputs producing comparable LNI estimates. The same omission, however, systematically overestimates Gandaglia-based ECE and SVI predictions; ipsilateral-only data therefore cannot be used interchangeably for nerve-sparing decisions and should not be entered into these models without recalibration.

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 CO ₂ equivalents (CO ₂ ‐eq; 95% confidence interval [CI] 58.8–162) for indwelling catheterisation, 39.8 kg CO ₂ ‐eq (95% CI 31.2–53.3) for disposable CISC catheters, and 16.1 kg CO ₂ ‐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.

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.

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