Urology

MRI-first, contrast-free screening improves clinically significant prostate cancer detection versus PSA-triggered MRI

In this single-center randomized trial (n = 759), all-comers biparametric MRI screening detected more clinically significant prostate cancer than PSA-triggered MRI (4.6% vs 1.8%). Biopsy and csPCa detection were higher in the MRI-first arm, with a relative risk for csPCa of 2.6 (95% CI 1.1–6.1). Benefit–harm metrics favored MRI-first, including higher grade selectivity, better biopsy efficiency, and greater biopsy avoidance. The MRI-first pathway showed an incremental cost-effectiveness ratio of about €2200 per additional csPCa detected, with no serious adverse events reported. 1

PET-guided, dose-escalated salvage RT improves event-free survival versus historical non–dose-escalated therapy

EMPIRE-2 randomized men with postprostatectomy biochemical recurrence and negative conventional imaging to [18F]-fluciclovine or [68Ga]-PSMA-11 PET, guiding dose-escalated salvage radiotherapy. Compared with the earlier EMPIRE-1 fluciclovine-guided but non–dose-escalated cohort, 2-year event-free survival improved from 80% to 87%. After propensity weighting, 2-year event-free survival was 84% in EMPIRE-2 versus 73% in EMPIRE-1, an 11% absolute gain (p = 0.01). Within EMPIRE-2, fluciclovine and PSMA had nearly identical 2-year event-free survival (87% vs 88%), suggesting benefit mainly from PET-guided dose escalation rather than tracer selection. 2

Docetaxel adds limited benefit to RT plus long-term ADT in high-risk localized prostate cancer

This ICECaP individual patient data meta-analysis pooled 1690 men with high-risk localized prostate cancer treated with radiotherapy plus long-term ADT ± docetaxel. Docetaxel did not significantly improve metastasis-free or overall survival (HR 0.89 and 0.88, respectively) despite modest event-free survival gains (HR 0.87). Prostate cancer–specific mortality improved (HR 0.70), but without a corresponding overall survival advantage. Benefits were similar in high- and very-high-risk subgroups, with no significant interaction by risk category. Findings argue against routine docetaxel intensification for all high-risk localized patients and support more selective, biomarker-driven use. 3

Real-world Aquablation shows very low bleeding and transfusion risk across prostate sizes

This prospective corporate database captured 70,270 Aquablation cases from 2019 to 2024 across Asia, Europe, and North America. Mean prostate volume was 87.3 mL, with treated glands up to 1189 mL, demonstrating use across an extremely broad size range. The combined rate of blood transfusion or return to the operating room for haemostatic fulguration was only 0.2%. Aquablation therefore appears to maintain a favorable bleeding safety profile across routine and extreme prostate sizes in real-world practice. 4