Welcome back to your Saturday PSAWeekly.

This week's thread is prediction versus proof: across the specialty, long-awaited outcome and consensus data are testing whether our defaults still hold. Ten-year registry results ask whether focal therapy can stand alongside radical treatment for prostate cancer, a 34-expert Delphi effort tries to standardize what's long been left to individual habit in prostate biopsy, and inter-radiologist data puts MRI response assessment to the test before we let it guide bladder-sparing decisions. Elsewhere, a VR-based 3D prostate model, a systematic review of fistula recurrence, and a fresh look at UTI/STI risk in young adults all ask the same underlying question: when checked against real outcomes, does the established approach still win?

This week's issue covers:

This prospective single-center study explored whether virtual reality-based 3D prostate models could serve as a useful preoperative and intraoperative tool during robot-assisted radical prostatectomy (RARP), focusing on two questions: how well these models match final histopathology, and whether VR-measured membranous urethral length (MUL) predicts early return of urinary continence.

Researchers built 3D VR reconstructions for 35 men with localized prostate cancer undergoing nerve-sparing RARP, using a CNN-assisted segmentation workflow applied to preoperative MRI. These models were compared against final pathology specimens for extraprostatic extension and seminal vesicle invasion, and MUL was measured directly on the 3D models by blinded biomedical engineers.

The VR models showed excellent agreement with actual pathology ; correctly identifying extraprostatic extension with high accuracy (94.3%, near-perfect agreement) and catching every case of seminal vesicle invasion with no false positives. Complications were minimal, and no patients needed transfusions. Continence recovery was strong overall, reaching 91.4% of patients by 6 months. Notably, men with longer membranous urethral length (as measured on the VR models) needed fewer pads afterward, and a cutoff of 14mm was identified as predicting which patients would regain continence earlier, though this threshold performed only moderately well as a specificity marker.

The authors frame this as hypothesis-generating rather than definitive: with only 35 patients from one center and 6-month follow-up, the findings need validation in larger multicenter trials before VR-based planning can be considered superior to conventional MRI approaches. Still, they suggest these models may aid nerve-sparing decisions, patient counseling, and surgical training.

This Polish cross-sectional online survey looked at how common urinary tract infections (UTIs) and sexually transmitted infections (STIs) are among university students, along with the behaviors that raise risk for each. Researchers surveyed 617 students (average age 21, about 79% women) between July and November 2025.

Roughly half of participants had been diagnosed with a UTI at some point, and nearly 38% had experienced repeat infections. Being sexually active, having relatives with a history of UTIs, holding in urine, and not drinking enough fluids each independently raised the odds of infection, with sexual activity showing the strongest link. Repeat infections were tied to these same factors plus regular use of intimate hygiene products like washes or foams, which may disturb the natural vaginal flora.

On the sexual behavior side, about 78% of respondents were currently sexually active, and having more partners along with more frequent oral and vaginal sex correlated with higher UTI rates. Around 10% of sexually active respondents reported having engaged in chemsex. Despite this, STI screening was uncommon: only about 18% had ever tested for HIV and under 6% had tested for chlamydia, gonorrhea, or syphilis. Awareness of prevention tools like PrEP or doxycycline post-exposure prophylaxis was low, and most students said social media and the internet were their main sources of sexual health information rather than clinicians.

Around 15% of students had treated a UTI on their own without seeing a doctor, most often using the over-the-counter drug furazidine, raising concerns about antibiotic misuse and resistance.

The authors conclude that young adults carry a substantial UTI burden and that risky sexual behavior is common but rarely accompanied by adequate STI testing, pointing to a need for better education (delivered through the online channels students already use) and expanded access to screening and non-antibiotic prevention strategies.

Limitations: self-reported data (recall/social-desirability bias), a female-heavy sample limiting generalizability to men, and no effect-size/CI reporting for the non-parametric behavioral comparisons.

This UK study pooled data from two nationally mandated prospective registries (HEAT for HIFU, ICE for cryotherapy) to report 10-year cancer control results after focal ablative therapy for localized prostate cancer. The cohort included 3,477 men treated at 14 UK centers between 2004 and 2024, most of whom received HIFU rather than cryotherapy. Notably, nearly half the group had favorable intermediate-risk disease, but a substantial share (about a quarter each) had unfavorable-intermediate or high-risk disease, a population usually excluded from focal therapy studies.

The treatment protocol allowed up to two focal ablation sessions per patient. At 10 years, death specifically from prostate cancer was extremely rare (0.13%), and only about 3% of patients developed metastatic spread. Overall survival at 10 years was around 88%, and roughly 14% of men eventually needed hormone therapy. When counting every further procedure, about a third of patients underwent repeat local treatment and about 30% eventually moved to radical treatment (surgery or radiotherapy). However, when the authors applied stricter criteria to identify only those who truly needed radical treatment for medical reasons (rather than those who could have simply had another round of focal ablation), those figures dropped sharply, to roughly 13% needing further local treatment and under 9% needing radical treatment.

A separate analysis of patients who stayed cancer- and recurrence-free for at least seven years showed the good outcomes held steady into years 10–12, with no additional cancer deaths appearing later. Outcomes were fairly similar whether patients received HIFU or cryotherapy, and, importantly, differences between risk groups were modest. Even high-risk patients did reasonably well, despite current guidelines generally reserving focal therapy for intermediate-risk cases only.

The authors argue these results, the largest and longest-term dataset of its kind, support offering focal HIFU or cryotherapy as a legitimate first-line option for well-selected patients rather than only radical surgery or radiation. They call for future work on a dedicated risk-prediction tool for patient selection, more evidence in high-risk disease specifically, and better methods for detecting and managing cancer that recurs after focal treatment.

Limitations include the inherent biases of registry-based (non-randomized) data and inconsistent local protocols for deciding when patients moved on to additional treatment.

This systematic review pulled together 21 studies (published 1994–2025) to identify which surgical and patient factors best predict whether a vesicovaginal fistula (VVF) repair will fail or recur. VVF, an abnormal opening between the bladder and vagina causing constant urine leakage, is usually fixed successfully on the first attempt (80–95% success), but 10–30% of cases still fail or come back. Because the underlying causes, patient populations, and surgical methods varied so much across studies, the authors combined findings narratively rather than running a formal meta-analysis.

Several factors consistently stood out as raising the risk of recurrence: a fistula larger than 2–3 cm, significant scarring or fibrosis around the fistula, involvement of the urethra or bladder neck, and having more than one fistula tract. Other contributors included longer-standing fistulas, active urinary infection at the time of surgery, and greater anatomical complexity as measured by classification systems like the Goh or Panzi scales. Notably, having undergone a prior failed repair did not consistently predict a worse outcome across studies; the evidence there was mixed.

On the positive side, several factors were linked to better outcomes: catching and treating the fistula early, having the operation done by experienced surgeons at specialized fistula centers, and using tissue interposition (such as Martius or omental flaps) during repair, especially in complex or previously irradiated cases. The review also found that how "success," "failure," and "recurrence" were even defined varied a lot between studies, which itself contributes to inconsistent reported rates.

Where the fistula originates differs by region: in lower-resource settings it's usually linked to prolonged obstructed labor, while in wealthier countries it's more often caused by pelvic surgery (especially hysterectomy) or radiation treatment. Most included studies carried a low-to-moderate risk of bias, with newer prospective studies generally better designed than older retrospective series.

The authors conclude that using these known risk factors, alongside standardized fistula classification systems, could help clinicians better predict who is at risk for repair failure and tailor treatment accordingly. They call for more prospective research, consistent outcome definitions, and better predictive models to help close outcome gaps between regions.

This study, drawing on 115 patients across three prospective trials (NABUCCO, TURANDOT, and PURE-01), examined how well MRI can track how muscle-invasive bladder cancer responds to immunotherapy given before surgery, and whether different radiologists reading the same scans agree with each other. Patients underwent scanning both before and after immunotherapy, and multiple radiologists independently scored the images using several standard methods, ranging from qualitative staging systems (like tumor stage classification or a simple visual 1-to-5 response scale) to quantitative measurements (tumor diameter or full tumor volume).

The researchers found that agreement between radiologists was reasonably good for qualitative visual scoring, but it was the semi-automatic volume measurement approach, where an AI tool draws an initial tumor outline that the radiologist then corrects, that produced the most consistent results across readers. All the assessment methods were fairly good at predicting which patients had achieved a complete pathological response (meaning no cancer cells left after surgery), but tracking the percentage change in tumor volume over time gave the best combination of consistency between readers and predictive accuracy.

The team also checked whether MRI-based volume changes lined up with two other biological measures: DNA fragments shed by tumors into the blood (ctDNA) and how densely packed cancer cells were in tissue samples. Both showed a moderate relationship with the MRI volume findings, suggesting the imaging results reflect real biological changes in the tumor rather than just measurement noise.

The authors conclude that AI-assisted volume measurement on MRI is a promising, reliable way to track how bladder tumors are responding to immunotherapy, and could eventually help identify patients who might be able to skip bladder removal surgery. However, they stress this needs to be confirmed in further prospective studies before it's used to actually guide treatment decisions, and note that their analysis only looked at the primary bladder tumor, not whether cancer had spread to nearby lymph nodes.

This paper reports the results of ProBIOPSY, an international expert consensus project aimed at standardizing how prostate biopsies are performed, given the wide variation currently seen across centers in patient selection, tools, technique, and biopsy strategy. A group of 34 experts from urology, radiology, radiation oncology, pathology, and nuclear medicine reviewed the existing evidence and then went through three rounds of structured voting (a modified Delphi process) on a growing list of statements, ultimately reaching agreement on 29 of 36 topic areas.

On imaging, the panel agreed that a shorter MRI protocol without contrast (biparametric MRI) works just as well as the full multiparametric version, as long as image quality is good, and this holds true whether MRI is used in an opportunistic or an organized screening setting. They stressed that formal image-quality checks are essential. There was no agreed cap on how many suspicious MRI lesions should be reported when several are visible. For unclear or indeterminate lesions, PSA density and, in some cases, added contrast imaging or a validated risk calculator were considered useful next steps. Newer tools like PSMA PET scans and micro-ultrasound were not endorsed as replacements for MRI, though PSMA PET was considered reasonable as a backup test when MRI is negative but suspicion remains high. AI tools were seen as acceptable for flagging suspicious areas on MRI before a radiologist's own review, though evidence here is still limited.

On the biopsy procedure itself, the panel settled on the term "perilesional biopsy" for extra needle samples taken around the MRI target, recommending these be taken within 10mm of the lesion, with the number of cores adjusted by lesion size. The combination of targeted plus perilesional biopsy was agreed to be the standard approach for diagnosing cancer in most cases with visible lesions on MRI. The transperineal approach (through the perineum rather than the rectum) was strongly favored as the standard route, done with local nerve-block anesthesia, and preventive antibiotics were generally not needed unless the patient had specific infection risk factors.

Where things got more complicated was in deciding how much biopsy sampling is needed to plan specific treatments. For nerve-sparing surgery, whole-gland or focal radiotherapy planning, and deciding how long a patient should stay on hormone therapy, the panel agreed that targeted plus perilesional biopsy alone was generally sufficient. However, for selecting patients for focal (partial-gland) therapy, they agreed that additional systematic sampling from the opposite side of the prostate was still necessary, to avoid missing cancer that wasn't visible on MRI. No consensus was reached on the best biopsy approach for planning pelvic lymph node removal.

The authors conclude that while targeted-plus-perilesional biopsy can serve as a strong general standard, no single biopsy strategy fits every treatment-planning scenario, meaning biopsy approaches still need to be tailored to the specific decision being made.

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