Editor's Note: The following is from the January 2025 issue of The Journal of Urology^®. Visit the The Journal of Urology Current Issue page to access these articles. Reprinted with permission from Siemens DR. Editor's Choice. J Urol. 2025;313(1):1-2. doi:10.1097/JU.0000000000004306

Incorporating MRI Findings into Active Surveillance: Are Systematic Biopsies Still Needed?

How are you incorporating MRI into your active surveillance (AS) practice? The question about how to use such imaging information to guide subsequent biopsies as we watch these men carefully is the subject of 2 important studies in [the January 2025] issue of The Journal of Urology^®.

First, Bhanji et al¹ evaluated the necessity of confirmatory biopsy in men with Grade Group (GG) 1 prostate cancer considering AS among 522 men. In this cohort from Johns Hopkins, reclassification was more common in patients with positive MRI, with 27% moving to GG ≥ 2 and 16% to unfavorable intermediate risk, compared with 9.2% and 5.5%, respectively, in those with negative MRI. In this cohort, systematic biopsy captured approximately one-third of reclassification events. The authors suggest that for men with positive MRI, both systematic and targeted confirmatory biopsies are still recommended to ensure accurate risk assessment. Furthermore, men with GG1 cancer and negative MRI (at an expert center) may safely defer confirmatory biopsy, especially as these men will continue close monitoring.

The second related manuscript is from Fakunle et al² who report a slightly different focus and message related to the need of systematic biopsies in those with MRI lesions on AS. These authors from the University of California, San Francisco evaluated the reliability of MRI-­targeted biopsy alone compared with systematic biopsy in detecting dominant lesions in men on AS. MRI-targeted detection aligned with ­systematic sampling in 95% of cases; only 5% of cases had unique findings from systematic biopsy outside the MRI target. Most of the unique lesions were low-volume GG2 with favorable histologic features. The results led the authors to suggest that MRI-targeted biopsy alone, perhaps with more sampling around any visible lesion, is sufficient for most patients on AS.

As MRI and other novel imaging come more on line in routine practice,³ these concepts will continue to evolve. If you manage patients with early prostate cancer, take a deep dive into these 2 articles and the editorial commentary that accompanies them.

Optilume Drug-Coated Balloon for Bulbar Urethral Strictures

Have we finally made a sustainable gain in the more conservative management of urethral strictures with the Optilume drug-coated balloon? DeLong et al⁴ in this issue of The Journal report the 5-year results of the ROBUST 1 trial highlighting its longer-term safety and efficacy in recurrent bulbar urethral strictures. The authors describe functional success at 58%, with an estimated freedom from repeat intervention at 5 years of 72%. These are impressive outcomes for this often challenging issue for our patients. The efficacy seems consistent with recent randomized trial evidence, but the authors are to be congratulated on reporting these longer-term results alongside important patient-reported ­outcomes.

Men’s Health Issues and Testicular Cancer Survivorship

“You only need one testicle to produce normal amounts of testosterone.” This is something, perhaps, you have heard explained to our young patients with testicular cancer despite several previous reports questioning this fact and attempt at reassurance. In this issue of The Journal, Pandit et al⁵ explore these issues by assessing the incidence of erectile dysfunction and testosterone deficiency in testicular cancer survivors within a large US veterans population. Testicular cancer survivors were significantly more likely to develop both of these men’s health concerns compared with controls. Importantly when considering potential explanatory factors, chemotherapy did not significantly influence these outcomes. The authors highlight that these findings support the need for routine sexual health assessments in survivorship care for all patients, regardless of their previous cancer management.