On the 10th of September 2025, I was delighted to have to opportunity to present the findings of my audit asking “Should We Increase Follow-Up Intensity for PIRADS 4 Prostate Lesions with Negative or Clinically Insignificant Biopsy?” at the the 22nd Meeting of the European Association of Urology Robotic Section (ERUS25) in London.
Men who have suspected prostate cancer undergo a multi parametric MRI scan and the PIRADS classification system allows for standardised reporting of these images, based on the degree of suspicion of prostate cancer. Men with PIRADS 4 lesions are likely to be diagnosed with clinically significant cancer, but uncertainty remains regarding men with suspicious MRIs who go on to have negative or clinically insignificant biopsy results. “False-positive MRI diagnosis” may occur due to PIRADS overestimation, ambiguous images being given high scores or missed lesions. Significant prostate cancer may therefore be present despite a negative or insignificant first biopsy, which suggests that initial histology may be a poor predictor of cancer likelihood on repeat biopsy.
We included 144 patients with PIRADS 4 prostate lesions in our analysis, of which 16% and 22% had negative and clinically insignificant (ISUP 1) cancer on initial biopsy, respectively. Our results showed that for PIRADS 4 lesions, the risk of an initial biopsy being a false negative may be up to 67%, of which 50% may actually have clinically significant (ISUP 2 or higher) cancer. Further, the risk of reclassification from Active Surveillance (to active treatment) in patients with ISUP 1 initially is 50% (within a median 1.2 years) and the risk of upgrade on prostatectomy histology in ISUP 1 patients pursuing an upfront prostatectomy, is 86%. This indicates likely undersampling or underestimation of aggressive disease during the initial biopsy, rather than true clinical progression of the cancer. We therefore recommend earlier repeat MRI or biopsy, ideally within 3-6 months, for patients with PIRADS 4 and negative or clinically insignificant biopsy, to ensure significant cancers are not missed on first biopsy. We also recommend having a lower threshold for radical treatment for men with PIRADS 4 lesions and ISUP 1 on initial histology.
Presenting my work was an incredibly valuable experience. Condensing several months of research into a five-minute oral presentation required me to think critically about how to communicate the key findings of our audit to an audience who were unfamiliar with the project. With limited time, it was a challenge to determine which aspects to highlight and what to leave out.
Presenting in front of an expert audience was also quite daunting, especially as a medical student still early in my training. I was particularly nervous about the questions I might be asked, but the preparation I did with my mentor helped build my confidence and equipped me to respond effectively. I was especially grateful to members of the Urology Department in Aberdeen who attended the presentation to support me - their presence really helped to calm my nerves.
The remainder of the conference was also very educational. I attended various sessions, including some specifically designed for early-stage surgical trainees, which I found particularly useful. A variety of robotic surgical platforms were showcased at the industry exhibition, and I was fortunate to try out the new Intuitive DaVinci 5 platform. Having previously had the opportunity to undergo simulation training exercises on the DaVinci XI model, I found it particularly interesting to compare the two, especially given that the new platform now includes force feedback technology, which allows the surgeon to feel tissue tension, a feature that was not available in the earlier models.
I also greatly enjoyed the live surgery sessions, where procedures being performed and moderated by experienced surgeons were live-streamed for attendees. Watching these in real time was a unique and valuable learning opportunity.
Finally, I would like to thank my supervisor, Mr Lam, the ARI Urology Department, and the University of Aberdeen for supporting me in this opportunity.
