Objective: To evaluate the early oncological outcomes of patients treated with robot-assisted radical prostatectomy for prostate cancer with multiple PIRADS lesions at baseline mpMRI in a tertiary referral center. Methods: Data of consecutive patients undergoing robot-assisted radical prostatectomy between 2020 and 2022 at a high-volume tertiary referral center were prospectively collected. mpMRI data was evaluated by two expert uro-radiologists at our center. All patients received an MRI-ultrasound fusion biopsy. Results: Overall, 286 patients with multiple PIRADS lesions treated with robot-assisted radical prostatectomy at a tertiary referral center were included. Unilateral and bilateral nerve-sparing were achieved in 63 (22.3%) and 124 (43.1%) patients, respectively. Median age was 69 years (IQR: 64-72), while median Charlson Comorbidity Index was 3 (IQR: 2-4). The presence of two PIRADS lesions was found in the 81.8% of cases, while 18.2% presented with three or more. Bilateral lesions were observed in 67.4% of cases. The dominant lesion was PIRADS 4 in 57.3% and PIRADS 5 in 32.3% of cases, with a median diameter of 12 mm (IQR: 10-17). Pathological upstaging to pT3 occurred in 61% of patients. Overall, 9.8% of cases exhibited positive surgical margins (PSMs), most of them single and limited in extent. Postoperative major complications were recorded in 6.3% of patients. At a median follow-up of 18 months (IQR: 6-29), biochemical recurrence (BCR) occurred in 8% of patients. Patients with PIRADS 5 lesions experienced shorter BCR-free survival compared to those with PIRADS 3-4. On multivariable Cox regression, PIRADS 5 independently predicted biochemical recurrence (HR: 2.52; 95% CI: 1.10-5.80; p = 0.029), after adjustment for age, number of lesions, and nerve-sparing status, with the performance of nerve-sparing not associated with an increased risk of recurrence, including in patients with multifocal disease. Conclusions: Nerve-Sparing Robot-Assisted Radical Prostatectomy in patients with multiple PIRADS lesions achieves encouraging short-term oncologic outcomes, with biochemical recurrence-free survival exceeding 84% at 3 years, despite high rates of multifocality and pathological upstaging.
Journal of clinical medicine. 2026 May 14*** epublish ***
Luca Lambertini, Simone Sforza, Filippo Lipparini, Marco Saladino, Fabrizio Di Maida, Antonio Andrea Grosso, Giulia Carli, Francesca Conte, Anna Cadenar, Beatrice Giustozzi, Francesco Lasorsa, Mattia Lo Re, Rino Oriti, Riccardo Fantechi, Gianni Vittori, Andrea Minervini, Andrea Mari
Department of Experimental and Clinical Medicine, University of Florence, 50121 Firenze, Italy., Urology, Andrology and Kidney Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari "Aldo Moro", 70121 Bari, Italy.