Impact of a robotic-assisted transperineal biopsy platform on pathologic upgrading and downgrading at prostatectomy

Pathologic concordance between prostate biopsy and radical prostatectomy (RP) remains suboptimal, even in the era of multiparametric MRI-targeted and transperineal sampling. We aimed to assess whether high-precision lesion targeting using a novel robotic-assisted transperineal fusion biopsy (RA-TP-FBx) platform reduces rates of upgrading and downgrading between biopsy and prostatectomy specimens and thus improves concordance. We reviewed all RA-TP-FBx cases recorded in the prospectively maintained database of a tertiary center between 2020 and 2024. Patients who subsequently underwent RP were included for analysis. Biopsies were performed using the iSR'obot Mona Lisa (Biobot) platform. In the presence of PI-RADS ≥ 3 lesions, both targeted and systematic biopsies were obtained. All biopsies, prostatectomies, and histopathological evaluations were conducted at a single institution. The total ISUP grade at biopsy was compared with final pathology following RP. Concordance, upgrading, and downgrading were reported as proportions, and agreement was quantified using Cohen’s kappa coefficient. A total of 448 men underwent RA-TP-FBx, of whom 118 (25.8%) subsequently underwent RP. Overall concordance between biopsy and final pathology was observed in 83.9% (99/118). ISUP upgrading occurred in 11.9% (14/118), while downgrading was observed in 4.2% (5/118). The corresponding Cohen’s kappa coefficient was 0.71, indicating good agreement. RA-TP-FBx demonstrated a high biopsy–prostatectomy concordance rate, ranking among the highest reported to date. These findings indicate that high concordance is achievable, challenge the notion that prostate biopsy is inherently limited in reflecting whole-mount pathology and suggest that robotic guidance may enhance lesion targeting and grading accuracy, supporting more reliable risk stratification and treatment planning.