How to cite: Kenigsberg A. Point Counter Point: The Case for Cognitive. Grand Rounds in Urology. October 2025. Accessed February 2026. https://grandroundsinurology.com/point-counter-point-the-case-for-cognitive/
Summary
Alexander Kenigsberg, MD, Assistant Professor, Director of Urologic Oncology, Virginia Commonwealth University Health, Massey Comprehensive Cancer Center, Richmond, Virginia, presents a detailed comparison of cognitive fusion and software fusion, reviewing accuracy data, workflow considerations, and focal therapy requirements. He begins by outlining the rationale for focal therapy, which aims to ablate the index lesion while avoiding the morbidity associated with whole-gland treatment. He explains the definitions of focal, partial gland, and quadrant-based ablation and positions his discussion within the context of partial gland ablation.
He describes software fusion as the overlay of previously acquired magnetic resonance imaging (MRI) onto real-time ultrasound with either rigid or elastic registration. He states that while software fusion offers three-dimensional reconstruction, deformation of the prostate limits the accuracy of registration. He highlights research showing that, despite technological sophistication, software platforms introduce targeting error.
Dr. Kenigsberg reviews biopsy evidence demonstrating that MRI-targeted biopsies improve the detection of clinically significant disease and reduce the identification of indolent disease. He then notes that equivalence studies show similar performance between cognitive and software fusion for biopsy targeting. He explains that even expert users of software platforms demonstrate a targeting error of three to six millimeters, and that novices have a greater error. He emphasises that millimeters matter.
He argues that these compounding errors make extreme precision unrealistic and that anatomic ablation strategies remain appropriate. He notes that hemiablation has declined over time but continues to be used. He presents evidence that anatomic ablation yields comparable quality of life and improved oncologic outcomes in some settings. He notes that cognitive fusion is dependable when paired with anatomic understanding, margin-based planning, and the use of simple tools that measure lesion size and treatment boundaries.
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ABOUT THE AUTHOR
Alexander Kenigsberg, MD, is an Assistant Professor in the Department of Urology at Virginia Commonwealth University (VCU) School of Medicine and Director of Urologic Oncology at VCU Massey Comprehensive Cancer Center in Richmond, Virginia. He specializes in urologic oncology, with a clinical focus on prostate, kidney, and bladder cancers.
Dr. Kenigsberg’s clinical interests include robotic and minimally invasive cancer surgery, focal therapy for prostate cancer, high-intensity focused ultrasound (HIFU), active surveillance, and organ-preserving approaches to urologic malignancies. His research focuses on improving minimally invasive cancer treatment, focal therapy, and expanding access to clinical trials for patients with genitourinary cancers.
He earned his medical degree from New York University Grossman School of Medicine, completed his internship and urology residency at UT Southwestern Medical Center, and subsequently completed fellowship training in urologic oncology at the National Cancer Institute, National Institutes of Health.
