The Importance of a Second Opinion in Urological Pathology
When it comes to your health, getting a second opinion can make all the difference — especially in the field of urological pathology, where subtle distinctions under the microscope can have a major impact on diagnosis and treatment.
What Is Urological Pathology?
Urological pathology is the study and diagnosis of diseases affecting the urinary tract and male reproductive organs — including the prostate, bladder, kidneys (excluding medical kidney diseases), testicles, penis, and scrotum.
Urological pathologists are physicians who specialize in examining tissue samples from these organs to determine whether a disease such as cancer is present, and how aggressive it may be.
This expertise is usually gained through specialized training known as a urological pathology fellowship, completed after general pathology training.
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Did you know?
Dr. Jonathan Epstein has directed the largest urological pathology fellowship program in the world, training 89 fellows to date. When he began his career, no formal urological pathology fellowships existed — he became self-taught through years of focused study, research, and clinical practice.
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Why a Second Opinion Matters
In both research and daily practice, Dr. Epstein and colleagues have shown that a second opinion in pathology can be vital for patients.
In some cases, a second review can even change a diagnosis entirely — for example, from benign to cancerous, or vice versa. Understandably, patients often ask, “How could that happen?”
Some urological cancers — such as prostate cancer or carcinoma in situ (CIS) of the bladder — are among the most challenging cancers to diagnose. Cancer cells can be extremely subtle, while certain benign conditions can closely mimic cancer, leading to potential overdiagnosis.
More commonly, a second opinion doesn’t change the diagnosis itself but refines the grade or aggressiveness of the disease, which can significantly influence treatment decisions.
How Grading Impacts Treatment
With prostate cancer, the assigned grade on a biopsy helps determine whether a patient is a candidate for active surveillance (close monitoring rather than immediate treatment). It can also guide the type of radiation therapy and whether hormone therapy is needed before or during treatment.
In many cases sent for expert review, Dr. Epstein finds that the cancer grade is lower than originally reported — meaning some patients who were previously considered ineligible for active surveillance may actually qualify for it.
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Why the difference?
While most pathologists are highly skilled, not all have subspecialty experience in urological pathology. Patients typically don’t get to choose who reviews their tissue — and even at major academic centers, specimens may be read by a junior or non-specialized pathologist.
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The Value of Expert Review
Even when the initial diagnosis is correct, a second opinion can reveal important missing details that directly affect treatment planning.
For instance, in prostate biopsy reports with Gleason scores 3+4=7 (Grade Group 2) or 4+3=7 (Grade Group 3), many reports do not include the percentage of Gleason pattern 4 — information that can determine eligibility for active surveillance.
- A patient with 1% pattern 4 may safely choose active surveillance.
- A patient with 50% pattern 4 may require treatment.
Additionally, not all Gleason pattern 4 cancers behave the same way. The large cribriform pattern is now known to be more aggressive, yet it’s often not mentioned in pathology reports.
Other findings, such as intraductal carcinoma of the prostate, can also have major implications for treatment and are sometimes missed without subspecialty expertise.
How to Get a Second Opinion
Many patients are unsure how to request a second opinion. The process is straightforward — and you have the right to do it.
Your tissue belongs to you, and asking for a second review is common and completely appropriate. It is not a criticism of your doctor or laboratory.
Most labs will readily send your slides to a consulting pathologist upon request. In some cases, the consulting physician’s office may need to contact the lab directly.
Importantly, sending slides for review does not damage or deplete your sample — molecular and genetic tests can still be performed later on the remaining tissue preserved in the paraffin (wax) block.
For a step-by-step guide to preparing for your pathology consultation and understanding what to expect, visit our Navigating Your Consultation page.