Soc. Int. Urol. J., Volume 6, Issue 3 (June 2025) – 13 articles

Background/Objectives: The management of localized prostate cancer with regional lymph node involvement (N1M0) presents significant clinical challenges. While once considered indicative of systemic disease, improved imaging and evolving treatment paradigms have redefined node-positive disease as potentially curable. This systematic review aims to assess current evidence regarding treatment modalities and outcomes for patients with localized N1M0 prostate cancer. Methods: A systematic review was conducted to identify studies evaluating therapeutic strategies for N1M0 prostate cancer. Eligible studies included randomized controlled trials, retrospective analyses, and consensus guidelines. Treatment approaches reviewed included radical prostatectomy (RP) with pelvic lymph node dissection (PLND), whole pelvic radiotherapy (WPRT), prostate-only radiotherapy (PORT), androgen deprivation therapy (ADT), and metastasis-directed therapy (MDT), including stereotactic body radiotherapy (SBRT). Key outcomes included overall survival (OS), biochemical recurrence-free survival (bRFS), disease-free survival (DFS), and treatment-related toxicity. Results: Multimodal approaches—particularly the combination of ADT with WPRT or adjuvant radiotherapy following RP—were associated with improved survival outcomes. Patients with limited nodal burden and undetectable postoperative prostate-specific antigen (PSA) levels derived the most benefit. The use of prostate-specific antigen membrane positron-emission tomography/computed tomography (PSMA PET/CT) enhanced detection and guided MDT in oligorecurrent disease. SBRT, simultaneous integrated boost (SIB), and hypofractionated regimens demonstrated promising efficacy with acceptable toxicity profiles. Conclusions: Node-positive localized prostate cancer is optimally managed with individualized, multidisciplinary strategies. Combining systemic and locoregional treatments improves outcomes in selected patients. Ongoing prospective studies are warranted to refine patient selection, optimize treatment sequencing, and integrate novel imaging and systemic agents. Full article

Background/Objectives: Prostate cancer is the most common cancer among men globally and a leading cause of cancer-related death. Germline genetic evaluation is increasingly recognized as essential for men with high-risk features such as a strong family history or advanced disease. Methods: Comprehensive genetic risk assessment should integrate three components: family history (FH), rare pathogenic mutations (RPMs), and polygenic risk scores (PRS). RPMs in DNA repair genes (e.g., BRCA2, CHEK2, ATM) can inform screening, prognosis, and treatment strategies, particularly for metastatic or aggressive disease. PRS, derived from common genetic variants, provides a personalized and independent measure of prostate cancer risk and may guide decisions on screening intensity and timing. Results: Although PRS cannot yet differentiate between indolent and aggressive cancer, it has the potential to stratify men into low and high-risk categories more effectively than FH or RPMs alone. Knowledge of specific RPMs can influence treatment decisions in clinically advanced prostate cancer. Challenges in clinical implementation include limited provider awareness, underutilization of genetic counseling, and lack of diversity in genomic datasets, which can lead to misdiagnoses. Emerging technologies and digital tools are being developed to streamline genetic testing and counseling. Population-level strategies and tailored screening protocols based on genetic risk are under active investigation. Conclusions: While early evidence suggests high satisfaction with genetic testing among patients, further studies in diverse populations are needed. Integration of germline genetic information into prostate cancer management offers promising avenues for personalized screening, surveillance, and treatment, ultimately aiming to reduce morbidity and mortality. Full article

Background/Objectives: Prostate cancer (PCa) is the second most common malignancy among men worldwide and a leading cause of cancer-related mortality. In 2022, over 1.4 million new cases were reported globally, with a prevalence exceeding 5 million. Despite its widespread occurrence, the incidence and mortality of PCa show substantial geographic variation, influenced by factors such as genetic predisposition, healthcare access, lifestyle, and the adoption of screening programs. Regions with high PCa incidence, such as Northern America and Oceania, often have lower mortality rates due to early detection and advanced healthcare infrastructure. Conversely, areas with limited access to medical resources, such as parts of Africa and Latin America, experience higher mortality rates. Methods: This review explores non-modifiable risk factors such as age, family history, and race, emphasizing their role in PCa development and progression. Results: Modifiable factors, including diet, physical activity, alcohol consumption, and smoking, are also addressed, with evidence suggesting their potential in mitigating risk. Emerging data on medications such as 5-alpha reductase inhibitors and statins, as well as dietary supplements such as vitamins D, indicate their potential for chemoprevention, though further research is needed to solidify these findings. Healthcare disparities, especially in low- and middle-income regions, highlight the need for equitable access to diagnostic tools and treatment options. The review underscores the significance of tailored screening approaches, particularly in high-risk populations, to optimize outcomes while minimizing overdiagnosis and overtreatment. Conclusions: The review concludes with recommendations for future research, including the need for standardized screening protocols and the exploration of novel biomarkers for early detection. By synthesizing epidemiological data and current evidence, this review aims to enhance understanding of PCa risk factors, geographic disparities, and preventive strategies, ultimately contributing to improved global PCa management and outcomes. Full article

Background/Objectives: Innovations in robotic prostatectomy have transformed a highly morbid operation to a procedure with fewer complications and shorter hospital stays, yet techniques continue to evolve. Our objective is to discuss the most recent advances in robotic prostatectomy techniques designed to minimize morbidity related to urinary incontinence and erectile dysfunction. Methods: This review is adapted from a comprehensive committee chapter on published in the 3rd WUOF/SIU (World Urologic Oncology Federation/Société Internationale d’Urologie) International Consultation on Urologic Diseases on Localized Prostate Cancer. Results: This review article describes both traditional and emerging techniques in robotic prostatectomy techniques and discusses their respective outcomes. Conclusions: Improved understanding of pelvic anatomy has enabled robotic-assisted techniques to preserve key structures and enhance recovery and functional outcomes while preserving oncologic safety Full article

Background/Objectives: Focal therapy (FT) for prostate cancer (PCa) is an alternative to radical treatments that aims to balance cancer control and quality of life preservation in well-selected patients. Understanding its general principles and outcomes is key for its widespread adoption and proper implementation. Methods: The International Consultation on Urological Diseases nominated a committee to review the literature on FT for PCa. A comprehensive PubMed search was conducted to identify articles focused on the different aspects of FT, including patient selection, imaging techniques, treatment modalities, cancer control and safety outcomes, integration with other approaches and future perspectives. Results: FT for PCa was introduced in the 1990s with cryotherapy and high-intensity focused ultrasound (HIFU) as pioneering modalities. Though initially guided by transrectal ultrasound (TRUS) and large biopsy templates, FT implementation expanded significantly with the advent of multiparametric magnetic resonance imaging (MRI) and the validation of the index lesion concept. Appropriate patient selection is key for FT and relies on prostate-specific antigen (PSA) metrics, MRI findings and targeted biopsy information. Multiple energy sources are now available, each with specific technical characteristics. Cancer control rates vary by energy modality, tumor characteristics, and institutional experience, demonstrating comparable outcomes to radical treatments in well-selected patients. The safety profile is excellent, with high rates of urinary continence and sexual function preservation. Post-treatment surveillance integrates PSA measurements, imaging, and histological assessment. Future directions for further FT adoption include the availability of long-term data, protocol standardization and technological improvements to enhance patient selection and treatment planning and delivery. Conclusions: FT is a valuable therapeutic option for selected patients with localized PCa, demonstrating promising oncological outcomes and better functional preservation compared to radical treatments. Understanding its principles and technical aspects is essential for offering comprehensive PCa care. Full article

Background/Objectives: Pathological factors are integral in the risk stratification and management of localized prostate cancer. In recent years, there has been an upsurge of studies that uncovered novel approaches and have refined prognostic factors for prostate cancer in needle biopsy and radical prostatectomy (RP) specimens. Methods: We conducted a review of literature and summarized the significant recent updates on pathological factors for localized prostate cancer. Results: Innovative factors derived from the traditional Gleason grading, such as the extent of Gleason pattern 4 and presence of cribriform pattern are now recognized to significantly improve discrimination of outcome. The components and rules of Gleason grading themselves underwent modifications, and the subsequent prognostic grouping of the different grades (Grade group) have resulted in enhanced stratification of behavior more meaningful in management decision. The approaches for grade reporting in systematic or targeted needle biopsies and in RP with multifocal cancers are also being optimized. Newer tumor growth pattern-based factors such as intraductal carcinoma and atypical intraductal proliferation can have ramifications in management, especially in the background of low to intermediate risk prostate cancers. Gleason grade considerations in the different post-treatment settings and for de novo and residual prostate cancers with varying treatment effects have also been explicated. Likewise, the application of more traditional factors in tumor extent and perineural invasion in biopsy, or positive surgical margin in RP, have also evolved. Conclusions: Some of these newer pathological factors are now officially recommended in standardized pathology reporting protocols and are applied in the management decision for localized prostate cancer. Full article

Background/Objectives: Primary prevention, germline, familial, or other pre- or post-diagnostic and standard treatment-elevated progression or recurrence risk and mitigating adverse events from systemic treatment are all clinical opportunities to reduce the risk of lethal prostate cancer. This review attempted to provide a practical and realistic consensus via an international committee of experts who, in general, harbor career-long experience in this discipline. Methods: A PubMed review primarily utilizing the latest meta-analyses, systematic reviews, and methodologically robust epidemiologic recent data adjusting for multiple confounding variables was conducted. The goal of this committee was to highlight tangible options for clinicians and patients. Results: Behavioral patterns and metrics known to reduce cardiovascular morbidity, mortality, and all-cause mortality (premature death) appear to prevent numerous lethal common cancers, including prostate cancer. This practical approach allows for the greatest probability of patient success since cardiovascular disease (CVD) is the primary cause of death in men with and without prostate cancer, and a notable source of morbidity and mortality in men with advanced disease due to systemic conventional treatment as well as the inflammatory contribution of cancer itself. Heart-healthy dietary patterns, exercise, healthy weight/waist circumference, eliminating tobacco, minimizing alcohol exposure, and other behaviors to reduce the risk of CVD should be prioritized. CVD-preventive medications, including aspirin, GLP-1 agonists, metformin, statins, etc., should receive attention to improve compliance for those that already qualify for these agents and to increase the probability of enhancing the quality and quantity of life. Dietary supplements do not have favorable data currently to espouse their utilization to prevent lethal prostate cancer but may have an ancillary role in mitigating some adverse effects of treatment. Conclusions: Remarkably, heart-healthy lifestyle changes, metrics, and promising repurposed medications known to reduce cardiovascular events, promote longevity, and improve mental health could simultaneously prevent lethal prostate cancer. This serendipitous association provides clinicians and their patients a higher probability of success, regardless of their prostate cancer pathway or circumstance. Full article

Background/Objectives: The diagnostic approach to prostate cancer (PCa) has evolved from systematic biopsies to imaging-guided strategies that improve detection of clinically significant PCa (csPCa) while reducing overdiagnosis. Multiparametric magnetic resonance imaging (mpMRI) has emerged as the gold standard for pre-biopsy evaluation, while micro-ultrasound (MicroUS) offers a promising alternative with real-time imaging capabilities. Methods: We examined the principles, image interpretation frameworks (Prostate Imaging Reporting and Data System (PI-RADS) and Prostate Risk Identification using Micro UltraSound (PRI-MUS)), and clinical applications of mpMRI and MicroUS, comparing their diagnostic accuracy in biopsy-naïve patients, repeat biopsy scenarios, active surveillance, and staging. Results: mpMRI improves csPCa detection, reduces unnecessary biopsies, and enhances risk stratification. Landmark studies such as PRECISION (Prostate Evaluation for Clinically Important Disease: Sampling Using Image Guidance or Not?) and PRIME (Prostate Imaging Using MRI±Contrast Enhancement) confirm its superiority over systematic biopsy. However, mpMRI remains resource-intensive, with limitations in accessibility and interpretation variability. Conversely, MicroUS, with its high-resolution real-time imaging, shows non-inferiority to mpMRI and potential advantages in magnetic resonance imaging (MRI)-ineligible patients. It improves lesion visualization and biopsy targeting, with ongoing trials such as OPTIMUM (Optimization of prostate biopsy—Micro-Ultrasound versus MRI) evaluating its standalone efficacy. Conclusions: mpMRI and MicroUS are complementary modalities in PCa diagnosis. While mpMRI remains the preferred imaging standard, MicroUS offers an alternative, particularly in patients with MRI contraindications. Combining these techniques could enhance diagnostic accuracy, reduce unnecessary interventions, and refine active surveillance strategies. Future research should focus on integrating both modalities into standardized diagnostic pathways for a more individualized approach. Full article

Background/Objectives: Focal therapy (FT) and technology are closely connected. Advanced imaging allows for precise identification of the index lesion, enabling the targeted use of various thermal and non-thermal energy sources through different approaches, with specific techniques tailored to lesion location and operator expertise. This personalized approach enhances both safety and effectiveness, facilitating customized treatment planning. Methods: The International Consultation on Urological Diseases formed a committee to review the current literature on FT for prostate cancer (PCa), focusing specifically on the technique. Following in-depth discussions, the committee chose a “by lesion” approach rather than the traditional “by energy” approach to structure the review. A comprehensive PubMed search was conducted to gather relevant articles on the various energy modalities and procedural approaches used in FT for PCa. Results: Lesions in the apex, anterior, and posterior regions of the prostate can be accessed through several FT approaches, each associated with specific energy modalities and techniques. The transrectal approach utilizes high-intensity focused ultrasound (HIFU) and focal laser ablation (FLA), while the transperineal approach is compatible with energy sources such as cryotherapy, irreversible electroporation (IRE), brachytherapy, and FLA. The transurethral approach supports methods such as transurethral ultrasound ablation (TULSA). Each approach offers distinct advantages based on lesion location, treatment area, and energy modality. The choice of technique evaluated the safety and efficacy of each energy source and approach based on specific treatment areas within the prostate, highlighting the need for robust research across lesion locations and modalities, rather than focusing solely on each modality for a specific region. Conclusions: FT is rapidly advancing with new energy sources, technological improvements, and increasing operator expertise. To further optimize FT, research should prioritize evaluating the safety and effectiveness of different energy sources for various lesion locations, focusing on the treatment area rather than the energy modality itself. Full article

Background/Objectives: Pelvic lymph node dissection during radical cystectomy has been established to be important for staging and therapeutic purposes. However, there is uncertainty regarding the optimal extent of nodal dissection. This study aimed to assess the impact of an extended pelvic lymphadenectomy template compared to a standard template in patients with bladder cancer undergoing radical cystectomy. Methods: We performed a systematic review and meta-analysis of randomised studies comparing extended pelvic lymph node dissection to standard pelvic lymph node dissection in patients undergoing radical cystectomy. A search of multiple databases was performed up to October 2024. The standard template was defined as including at least the obturator and internal and external iliac nodes. An extended template was defined as a standard template plus the removal of proximal nodal packets. The primary outcomes were overall survival and major Clavien–Dindo complications. Results: Two studies encompassing a total of 933 participants met the eligibility criteria. There was no observed improvement in overall survival with extended lymph node dissection compared to limited dissection [HR 0.95, 95%CI 0.66–1.4]. In addition, extended lymph node dissection was associated with an increased risk of grade ≥3 Clavien–Dindo complications compared to limited nodal dissection [RR 1.2, 95%CI 1.02–1.37]. There was also an increased risk of lymphoceles requiring intervention with extended lymphadenectomy. Conclusions: Extended pelvic lymphadenectomy does not improve oncological outcomes and is associated with increased morbidity compared to a standard template in bladder cancer patients undergoing radical cystectomy. Full article

Background/Objectives: Randomised trials show that screening with prostate-specific antigen (PSA) and systematic prostate biopsies can reduce prostate cancer mortality but leads to high rates of overdiagnosis. Today, improved diagnostic methods more selectively detect potentially lethal, high-grade prostate cancer. Methods: This is a narrative review of modern diagnostic methods, ongoing trials, national policies and knowledge gaps related to screening and early detection of prostate cancer. Results: Screening intervals can be prolonged in men with PSA values below around 1 ng/mL as these men are at very low long-term risk of prostate cancer death. Overdiagnosis can be reduced by magnetic resonance imaging (MRI) and lesion-targeted prostate biopsies. Risk calculators and ancillary biomarkers can select men for further investigation and thereby reduce resource needs. These new methods are evaluated in large, randomised screening trials. The remaining knowledge gaps include optimal PSA cut-offs, screening intervals, start and stop ages, and the long-term balance between benefits and harm. Until recently, almost no national healthcare authority recommended population-based screening for prostate cancer. Now, the European Union Council recommends an evaluation of the feasibility of organised, risk-stratified screening. This has led to several pilot projects. In some other parts of the world, such as sub-Saharan Africa and the Caribbean, such initiatives are lacking despite high prostate cancer mortality rates. Conclusions: Risk-stratified prostate cancer screening including MRI and targeted biopsy reduces overdiagnosis. Results from ongoing research are needed to optimise screening protocols and to define long-term benefits and harms. Initiatives for early detection and screening are emerging across the world but are still lacking in many countries with high prostate cancer mortality. Full article