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With the overall technological diagnostic improvement of prostate cancer (PCa), focal therapy has emerged as a promising approach for the treatment of localized PCa, offering in a selected group of patients an intermediate option between active surveillance and radical interventions. The primary goal of focal therapy is to avoid local progression and metastatic disease, and decrease the morbidity associated with whole gland therapy. Selection of energy source and approach depends on the index lesion(s) location, size, prostate anatomy, surrounding structures, overall clinical characteristics, patient expectations, and surgeon experience. Further long-term prospective data assessing the outcomes of focal therapy are still required.
High-risk non-muscle-invasive bladder cancer (HR-NMIBC) represents a biologically aggressive disease state with substantial risk of recurrence, progression, and need for radical cystectomy. While intravesical Bacillus Calmette-Guérin (BCG) remains first-line for HR-NMIBC is standard of care, both recurrence and progression have led to the development of novel intravesical agents therapies. This article summarizes key clinical trials that are reshaping the management of HR-NMIBC, with particular emphasis on BCG-unresponsive disease. Approved intravesical and systemic agents demonstrate meaningful response rates and durable disease control in select patient populations. Emerging therapies and combination intravesical chemotherapies further expand the available therapies.
Prostate cancer progression is largely driven by androgen receptor signaling. While androgen deprivation therapy remains a cornerstone of treatment, it imposes a selective pressure that ultimately leads to the emergence of a castration-resistant phenotype, driven by a range of adaptive molecular mechanisms. In recent years, significant advances have been made in understanding its complex biology, making it a critical focus of ongoing research. The application of multi-omics approaches has played a pivotal role in uncovering the molecular underpinnings of this disease, offering deeper insights into its heterogeneity and resistance mechanisms.
A review of the literature indicates that an extended pelvic lymph node dissection is the best staging template for localized prostate cancer. A large randomized clinical trial showed a therapeutic benefit in reducing metastasis. However, the European Association of Urology recent guidelines have not yet taken a position in favor of extended pelvic lymph node dissection, citing, an increased morbidity associated with pelvic lymph node dissection. Level 1 evidence indicates the overall complication rates are in fact low. With the recent advances in molecular imaging, the future directions of pelvic lymph node dissection will likely be through intraoperative optical imaging.
Systemic therapy intensification has improved outcomes for patients with de novo metastatic prostate cancer. Retrospective studies highlighted the benefits of radiotherapy to the local tumor, prompting prospective evaluation via the HORRAD, STAMPEDE, and PEACE-1 trials. While the HORRAD trial suggested a trend toward improved survival, the STAMPEDE trial demonstrated a statistically significant overall survival benefit in patients with lower-risk or lower-volume disease. The PEACE-1 trial investigated local radiotherapy in the era of intensified systemic therapy. Benefits including improved radiographic progression-free survival, castrate resistance-free survival, and genitourinary side effects make local radiotherapy a valuable therapy for subgroups of patients.
The main cornerstone of surgical treatment of prostate cancer is robot assisted radical prostatectomy (RARP). In the United States, RARP has emerged as the gold standard for surgical therapy. Ten times magnification, 3-dimensional vision, and wrist-held devices enabling difficult dissections and accurate suture application are the benefits of robotic technology. Robot-assisted laparoscopic prostatectomy has several benefits over open techniques. Focal therapy for prostate cancer has staged a comeback due to improvements in imaging modality and improved safety profiles of newer focal therapy devices. Long-term efficacy of focal therapy is still unknown. Recent technological advances improve overall performance of surgical therapy.
The role of pelvic lymph node dissection (PLND) at the time of radical prostatectomy for clinically localized prostate cancer has remained controversial. While providing the most accurate staging for prostate cancer, the data regarding the therapeutic benefits of a PLND is inconclusive. In this article, we summarize the different PLND templates as well as the data both for and against performing a PLND. Finally, we outline future directions in selecting patients for PLND, and propose a theory on how pelvic lymph nodes may play a vital role in developing novel immunotherapy regimens.
The detection of localized prostate cancer has transformed tremendously in the twenty-first century with the emergence of more accurate imaging technologies. The standard transrectal ultrasound is now supported by the widespread adoption of MRI, with growing investigation into modalities such as micro-ultrasound and prostate-specific membrane antigen imaging. The value of these imaging techniques is still being understood, as seen by their increasing application for management decisions, treatment planning, and treatment monitoring. This article aims to provide a comprehensive understanding of contemporary imaging techniques for localized prostate cancer, including relevant data.
This narrative review explores the emerging role of locoregional therapy (LRT) in metastatic prostate cancer, highlighting evidence from randomized trials and observational studies. LRT, including prostate radiotherapy, radical prostatectomy, and ablation, may benefit select patients, particularly those with low-volume or oligometastatic disease. Advanced imaging integration such as prostate-specific membrane antigen positron emission tomography and evolving risk stratification systems supports more tailored approaches. While early outcomes are promising, prospective studies are needed to define LRT's optimal use in modern metastatic prostate cancer management. The treatment paradigm for metastatic prostate cancer continues to evolve with the integration of novel systemic therapy agents.
Bladder cancer is the 6thth most common type of cancer in the United States and tobacco smoke remains the leading environmental risk factor of the disease. Non-muscle invasive bladder cancer (NMIBC) makes up the majority of bladder cancer cases and is a subtype of bladder cancer that has a high heterogenicity in rates of recurrence and prognosis. The aim of this article is to dive into the prevalence of NMIBC, review the literature and guidelines on how NMIBC is risk stratified, and discuss the utility of early diagnosis of this disease and ways this can be achieved.
High-risk localized prostate cancer (HR-PCa) presents a substantial risk of recurrence and progression despite definitive local treatment. This article evaluates the evolving role of neoadjuvant and adjuvant therapies, including androgen deprivation therapy, second-generation androgen receptor pathway inhibitors, and chemotherapy. While neoadjuvant strategies improve pathologic responses, survival benefits remain unproven. Adjuvant therapy is increasingly individualized, with early salvage radiotherapy favored over routine adjuvant radiotherapy based on recent trial data. Ongoing studies, molecular profiling, and advanced imaging aim to refine patient selection and personalize treatment, balancing oncologic control with quality of life in the management of HR-PCa.
This comprehensive article explores the evolution, clinical evidence, and positioning of drug-coated balloon dilation (Optilume) for benign prostatic hyperplasia (BPH). The paclitaxel-coated balloon technology represents a significant advance over earlier balloon dilation attempts by preventing tissue regrowth. Clinical evidence demonstrates durable symptom improvement with 67.5% of patients showing 30% or greater IPSS improvement at 24 months without retreatment. This office-based procedure preserves sexual function while delivering significant improvement in urinary flow rates. The article analyzes available data, compares Optilume with other treatment options, and discusses its positioning within the BPH treatment spectrum.
Radiation therapy (RT) is a cornerstone in the management of prostate cancer, spanning localized, recurrent, and metastatic disease. Advances in technology, fractionation schedules, and combination strategies have expanded the role of RT and improved patient outcomes. Some studies show long-term biochemical control rates reaching above 90% for low-risk and favorable intermediate risk, and rates frequently exceed 75% in less favorable risk patients. Additional uses of radiation include the management of recurrent and oligometastatic disease with favorable outcomes. Lastly, adverse events due to radiation are of concern, but rates of long-term toxicity remain low.
Transurethral resection of bladder tumor (TURBT) remains the foundation of nonmuscle invasive bladder cancer (NMIBC) diagnosis and treatment. The article covers preop evaluation (history, imaging, vesical imaging-reporting and data system, multiparametric MRI, office cystoscopy, and biomarkers), anesthesia/energy choices to limit obturator reflex/perforation, and operative technique using enhanced cystoscopy and selective en bloc resection (EBRT). It stresses meticulous specimen handling, immediate use of intravesical chemotherapy, and indications for second-look TURBT. Despite progress, incomplete resection and understaging are frequent; and broader use of visualization technologies, EBRT in selected cases, and quality programs are key to reducing recurrence and progression of NMIBC.
High-risk prostate cancer (HRPCa) is a heterogeneous disease with variable presentations and outcomes. While radiotherapy with androgen deprivation therapy was historically favored, radical prostatectomy (RP) is now increasingly employed as a primary treatment. Emerging evidence supports RP as an effective option in select patients, potentially avoiding the adverse effects of combined therapy. Advances in imaging and surgical techniques allow for more personalized surgical care in HRPCa, thereby reducing RP morbidity without compromising oncologic control. Ongoing trials are evaluating the role of RP within a multimodal therapy approach and will provide data on the optimal treatment of HRPCa.
Non-muscle invasive bladder cancer represents the majority of bladder cancer cases and imposes a significant economic burden due to high recurrence rates and intensive surveillance. Cost-effectiveness analyses help compare treatment strategies, but integration into clinical guidelines remains limited. Financial toxicity affects many patients, particularly those with lower income. While novel therapies and diagnostic tools show promise, their cost-effectiveness is variable. Future efforts should focus on incorporating cost-utility data into guidelines and addressing both direct and indirect costs to optimize care and reduce financial strain for patients and health care systems.
Genetic testing is increasingly central to the management of localized prostate cancer (PCa). Advances in next-generation sequencing have revealed both germline and somatic alterations that influence disease risk, prognosis, and therapeutic response. Approximately 10% to 15% of men with PCa carry pathogenic germline variants, most commonly in BRCA2, ATM, CHEK2, HOXB13, and mismatch repair genes. Consensus recommendations and guidelines now endorse routine germline testing in men with high-risk localized disease, strong family history, or known familial mutations. Germline information, as well as somatic genomic classifiers, is increasingly being used to help guide screening and treatment recommendations.
Non-Muscle-Invasive Bladder Cancer poses significant therapeutic challenges due to high recurrence and progression rates. While intravesical Bacillus Calmette-Guérin (BCG) has long been the standard, limitations in efficacy, global shortages, and patient-specific contraindications to radical cystectomy have fueled the development of novel bladder-sparing therapies. Recent advances include UGN-102 for low-grade/intermediate-risk disease and multiple FDA-approved agents-nadofaragene firadenovec, TAR-200, and nogapendekin alfa inbakicept-for BCG-unresponsive disease. Ongoing trials of TAR-210, cretostimogene, and other combination regimens promise to further expand options. Comparative studies and real-world evidence will be critical to define optimal sequencing, benchmark outcomes against radical cystectomy, and address quality-of-life considerations.
This comprehensive review highlights recent advancements in the evaluation and management of benign prostatic hyperplasia (BPH), emphasizing updates from the 2023 American Urologic Association Guidelines. It outlines an individualized, algorithmic approach to diagnosis using clinical, imaging with emerging roles for artificial intelligence and machine learning. Surgical options span from minimally invasive treatments like prostatic urethral lift, water vapor injection therapy, and temporary implanted prostatic devices to definitive therapies like holmium laser enucleation of the prostate, photoselective vaporization of the prostate, robotic waterjet treatment, and robotic prostatectomy. Future directions involve novel therapeutics, precision medicine, and cost-effectiveness in optimizing BPH management.
Despite recent advances, advanced prostate cancer remains a morbid disease. Next-generation androgen receptor pathway inhibitors, PARP inhibitors, and radiopharmaceuticals, such as Lutetium-177Lu-PSMA-617, have revolutionized the field, and newer therapies attempt to build on these successes. In this article, the authors detail treatments on the horizon for advanced prostate cancer-including novel hormonal therapies and targeted agents, new radiopharmaceuticals, and the introduction of immune therapies.