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.

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.

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.

This article examines the current landscape of molecular biomarkers for diagnosing localized prostate cancer (PCa), from the prostate-specific antigen (PSA) test to newer blood, urine, or tissue-based biomarkers which can improve the accuracy of PCa diagnosis compared with PSA alone. The article further examines how tissue-based biomarkers are being used for predicting outcomes and affecting treatment decisions. These biomarkers have the potential to transform the clinical management of PCa, but future studies are needed to optimize and standardize their use in combination with other tests, including modern imaging, to provide maximum benefit to PCa patients.

The diagnosis and management of localized prostate cancer (PCa) remains an active field of research, with many recently published and upcoming clinical trials. Advances in local therapy, management of pelvic lymph nodes, imaging, systemic treatments, and quality of life have the potential to optimize outcomes while minimizing toxicity. This review synthesizes findings from recently completed phase III trials, highlights ongoing studies and provides an update on evidence-based management approaches and emerging innovations which may improve the care of patients with localized PCa.

Recent changes in grading guidelines include the adoption of grade groups, reporting of percentage of pattern 4, reporting of intraductal carcinoma, and presence of cribriform pattern, making pathology reports more prognostically accurate and less confusing. However, pathologists in their daily practice still face challenges related to the subjective nature of identification of cancer growth patterns and difficulties related to tangential sectioning, leading to high intra- and interobserver variability of prostate cancer grades in some cases. Reporting and grading small cancer areas, reporting tertiary Gleason patterns, and precise identification and grading of intraductal carcinoma all remain problematic areas of prostate pathology.

The ultrasound-guided, transrectal, sextant prostate biopsy procedure has undergone numerous modifications to improve its diagnostic yield and safety. Biopsy templates evolved from six to as many as twenty-four samples, with the 10-12 core template proving most effective. The advent of multi-parametric magnetic resonance imaging has been instrumental in addressing the concerns about overdiagnosis of low-risk prostate cancer. The gap in evidence regarding the efficacy and safety of transrectal and transperineal prostate biopsy has been addressed by three large, randomized trials demonstrating similar outcomes. Forthcoming refinements in biomarkers and molecular imaging are destined to enhance the efficacy and safety of prostate biopsy.

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.

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.

Gleason 6 prostate cancer, also classified as grade group 1 (GG1), demonstrates exceptionally indolent behavior with minimal risk of metastasis or mortality. Despite this, its designation as cancer drives overdiagnosis, overtreatment, and patient anxiety. This review examines the historical evolution of the Gleason grading system, pathologic and molecular characteristics of GG1 disease, and long-term outcomes from landmark trials and contemporary cohorts. We explore the implications of current diagnostic and management strategies and finally propose guideline reforms and implementation strategies aimed at reducing overtreatment, improving communication, and supporting observation and PSA-based monitoring as preferred options for most men with GG1 disease.

One of the critical challenges in managing localized prostate cancer is in balancing the need for appropriate treatment of aggressive disease while avoiding overtreatment of indolent cases. Gleason Grade Group 1 prostate adenocarcinoma has emerged as a focal point in this discussion due to its low metastatic potential. At this point in time, some clinicians and researchers are advocating for this entity to be renamed to something other than "cancer" (ie, localized indolent disease). This article explores the history of the Gleason grading system, histopathologic characteristics of Gleason score 6 disease, and its clinical implications.

Active surveillance (AS), first described as a management strategy for favorable risk prostate cancer more than 20 years ago has now been widely adopted as the treatment of choice for these patients. AS surveillance initially consisted of regular PSA monitoring with periodic biopsies, with intervention indicated for rapid rise in PSA or upgrading. Novel tools in the AS pathway and a deeper understanding of the biology of prostate malignancies have allowed the approach to be considerably refined.

Prostate cancer screening has evolved significantly over the past 2 decades. Traditional prostate-specific antigen-based approaches reduced mortality but led to overdiagnosis and overtreatment. Contemporary strategies now integrate risk stratification, multiparametric MRI, biomarkers, and genomics to improve the detection of clinically significant disease while minimizing harm. Landmark trials and emerging evidence support a more personalized approach to screening. This article discusses the historical context, challenges, and future directions of prostate cancer screening, emphasizing innovations that aim to enhance early detection and reduce unnecessary interventions.

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.

Benign prostatic hyperplasia (BPH) affects the majority of aging men, with medical therapy representing the first-line treatment of lower urinary tract symptoms (LUTS). This article comprehensively examines current medical therapies, their mechanisms, efficacy, and optimal patient selection strategies through a literature review of pivotal clinical trials, systematic reviews, and treatment guidelines from 2000 to 2024. Medical therapy for BPH/LUTS has evolved from symptom management to disease modification, and combination therapy with alpha-1 adrenergic antagonists and 5-alpha reductase inhibitors represents optimal treatment of men with moderate-to-severe symptoms and enlarged prostates (≥30 mL).

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.

Benign prostatic hyperplasia (BPH) and prostate cancer (PCa) frequently coexist, posing unique challenges for the clinician. This article explores how various surgical and minimally invasive therapies for BPH can be utilized in patients with PCa, including those managing with active surveillance or pursuing radiation treatment. The discussion herein highlights the efficacy, complications, and oncological implications of these treatments. Ultimately, treatment selection requires shared decision-making and a multidisciplinary approach to achieving symptom relief while maintaining cancer control. Future research will be critical to refine best practices and assess long-term outcomes in these clinical situations.