The present and the future of urological management of prostate cancer

The incidence of prostate cancer is increasing in high-income regions, with a global 161.53% increase from 1990 to 2021, making it the second most common cancer among men after lung cancer (1). Part of this growth is linked to modifiable risk factors due to changes in lifestyle habits which are shifting our management plans to prevention as well (2). In addition to primary prevention, several improvements in medical and surgical treatments over the past two decades have changed the landscape for physicians and patients with prostate cancer. Some of the most relevant emerging issues have been discussed in this special series “New Evidence and Advances in Surgical Treatment of Prostate Cancer”. The first one is the continuous improvements in robotic surgery, not only in terms of expanding our indications in very complex cases, guaranteeing the same functional and oncological outcomes in patients with previous radiotherapy or prostate surgery (3,4), but also in terms of different approaches (trans-peritoneal versus extra-peritoneal, multi-port versus single-port) (5,6). Furthermore, robotic surgery, in addition to facilitating procedures, opens up new possibilities for training, particularly with the modular training console and the virtual reality simulator (7).

A further interesting topic is the advent of new robotic platforms. Nowadays, after more than 20 years of availability of a single robotic platform, new platforms have been introduced on the market. Currently, there is no data regarding the advantages and limitations of one platform compared to another (8), but the presence of different platforms is certainly a new stimulus for researchers and industries.

Another extremely important aspect is the advancement of imaging modalities such as the ex vivo fluorescent confocal microscope, the multiparametric magnetic resonance imaging (MRI), the 3D virtual models and augmented reality to guide the nerve-sparing procedures and reduce the rate of surgical margins during radical prostatectomy, and prostate-specific membrane antigen-positron emission tomography (PSMA-PET) to detect lymph nodes metastasis (9-12). All these new imaging modalities aim to improve surgical precision and permit gaining the trifecta outcomes (13). In particular, the role of pre-operative PSMA-PET in deciding whether to perform lymphadenectomy or not is the most promising field of investigation (14,15).

However, all these data should be analysed and incorporated in nomograms to guide our decisions and predict prognosis. Artificial intelligence (AI) is the next frontier in medicine for managing and integrating these data. These innovations are an incentive for a new evolution of technology with the integration of AI into robotic platforms (5,16).

Last but not least, the new hormonal agents are a further interesting topic. According to international guidelines, androgen receptor target therapies are recommended only in hormone-sensitive metastatic prostate cancer (abiraterone, apalutamide, enzalutamide/prednisone and darolutamide plus docetaxel) and abiraterone only in cN0M0 patients with at least 2 risk factors (cT3–4, Gleason ≥8 or prostate-specific antigen ≥40 ng/mL). Due to the efficacy, the practicality and the low side-effect rate (especially for darolutamide) (17), the interest in their employment in the neo-adjuvant or adjuvant setting in hormone-sensitive, high risk, locally advanced or oligometastatic prostate cancer in combination with local treatments (radical prostatectomy or radiotherapy) is rising. However, if literature data are consistent with a benefit in pathologic responses, in terms of downgrading and staging in the neoadjuvant setting, at the same time there is an agreement on the absence of clear advantages in terms of oncological benefits (18-21). Further studies and randomized controlled trials are thus awaited in order to clarify the real role of these new hormonal treatments. We will discuss all of these challenges and opportunities in the present series.

In conclusion, in this special series we have tried to report the novelty and the potential evolution in the surgical treatment of prostate cancer, including the new instruments for improving surgical planning and the potentiality of the new androgen receptor target therapies in a multimodal approach.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Chinese Clinical Oncology for the series “New Evidence and Advances in Surgical Treatment of Prostate Cancer”. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-2025-1-138/coif). The series “New Evidence and Advances in Surgical Treatment of Prostate Cancer” was commissioned by the editorial office without any funding or sponsorship. D.C., S.P. and S.F. served as the unpaid Guest Editors of the series. D.C. also serves as an unpaid editorial board member of Chinese Clinical Oncology from August 2024 to July 2026. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Davide Campobasso

Stefano Puliatti

Stefania Ferretti