This special collection focused on some hot topics in the diagnosis and treatment of prostate cancer (PCa) and benign prostatic hyperplasia (BPH) has been developed in collaboration with the scientific office of the Italian Society of Urology (Società Italiana di Urologia—SIU). Promising young Italian urologists conducted interesting systematic reviews of the Literature discussing available evidence together with several international opinion leaders offering to the Prostate Cancer and Prostatic Diseases journal readers accurate and updated papers.

The use of multiparametric Magnetic Resonance Imaging (mpMRI) significantly revolutionized the diagnosis of PCa allowing us to perform targeted prostate biopsy (MRI-TBx) of visible suspicious lesions (PI-RADS 4 and 5). However, controversies are still present about the best technique to guide MRI-TBx. Indeed, current knowledge comparing the different MRI-TBx techniques is limited. In this collection articles, Falagario et al. performed a systematic review and meta-analysis of studies comparing MRI-TBx using cognitive registration, software-assisted image fusion or in-bore guidance in terms of clinically significant (csPCa) or insignificant PCa (iPCa) detection rates and complication rates [1]. A total of twenty studies including 4,928 patients were analyzed by the Authors. Meta-analyses showed no differences between the different methods used to guide MRI-TBx both in terms of csPCa and iPCa detection rates. Similarly, cognitive, fusion or in-bore TBx were associated with comparable complication rates.

These data confirmed those previously reported in other two meta-analyses suffering of a potential more limited validity because of not restricted to comparative studies [2, 3]. Therefore, according to Falagario et al. the choice between the different techniques to guide the MRI-TBx should be influenced by resource availability, cost-effectiveness, and operator preferences. Moreover, patients should be appropriately counseled before prostate biopsy and informed that more complex software-assisted image fusion TBx or more expansive in-bore guided TBx seems not improve the detection rate of csPCa in comparison with the easier and cheaper cognitive approach. New well-conducted studies, as well as new target biopsy platforms and more accurate imaging analysis techniques, could offer us a completely new scenario over the next years.

Another promising novel imaging modality in the management of PCa is represented by the Positron Emission Tomography-Computed Tomography using Prostate-Specific Membrane Antigen (PSMA PET/CT). The use of PSMA PET/CT in clinical practice is mainly recommended in the evaluation of patients with suspicious PCa recurrence after treatment of primary tumor. However, several clinicians support the use of PSMA PET/CT scan instead of conventional imaging (abdominal-pelvic CT and bone scan) in nodal and metastasis staging before curative-intent surgery or radiotherapy [4]. To investigate this interesting topic, Mari et al. performed a systematic review of the Literature evaluating the diagnostic accuracy of PSMA PET/CT in the initial staging of PCa. Meta-analysis of available studies showed that PSMA PET/CT scan is really promising to detect seminal vesicle invasion and lymph nodes involvement [5]. Data reporting the performance of PSMA PET/CT in the detection of patients with lymph nodes involvement suggest that while the test reliably identifies true negatives, its ability to identify true positives may be less consistent. Therefore, patients with high-risk PCa without lymph node involvement at PSMA PET/CT could avoid pelvic lymphadenectomy during radical prostatectomy, reducing the morbidity of the surgical procedure. Few studies evaluated the role of PSMA PET/CT in the definition of the extraprostatic extension. Although preliminary data seems to be promising, further studies are needed to better investigate the potential role of PSA PET/CT scan.

Two articles in this collection have been focused on radical prostatectomy. In the last decades, new robotic approaches have been proposed mainly with the objective of improving functional outcomes. In their systematic review of the Literature Ficarra et al. evaluated the impact of transperitoneal anterior, Retzius-sparing (RS), extraperitoneal, transvesical and perineal approaches on urinary continence recovery in patients who underwent robot-assisted radical prostatectomy [6]. This is a timely article considering the recent introduction of single-port and novel multiport robotic platforms. Notably, the meta-analysis of studies comparing anterior Vs posterior (RS) RARP showed a better urinary continence rate in patients who underwent RS-RARP at all the evaluated different follow-ups. However, meta-analysis of available RCTs (Level 1 of evidence) showed a significant advantage immediately after catheter removal, 1- and 3-mo after surgical procedure. The preservation of pre-vesical and lateral fibro-connective tissue, as well as the limited demolition or the total preservation of the anterior anatomical structures involved in the urinary continence, represent the anatomical rationale justifying the advantages of RS-RARP in comparison to the transperitoneal anterior approach in terms of early urinary continence recovery. However, further studies confirming the oncologic safety of the RS approach in terms of biochemical recurrence-free survival are needed. Notably, in their systematic review of the Literature Ficarra et al. also considered studies comparing SP versus multi-port (MP) RARP showing similar urinary continence rates at different follow-up time points regardless of the extraperitoneal or transvesical approach used with the SP platform.

The Da Vinci Single-Port (SP) has led urologists to reconsider the less commonly used extraperitoneal and transvesical approaches with the multiport platform. In particular, the transvesical approach offers a valid way to perform both simple and radical prostatectomy using the SP platform. Systematic review and meta-analysis performed by Franco et al. confirmed that extraperitoneal and transvesical approaches can reduce postoperative pain and in-hospital stay time in patients requiring prostatic surgery for both benign prostatic hyperplasia and PCa [7]. These advantages could compensate for the higher disposable costs with SP. Interestingly, most of the studies included in the review were performed in referral centers in United States (US). Well-conducted cost-effectiveness studies comparing SP and MP procedures will be strongly needed to justify the use of SP technology instead of MP ones. Notably, cost-effectiveness studies will have to consider the different health system models because some advantages in United States health system could be less relevant in different countries of European Union.

Literature reporting sexual outcomes after radical prostatectomy is mainly oriented on heterosexual men. However, it is estimated that one in six men who have sex with men (MSM) receive a PCa diagnosis over their lifetime. MSM who received radical prostatectomy may experience all sexual dysfunctions also experienced by men who have sex with women (MSW), but they also complain of specific problems due to the different dynamic of their intimacy. Notably, these men often receive insufficient information about potential side effects of cancer therapies that address their specific sexual behaviors. Interestingly, in their systematic review of the Literature, Vedovo et al. analyzed sexual outcomes after radical prostatectomy in MSM [8]. Available studies showed that in men undergoing insertive anal intercourses (AI) erectile dysfunction may have a more pronounced effect in comparison with MSW because they need firmer erections than vaginal intercourse. Moreover, MSM candidates to radical prostatectomy must be carefully informed about potential sexual dysfunction such as painful AI, anodyspareunia, loss of the ability to ejaculate and the appearance of climacturia during oral sex. Lessons learned from Vedovi et al. are that urologists must carefully take into consideration sexual orientation of their patient’s candidate to radical prostatectomy to adapt preoperative counseling and post-operative rehabilitation. Notably, specific questionnaires evaluating sexual behaviors in MSM should be tested and validated.

External-beam radiation therapy (EBRT) represents a valid treatment with curative intent for patients with organ-confined PCa. However, management of radio-recurrent disease is a challenging clinical scenario, with androgen deprivation therapy (ADT) remaining the most frequently adopted strategy. Moreover, guidelines strongly recommended offering local salvage treatments to highly selected patients in the context of clinical trials or well-designed prospective cohort studies [9]. Local salvage treatment could improve the local control of the disease reducing the potential risk of metastatic spread of the disease and postponing the need for systemic therapies. Creta et al. focused their systematic review of the Literature on this controversial and few explored topics with the aim of identifying the best strategy to treat patients with local recurrence after external-beam radiotherapy [10]. Salvage options evaluated include re-irradiation through brachytherapy (BT), re-EBRT, High-Intensity Focused Ultrasound (HIFU), radical prostatectomy, and cryotherapy. Creta et al. highlighted that BT represents the best re-irradiation option due to the ability to deliver high conformal high-dose radiation with a step-dose gradient and rapid fall-off. However, BT requires expertise and should be performed in high-volume expert centers. Promising results were also reported after the non-invasive stereotactic body radiation therapy. Considering the available limited evidence, the use of other salvage procedures in patients with radio-recurrent PCa should be further evaluated in well-designed clinical studies.