More than 2,000 abstracts were presented at the 2026 annual meeting of the American Urological Association (AUA), spanning nearly every aspect of urologic care. This review highlights several important and evolving areas in prostate cancer diagnosis and treatment, focusing on challenges in risk stratification, active surveillance, focal therapy, and emerging applications of artificial intelligence (AI).
Guidelines increasingly recommend mpMRI before prostate biopsy in men with elevated PSA or suspected prostate cancer (PCa). While mpMRI has improved detection of clinically significant prostate cancer (csPCa)—the cases most likely to require treatment—it remains imperfect. Negative MRI findings, as well as negative biopsies in men with suspicious imaging, do not fully eliminate the possibility of significant underlying disease. Several presentations at this year’s meeting addressed these diagnostic limitations.
Wang et al. evaluated the role of PSA density (PSAD), calculated by dividing serum PSA by prostate volume measured on MRI, as an adjunct to biopsy decision-making. Increasing PSAD was associated with progressively higher detection rates of csPCa, rising from 32.5% among men with PSAD <0.10 to 80.3% among those with PSAD >0.20. Detection rates for intermediate PSAD ranges were 45.6% (0.10–0.15) and 59.7% (0.15–0.20). The authors concluded that incorporating PSAD thresholds into biopsy planning may help reduce unnecessary procedures while improving identification of higher-risk patients, especially in men with a negative mpMRI.
Micro-ultrasound (MUS) is another emerging technology that may complement MRI in prostate cancer detection. MUS uses very high frequency waves (29 MHz) and provides over 300% image resolution improvement compared to standard technology. Filho et al. studied 339 men who underwent both MRI and MUS before biopsy. Among patients with negative MRI findings, MUS identified clinically significant prostate cancer in 62.5% of ultrasound-suspicious lesions, suggesting a potential role for MUS in detecting cancers that might otherwise be missed.
Approximately 40–60% of men diagnosed with localized prostate cancer are candidates for active surveillance (AS). Current guidelines recommend confirmatory biopsy within 12 months of diagnosis because prior studies have demonstrated the disease upgrading in 20–45% of patients. Wan et al. evaluated 733 men managed with AS between 2018 and 2024 and found that 530 (73.3%) underwent confirmatory biopsy within 24 months. Among those re-biopsied, 34.5% demonstrated upgrading of disease severity. These findings underscore the importance of adherence to surveillance protocols and timely follow-up to identify patients who may require definitive treatment.
Definitive treatment for localized prostate cancer has traditionally consisted of radical prostatectomy or radiation therapy. Unlike breast cancer, where breast-conserving approaches are common, partial gland ablation or focal therapy have not yet become standard practice. Nevertheless, multiple centers presented outcomes using focal treatment modalities, including high-intensity focused ultrasound (HIFU), cryotherapy, and brachytherapy.
Although surgery and radiation may result in recurrence, persistent or recurrent disease following focal therapy also remains an important concern. Recurrences may occur within the treated area (in-field) or outside the treatment zone (out-of-field). Light et al. analyzed outcomes among 1,050 patients treated with HIFU (n=718) or cryotherapy (n=332), reporting a five-year cumulative incidence of recurrent cancer of 18.3% (95% CI 14.8–22.1). Similarly, Reddy et al. evaluated 575 patients from seven centers treated with HIFU or cryotherapy who subsequently underwent biopsy surveillance. Positive in-field biopsies were identified in 16.7% of patients, emphasizing the need for rigorous post-treatment monitoring, preserving the potential for early salvage therapy.
Reducing recurrence rates remains critical to realizing the full potential of focal therapy. Govorov et al. analyzed outcomes from 180 focal HIFU procedures in men with MRI-visible index lesions (PIRADS ≥3) and clinically significant disease (ISUP Grade Group ≥2). One-year recurrence was assessed using MRI-guided transperineal fusion biopsy. Local recurrence rates declined from 24.5% to 15.8% over time (p=0.018), coinciding with increased treatment energy density (25.2 to 38.5 kJ/cc; p=0.02), wider treatment margins (10.5 mm vs 5 mm; p<0.01), and a transition from highly focal therapy toward quadrant ablation approaches. The authors suggested that broader margins and greater energy delivery may improve local tumor control following focal HIFU.
AI is also beginning to emerge as a potential tool for predicting treatment outcomes after focal therapy. Sonawane et al. applied a previously trained deep-learning model (3D nnU-Net) to biparametric MRI studies from men undergoing HIFU. The model generated more than 1,100 quantitative imaging features from the ablated region and achieved modest predictive performance (AUC 0.68 ± 0.08), with significant separation between recurrence risk groups (p<0.05). Although preliminary, these findings suggest AI-assisted imaging analysis may eventually enhance patient selection and individualized treatment planning.
Collectively, these studies highlight a central challenge in contemporary prostate cancer management: balancing efforts to reduce overtreatment while minimizing missed clinically significant disease. Advances in MRI interpretation, PSA density assessment, micro-ultrasound, focal therapy optimization, and AI-based imaging analysis may improve individualized care. However, continued surveillance, confirmatory testing, and careful follow-up remain essential components of effective prostate cancer management.
Dr. Stone has no relevant conflicts of interest to report.
Image by rob dobi / Getty Images
