Imaging modalities in advanced prostate cancer: Interim analysis of the Spanish cohort of the RING registry.

INTRODUCTION AND OBJECTIVE: Despite superior accuracy of next-generation imaging (NGI) over conventional imaging (CI), its integration into prostate cancer management remains heterogeneous. We describe real-world imaging strategies for primary staging and restaging at biochemical recurrence (BCR) in the Spanish cohort of the RING registry, and identify clinical factors associated with NGI use and stage reclassification. MATERIALS AND METHODS: RING is a prospective, non-interventional, multicentre registry. This analysis included 213 men from six Spanish centres (January 2025-January 2026) undergoing imaging for primary staging (n = 156) or BCR restaging (n = 57). Logistic regression evaluated predictors of NGI use and escalation to NGI after CI. RESULTS: Overall, 63/213 (29.6%) underwent CI only, 114/213 (53.5%) NGI only, and 36/213 (16.9%) both modalities. Among treatment-naïve patients, ISUP ≥ 4 independently predicted NGI use (adjusted OR 3.86, 95% CI 1.35-12.2; p = 0.015). In the BCR cohort, NGI predominated (89.5%). In the both-imaging subgroup (n = 36), CI-to-NGI escalation occurred in 33/36 (91.7%), with stage migration in 16/33 (48.5%): 7 upgrades (43.8%) and 9 downgrades (56.2%). Predictors of escalation were ISUP ≥ 4 (adjusted OR 7.3, 95% CI 1.81-37.5; p = 0.009), higher PSA (OR 1.9 per log2 doubling; p = 0.047), and younger age (OR 0.89/year; p = 0.017). CONCLUSIONS: NGI was the dominant strategy at BCR and in high-grade primary disease. When added after indeterminate CI, NGI reclassified staging in nearly half of patients, with both upgrades and downgrades observed. Further registry follow-up will determine whether imaging pathway influences treatment decisions and long-term patient outcomes.