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The detection of pancreatic cystic lesions (PCLs) has significantly increased over the past twenty years, mainly due to the widespread use of high-resolution cross-sectional imaging. Among these lesions, intraductal papillary mucinous neoplasms (IPMNs) have become one of the most clinically important entities because they serve as macroscopic precursors in the multistep process leading to pancreatic ductal adenocarcinoma. Their importance stems from their broad biological diversity: while some IPMNs, especially main-duct or mixed-type lesions, carry a high risk of high-grade dysplasia or invasive cancer, most small branch-duct lesions remain stable on imaging over time and may never progress. Over the past decade, international guidelines and more advanced clinical evidence have improved algorithms for risk assessment, monitoring and surgical decisions. Recent research has enhanced our understanding of their long-term natural history, clarified the balance between careful monitoring and unnecessary surveillance, and introduced personalized models that consider cyst stability, growth rate, age, overall health, and economic factors. This review combines current evidence on the epidemiology, pathology, diagnosis, natural progression, monitoring strategies, surgical results, prognostic differences among IPMN subtypes and suggests a modern approach for personalized, value-based care.