Urology

Definitive local therapy did not improve PFS in de novo metastatic prostate cancer

This phase 2 trial randomized 119 men with de novo metastatic prostate cancer after 6 months of best systemic therapy to local therapy or continued systemic therapy alone. Median progression-free survival was 17.9 months with systemic therapy alone and 14.8 months with added prostate surgery or radiotherapy (HR 0.89; p = 0.6). Grade 3 toxicity occurred only in the local-therapy arm (6.7%), indicating added morbidity without PFS gain. More patients without planned local therapy later required palliative prostate interventions or crossover, suggesting local treatment may still aid symptom control. 1

High NPV of negative PSMA PET for nodal disease in intermediate-risk prostate cancer

This systematic review and meta-analysis included 12 studies with 1619 intermediate-risk men undergoing PSMA PET/CT before radical prostatectomy. Pooled sensitivity and specificity for lymph node invasion were 49% and 95%, respectively, against histopathology and clinical follow-up. The pooled negative predictive value was 95%, indicating few nodal metastases among patients with negative PSMA PET. Authors suggest pelvic lymph node dissection may be omitted for intermediate-risk patients with negative PSMA PET, using shared decision-making. 2

BCG-failure subgroups in NMIBC show marked heterogeneity in progression risk

This multicentre cohort study evaluated 591 patients with high-grade NMIBC recurrences after BCG using International Bladder Cancer Group categories. Overall, BCG-unresponsive and BCG-exposed disease showed similar progression-free survival, cancer-specific mortality, and overall mortality. Five refined subgroups had divergent 5-year progression: about 30% for BCG-unresponsive, late relapse after adequate BCG, and BCG-exposed with inadequate BCG. BCG-resistant and very late relapse subgroups had lower 5-year progression rates of 6.2% and 14%, respectively. 3

Darolutamide outperforms other AR inhibitors in real-world nmCRPC practice

DEAR-EXT analyzed 1375 US nmCRPC patients starting darolutamide, enzalutamide, or apalutamide in routine urology practices. After adjustment, discontinuation risk was lower with darolutamide versus enzalutamide (HR 0.73) and apalutamide (HR 0.69). Risk of progression to metastatic CRPC was also reduced with darolutamide versus enzalutamide (HR 0.63) and apalutamide (HR 0.72). Metastasis-free survival favored darolutamide, with higher 24- and 36-month MFS rates than the comparator AR inhibitors. 4