Our aim was to evaluate the effect of addition of radical prostatectomy (RP) to best systemic therapy (BST) on cancer-specific mortality (CSM) in patients with oligometastatic prostate cancer (omPC). This randomised controlled trial included patients with omPC with a low metastatic burden (1-5 bone metastases with/without nodal involvement) on conventional or PET imaging. Patients were randomised to receive either RP with pelvic lymph-node dissection plus BST (RP + BST) or BST alone. The primary endpoint was CSM. Secondary endpoints included clinical progression and overall survival (OS). Study accrual was stopped early because of a change in medical practice. Statistical analyses included cumulative incidence plots, Gray's test, competing-risks regression, Kaplan-Meier estimates, and log-rank tests. Between May 2015 and December 2018, 132 patients were randomised. The median age was 67 yr (interquartile range 63-71) and median prostate-specific antigen was 20 ng/ml (interquartile range 10-39). The 5-yr CSM cumulative incidence was 13% for RP + BST and 23% for BST alone (p = 0.037), with a hazard ratio of 0.39 (95% confidence interval 0.16-0.98; p = 0.045). The 5-yr cumulative incidence of clinical progression including CSM was 59% for RP + BST and 60% for BST alone. The 5-yr OS rate was 81% for RP + BST and 74% for BST alone. Clavien-Dindo grade ≥III surgery-related complications occurred in nine of 66 (14%) patients in the RP + BST arm. Limitations include early discontinuation of study accrual and the lack of statistical significance for the OS benefit. While this trial has substantial limitations, the results support addition of RP as local therapy to BST in omPC. This trial is registered on ClinicalTrials.gov as NCT02454543.

Objectives: It is not known whether cancer‐specific mortality (CSM) differences distinguish radical cystectomy (RC) from trimodal therapy (TMT) in octogenarians harbouring organ‐confined (T2N0M0) urothelial cancer of the urinary bladder (UCUB). Methods: Within the Surveillance, Epidemiology, and End Results database (2004–2021), CSM and other‐cause mortality (OCM) rates were computed in octogenarian patients with organ‐confined UCUB undergoing either TMT or RC. Smoothed cumulative incidence plots depicted 5‐year CSM and OCM rates according to RC vs TMT. Competing risks regression (CRR) models were fitted, adjusting for age, gender, and race/ethnicity. Nearest‐neighbour 1:1 propensity‐score matching (PSM) for age and gender was also applied. Sensitivity analyses were additionally performed, focusing on White patients. Results: Of 2335 octogenarian patients with T2N0M0 UCUB, 1562 (66.3%) received TMT and 793 (33.7%) received RC. Of those, 2082 (88.4%) were White. TMT rates increased from 53.5% in 2004 to 82.2% in 2021 ( P < 0.001). The 5‐year CSM rate was 50.1% for TMT vs 31.1% for RC. After multivariable CRR, TMT independently predicted 1.7‐fold higher CSM ( P < 0.001). After additional PSM, TMT also independently predicted 1.7‐fold higher CSM ( P < 0.001). In sensitivity analyses exclusively focusing on White patients, almost identical results were recorded. Conclusion: Rates of TMT have nearly doubled in octogenarian patients with organ‐confined UCUB in recent years; however, CSM rates after TMT are also nearly twice as high as those observed after RC. It is crucial to communicate these observations.

Introduction: Leukemia history affects some radical prostatectomy (RP) patients. Although its prevalence and effect as an adverse risk factor are well known in cardiac surgery, the number of RP patients with a leukemia history, as well as their rate of adverse in-hospital outcomes, are unknown. Methods: We identified RP patients (National Inpatient Sample 2000–2019), stratified according to the presence or absence of a leukemia history. Descriptive analyses, propensity score matching (PSM, ratio 1:10), and multivariable logistic regression models were used. Results: Of 259,939 RP patients, 416 (0.2%) had a leukemia history. Their proportion increased from 0.1 to 0.2% covering the study span (p < 0.01). Leukemia history patients were older (median age, 64 vs. 62 years, p < 0.001). After PSM for age, insurance status, ethnicity, pelvic lymph node dissection, and Charlson Comorbidity Index, leukemia history RP patients exhibited higher rates of acute kidney injury (<2.6 vs. 0.9%; Odds Ratio [OR] 2.0, p = 0.02), more frequently underwent dialysis (3.6 vs. 1.9%; OR 1.9, p = 0.03), and more frequently had a length of stay exceeding one week (4.8 vs. 2.5%; OR 2.0, p = 0.006). Conclusions: Although leukemia history RP patients are rare, their numbers have increased. Renal complications and extended hospital stays are more frequent in those individuals.

Background: Despite modern imaging modalities, lymph-node staging before radical prostatectomy (RP) remains challenging in patients with prostate cancer (PCa). The visibility of lymph-node metastases (LNMs) is critically influenced by their size. Objective: This study aims to describe the distribution of maximal tumor diameters (i.e., size) in LNMs of pN1-PCa at RP and its consequences on visibility in preoperative imaging and oncological outcomes. Design, setting, and participants: A total of 2705 consecutive patients with pN1-PCa at RP, harboring a cumulative 7510 LNMs, were analyzed. Descriptive and multivariable analyses addressed the risk of micrometastases (MM)-only disease and the visibility of LNMs. Kaplan–Meier curves and Cox analyses were used for biochemical recurrence-free survival (BCRFS) stratified for MM-only disease. Results: The median LNM size was 4.5mm (interquartile range (IQR): 2.0–9.0 mm). Of 7510 LNMs, 1966 (26%) were MM (≤ 2mm). On preoperative imaging, 526 patients (19%) showed suspicious findings (PSMA-PET/CT: 169/344, 49%). In multivariable analysis, prostate-specific antigen (PSA) (OR 0.98), age (OR 1.01), a Gleason score greater than 7 at biopsy (OR 0.73), percentage of positive cores at biopsy (OR 0.36), and neoadjuvant treatment (OR 0.51) emerged as independent predictors for less MM-only disease (p < 0.05). Patients with MM-only disease compared to those harboring larger LNMs had a longer BCRFS (median 60 versus 29 months, p < 0.0001). Conclusion: Overall, 26% of LNMs were MM (≤ 2mm). Adverse clinical parameters were inversely associated with MM at RP. Consequently, PSMA-PET/CT did not detect a substantial proportion of LNMs. LNM size and count are relevant for prognosis.