Prostate cancer is the most common solid neoplasm in men, with an increasing incidence. This study describes clinical and sociodemographic features and PSA levels, and evaluate their associations with stage, risk categories, metastasis, and mortality in a public tertiary hospital in southern Colombia. The present retrospective cohort study included 590 patients diagnosed with prostate cancer between 2020 and 2023. Sociodemographic and clinical variables, PSA levels, pathological characteristics and risk scales were analyzed. Patients were categorized into two groups: living (n = 429) and deceased by prostate cancer (n = 109), and other causes (n = 44). Statistical analyses were performed to determine associations with mortality and presence of metastasis. PSA screening was more frequent among survivors (66.9%, n = 287) than among deceased (22.0%, n = 24; p < 0.001). Median PSA at diagnosis was higher in those who died (123 vs 16 ng/mL; p < 0.001). PSA > 100 ng/mL was associated with ~50% probability of metastatic disease, rising to >95% for PSA > 323 ng/mL. High-risk D'Amico classification was strongly associated with metastasis (RR 6.67) and mortality (OR 14.24, p < 0.001). Bone pain was the predominant presenting symptom in the deceased group (76.1%, n = 83) and showed a strong association with metastasis (RR 8.146). PSA screening was strongly associated with improved survival outcomes. Elevated PSA levels, high risk D'Amico classification and the presence of bone pain were important predictors of metastasis and mortality. The need to strengthen early detection in our population is evident, given the high percentage of patients presenting at advanced stages.

ObjectiveThe objective of the study was to determine the prevalence of elevated PSA levels (> 4.0 ng/mL) and examine sociodemographic and modifiable lifestyle risk factors associated with PSA elevation among asymptomatic Rwandan men aged ≥ 40 years.Material and MethodsA cross-sectional study was conducted at Kabutare District Hospital in Rwanda between March and April 2025, enrolling 136 asymptomatic male participants aged ≥ 40 years. Lifestyle and anthropometric data were collected via structured interviews. Serum total PSA was measured using the enzyme linked immunosorbent assay (Fortress BXE0851A kit). Elevated PSA was defined as > 4.0 ng/mL. Statistical analyses included descriptive statistics and Chi-square/Fisher’s exact tests for bivariate associations.ResultsElevated PSA was observed in 14% of participants. Chi-square analysis revealed significant associations between elevated PSA and BMI category (p < 0.001), smoking status (p < 0.001), alcohol use (p < 0.001), sexual activity frequency (p = 0.018), and occupation (p < 0.001).ConclusionElevated PSA prevalence among asymptomatic Rwandan men mirrors global patterns observed in Black populations. Associations with underweight status, occupational exposure, and alcohol use suggest multifactorial influences. These findings highlight the need for targeted screening strategies and community-level interventions to promote early prostate cancer detection in Rwanda.

Abstract Introduction Neuroendocrine tumours (NETs) of the small bowel are often indolent but typically present late with metastatic disease. Management becomes particularly complex in the presence of bilobar liver metastases and carcinoid heart disease. A multidisciplinary, multimodal approach is essential to achieve disease control and optimise patient outcomes in such challenging scenarios. Case Presentation A 58-year-old male was incidentally diagnosed with a DOTATATE-avid jejunal NET and extensive bilobar liver metastases during workup for elevated PSA. Further complexity was added by carcinoid heart disease requiring tricuspid valve replacement. Initial management involved bland embolisation of a dominant segment IVb/V liver lesion. This was followed by debulking surgery with non-anatomical resection of liver segments IVb, V, and VI, and cholecystectomy. Histology confirmed well-differentiated G1 NET with Ki-67 &amp;lt;2%. Residual left-lobe liver disease was treated with image-guided Irreversible Electroporation (IRE). Final surgical intervention included complete resection of the jejunal primary, mesenteric nodal clearance, and redo non-anatomical resection of liver segments VII and VIII. Discussion The case illustrates the value of a sequential, MDT-guided treatment strategy incorporating embolisation, surgical resection, and ablative therapies to manage extensive metastatic NET while addressing associated systemic disease. Conclusions The patient recovered well after surgery. Follow-up imaging shows no evidence of recurrence. Complete resection of the primary tumour has been achieved, and the case is currently pending further review at the specialist NET MDT.

An 81-year-old man was found to have an elevated PSA, prompting a prostate biopsy that revealed Gleason grade 7 (3+4) prostate cancer. For staging purposes, an 18F-DCFPyL PSMA PET/CT was performed, which demonstrated focal uptake in the pituitary region corresponding to a suprasellar mass. Subsequent pituitary MRI confirmed the presence of a pituitary macroadenoma. The expanding global use of PSMA PET has increasingly revealed PSMA ligand uptake in a variety of non-prostatic benign and malignant conditions, creating false positive results. Our case highlights that pituitary macroadenoma may have strong PSMA expression and should be recognized as a potential imaging pitfall.

Prostate adenocarcinoma is mainly diagnosed based on serum PSA levels, but elevated PSA levels can also be caused by BPH, which weakens its specificity. Recent scientific studies have demonstrated that specific microRNAs regulate cancer cell proliferation by modulating the Wnt/β-catenin pathway. To date, no published literature has provided a comprehensive assessment of the interactions between miR-106a-5p and miR-375-3p and components of the Wnt/β-catenin pathway in prostate cancer. Therefore, the aim of the present study was to perform a pilot evaluation of the expression of miRNAs 106a-5p and 375-3p, as well as β-catenin, Fzd8, Wnt5a, and cyclin D1 in prostate adenocarcinoma compared with BPH. The study material consisted of samples collected from 30 patients with prostate cancer and 30 with BPH. Protein expression was analyzed using IHC and qRT-PCR methods, while miRNA levels were quantified by dPCR. Our study results revealed lower immunoreactivity and expression of genes encoding β-catenin, Fzd8, Wnt5a, and cyclin D1 and significantly higher fluorescence intensity of miRNA 106a-5p and 375-3p with prostate adenocarcinoma compared to BPH. These parallel alterations in miRNA expression and Wnt/β-catenin-related components reflect disease-specific expression patterns and warrant further investigation in larger cohorts to determine their potential utility as diagnostic biomarkers in prostate diseases.

Abstract Introduction While prostate cancer (PCa) diagnosis and treatment are known to increase mental health (MH) risks, less is understood about the psychological distress during each specific phase of the journey, such as that instigated by erectile dysfunction (ED) and urinary incontinence (UI). Clarifying MH risks for patients with ED and UI throughout the prostate cancer care continuum is crucial for appropriate patient counseling, timely intervention, and improved support. Objective To assess the incidence and risk of MH disorders among men with ED and UI as they progress through evaluation and management of PCa. Methods A retrospective cohort study was conducted using IBM MarketScan claims database between 2011–2020. Using ICD9/10 and CPT codes, we identified all patients with a diagnosis of PCa and matched each to a control without PCa by age and Charlson comorbidity index (CCI), modified to exclude cancer diagnoses. Controls with elevated PSA or biopsy were also excluded. For PCa cases, groups were a time-varying covariate that patients moved through depending on where they were in the prostate cancer journey. The six groups analyzed were: controls, pre-cancer (PCa patients prior to work-up of elevated PSA or diagnosis), elevated PSA/biopsy (PCa patients prior to PCa diagnosis), watching (PCa patients with a diagnosis of PCa without treatment), prostatectomy and radiation. We noted the first diagnosis of ED and UI for each patient as well as any MH diagnoses, including depressive disorders, anxiety disorders, substance use disorders, and self-harm/suicidality. Multivariable Cox proportional hazard models were used to assess the relationship between PCa, ED, or UI, and MH diagnoses. Interaction terms between PCa status and ED or UI were included to test for differential responses to urologic comorbidities between cancer patients and cancer-free controls. Results A total of 1,323,072 men (661,536 controls; 661,536 PCa patients) were included in the analysis. PCa patients without ED or UI showed a significantly decreased risk of being diagnosed with a MH condition compared to controls (HR for the pre-cancer, elevated PSA/biopsy, watching, prostatectomy and radiation groups: 0.902 (0.88-0.92), 0.811 (0.78-0.85), 0.96 (0.94-0.97) 0.79 (0.752-0.835) and 0.93 (0.89-0.96), respectively; p &amp;lt;0.001). MH diagnosis was significantly increased in controls with ED (HR: 1.61 (1.13-1.19); p&amp;lt;0.001) and the effect was significantly ameliorated in the watching, prostatectomy and radiation groups (ED*group interaction HRs: 0.87 (0.84–0.90), 0.87 (0.81-0.93) and 0.85 (0.79-0.92), respectively; p&amp;lt;0.01). UI also significantly increased the likelihood of a MH diagnosis in controls (HR: 2.02 (1.94-2.10); p&amp;lt;0.001) and the effect was significantly dampened in all PCa groups (UI*group interaction HR for the pre-cancer, elevated PSA/biopsy, watching, prostatectomy and radiation groups: 0.85 (0.76-0.95), 0.80 (0.67-0.97), 0.69 (0.65-0.72), 0.55 (0.51-0.60) and 0.70 (0.62-0.78), respectively; p&amp;lt;0.02). Conclusions ED and UI were independently linked to higher MH risk, particularly among controls, but their effect was less pronounced in men with PCa-supporting the "cancer paradox," where psychological impact of functional decline is mitigated by cancer context. Appropriate counseling and resources are necessary to support patients at all stages in the PCa journey to further decrease the risk of MH diagnoses. Disclosure No

Background/Objectives: Elevated PSAs combined with an abnormal digital rectal examination (DRE) are strong indicators of the possibility of a prostate cancer (PCa) and are used to guide biopsy decisions. We evaluated whether PROSTest, a novel, clinically validated, blood-based multigene mRNA test could aid in biopsy decision-making irrespective of DRE results in subjects ≥45 years with PSA ≥ 3 ng/mL. Methods: A retrospective cohort analysis was performed with a prespecified statistical analysis plan to test the null hypothesis that an abnormal DRE does not materially affect the sensitivity, specificity, or overall stratification performance of PROSTest. The pool included 327 subjects aged ≥45 years with abnormal PSA (≥3 ng/mL) who had undergone DRE and prostate biopsy. Diagnostic performance of PROSTest (measured pre-biopsy) was evaluated within two PSA strata (3-10 ng/mL and >10 ng/mL) and compared to DRE in the same strata. Metrics including sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. Results: Among 327 subjects, 215 had PSA 3-10 ng/mL and 112 had PSA > 10 ng/mL. A total of 131 cancers (40.1%) were diagnosed. PROSTest achieved high sensitivity (93.9-96.6%), specificity (82.4-92.7%), and overall accuracy (up to 94.1%) across all DRE/PSA combinations. The DRE+/PROSTest+ group demonstrated similarly high sensitivity (96.6%) and specificity (92.7%), comparable to the DRE-/PROSTest+ group. Multivariate analysis confirmed PROSTest as an independent predictor of PCa (OR: 154, p < 0.0001), outperforming DRE. Conclusions: PROSTest provides highly accurate risk stratification in men with elevated PSA, independent of DRE findings and may be used with PSA to much more effectively guide biopsy decisions.

ABSTRACT Prostate cancer is typically the leading diagnosis in patients with elevated PSA and abnormal digital rectal exam findings. Clinicians should consider mimickers such as xanthogranulomatous prostatitis in the differential diagnosis, particularly in cases with discordant PSA levels and imaging characteristics. A multidisciplinary approach integrating clinical, radiological, and histopathological findings is essential to avoid misdiagnosis and ensure accurate management.

A case of composite lymphoma and multiple cancer diagnoses in an individual heterozygous for FANCI variant

Abstract Introduction/Objective PIN4 stain is routinely used to differentiate benign and malignant atypical foci of prostate glands. However, rare cases exhibit aberrant p63 expression, posing a diagnostic challenge. This report presents two such cases. Methods/Case Report Two cases identified during routine sign-out at our institution from 2020-2024 are described herein with detailed immunohistochemistry work-up. Results Case1: A 71-year-old patient with elevated PSA underwent prostate biopsy. 3/12 specimens showed foci suspicious for carcinoma but required PIN 4 confirmation. PIN4 stain showed nuclear positivity in foci of interest, suggesting a benign pattern. Given high suspicion additional immunostains were performed, showing positivity for NKX3.1 and p63 and negative staining for CK5/6, 34BE12 and GATA3, clinching the diagnosis of GS3 + 4=7 prostatic adenocarcinoma with aberrant p63 expression. Case2: A 63-year-old male underwent cystoprostatectomy for urothelial carcinoma. Incidental focus (&amp;lt;1% tissue) concerning prostate adenocarcinoma was identified. PIN4 showed non-basal nuclear positivity. CK5/6 showed absence of basal cells, consistent with p63-positive prostate adenocarcinoma (GS3 + 3=6). Perineural invasion supported the diagnosis. Conclusion Careful correlation with H&amp;E features and recognition of luminal rather than basal cell p63 positivity can prevent misdiagnosis in p63+ prostate carcinoma. If H&amp;E is worrisome and PIN 4 stain favors benign, use of individual stains is recommended.

Objective: The objective of the study is to evaluate rates of clinically significant prostate cancer (CSPC) in patients referred with abnormal DRE, elevated PSA or both, on the NHS England Best-Timed Pathway for Prostate Cancer (BTiPP). Patients and Method: Patients referred on a BTiPP in 2021 were grouped into Abnormal DRE with Normal PSA, Elevated PSA with Normal DRE and Abnormal DRE with Elevated PSA. The primary outcome was diagnosis of CSPC. For patients who underwent an MRI, a secondary outcome was abnormal MRI. Multivariate logistic regression models were developed to estimate adjusted odds ratios (aORs) for CSPC and abnormal MRI. Results: A total of 399 patients were included for analysis. Age was comparable across the groups. Compared with the Abnormal DRE with Normal PSA group, the odds of CSPC were significantly higher in the Abnormal DRE with Elevated PSA group (aOR = 6.81; p &lt; 0.01) but not the Elevated PSA with Normal DRE group (aOR = 1.32; p = 0.46). A total of 291 patients underwent MRI and compared with the Abnormal DRE with Normal PSA group the odds of abnormal MRI were significantly higher in the Abnormal DRE with Elevated PSA group but not in the Elevated PSA with Normal DRE group. Conclusion: Abnormal DRE with Elevated PSA is associated with higher odds of CSPC and abnormal MRI, compared with Elevated PSA with Normal DRE or Abnormal DRE with Normal PSA. About 12.4% of Abnormal DRE with Normal PSA patients were diagnosed with CSPC. This highlights the continued relevance of DRE in men referred with suspected prostate cancer. Level of evidence: 3b (single case-control study)

Interleukin gene polymorphisms (IL1B, IL6, IL10, IL16, IL28B) increase prostate cancer risk and associate with aggressive disease features in Iraqi men: A case-control study.

The need for prostate cancer (PCa)-specific biomarkers that enable more accurate detection of the disease and better prediction of tumor aggressiveness remains ongoing due to the low cancer specificity of PSA screening. Several potential mRNA markers for diagnosing PCa, in tissue and urine, have been reported in the literature. In this study, we aim to explore the potential of selected prostate-specific molecules and transcripts contained in small extracellular vesicles (sEVs) in semen to predict PCa risk reclassification for patients with moderately elevated PSA levels—a clinical scenario where identifying truly non-invasive biomarkers is especially critical. RT-qPCR analysis in semen sEVs successfully showed differential expression of KLK3 and PCA3 genes between PCa and healthy controls, whereas CREB3L4, CCNQ and DUSP23 levels were related to the severity or degree of PCa affectation. Our findings also present strong evidence that classifiers based on combined long transcript levels in semen sEVs serve as effective biomarkers. They can be used alone or in combination with blood PSA and/or semen citric acid levels to improve the diagnosis of PCa and assess its severity and disease progression with high accuracy. This strategy would allow a more comprehensive assessment, increase prognostic accuracy, and facilitate accurate clinical decision-making in the management of PCa.

BackgroundNon-metastatic castration-resistant prostate cancer (nmCRPC) is often asymptomatic but carries a risk of progression to metastatic disease. Apalutamide (APA) and darolutamide (DARO) have been shown to improve metastasis-free survival (MFS). This study evaluated the real-world efficacy and safety of APA and DARO in Japanese patients with nmCRPC.MethodsWe retrospectively analyzed 67 nmCRPC patients treated with APA (n = 32) or DARO (n = 35). Outcomes included time to treatment discontinuation or mCRPC progression, time to mCRPC, PSA response rate, treatment-related adverse events (TRAEs), post-mCRPC treatment patterns, and predictors of progression.ResultsIn patients with prostate-specific antigen doubling time (PSADT) < 10 months, no significant difference was observed between the APA and DARO groups in the time to progression to mCRPC. PSA response and MFS were comparable between groups. TRAEs were significantly more frequent with APA (75.0% vs. 25.7%), with rash being the most common. High PSA at treatment initiation (≥ 3.6 ng/mL) and PSA response < 90% were independent predictors of progression. Abiraterone was the most common first-line agent after mCRPC.ConclusionsDARO was associated with a lower incidence of TRAEs compared to APA. Rash was more prevalent with APA. Elevated baseline PSA and suboptimal PSA response were associated with progression.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12894-025-01919-z.

Prostate cancer (PCa) diagnosis is often hindered by the need to detect clinically significant disease (csPCa) while minimizing unnecessary biopsies. The Prostate Health Index (PHI) and multiparametric magnetic resonance imaging (mpMRI) are promising tools to address these challenges. To develop and internally validate a predictive model for PCa and csPCa by combining PHI and mpMRI in a high-risk population. This retrospective study included 179 patients who underwent prostate biopsy between 2019 and 2023. Inclusion criteria comprised elevated PSA (> 3 ng/mL), suspicious digital rectal examination and/or family history, PHI values, and pre-biopsy mpMRI. Logistic regression models were developed, and model performance was assessed using C-statistics, calibration plots, and decision curve analysis (DCA). PCa was diagnosed in 40.2% of patients, and csPCa in 34.7% of them. A multivariate model including PHI, prostate volume, and mpMRI achieved an AUC of 0.81 for PCa. For csPCa, the best model combined PHI and prostate volume (AUC 0.76). In the PI-RADS 3 subgroup, PHI showed high discriminatory performance (AUC 0.81), surpassing PSA density (PSA-D). The DCA showed a superior net benefit of the multivariable models compared to single-parameter strategies. Integrating PHI and mpMRI improves PCa diagnostic accuracy and clinical decision-making, especially in ambiguous cases such as PI-RADS 3 lesions, and reduces unnecessary biopsies in clinical practice.

Background: Biochemical recurrence after radiotherapy for prostate cancer is commonly defined by the Phoenix criteria (prostate-specific antigen [PSA] nadir + 2 ng/mL). However, some patients experience PSA elevation without clinical recurrence, which is known as PSA bounce. This study aimed to evaluate PSA kinetics after scanning-method carbon ion radiotherapy (CIRT) in patients with high-risk prostate cancer (HR-PCa) and to assess the clinical validity of the Phoenix criteria. Methods: We retrospectively analyzed 171 patients with HR-PCa who underwent CIRT and 2 years of androgen deprivation therapy. Patients were classified into three groups based on post-treatment PSA kinetics: non-recurrence, pseudo-recurrence (PR; PSA > 2 ng/mL followed by spontaneous decline without salvage therapy), and recurrence (R; PSA > 2 ng/mL with salvage therapy). PSA bounce was defined as a transient PSA increase > 0.4 ng/mL followed by spontaneous decline. Kaplan-Meier and receiver operating characteristic (ROC) analyses were used to evaluate biochemical relapse-free survival and determine the optimal PSA cutoff. Results: Among 171 patients, 18 (10.5%) met the Phoenix criteria (R+PR), of whom 6 (33.3%) experienced spontaneous PSA decline. The 5-year biochemical relapse-free survival rate was 90.0%. PSA bounce occurred in 33.9%. ROC analysis identified an optimal PSA cutoff of 1.91 ng/mL (area under the curve: 0.985), whereas the positive predictive value at the 2 ng/mL cutoff was as low as 61.1% due to the influence of PSA bounce. Conclusions: After CIRT, a PSA rise of >2 ng/mL does not always indicate HR-PCa recurrence and should be interpreted with caution to avoid overtreatment.

Background:PSA is central to referrals for prostate biopsy but has low specificity for aggressive prostate cancer. This study evaluates the 4Kscore (OPKO Diagnostics) versus total PSA in predicting short- and long-term risks of aggressive prostate cancer.Methods:Baseline blood samples from 1,658 men diagnosed with prostate cancer (median diagnosis time = 8.6 years) and 1,658 matched controls in the European Prospective Investigation into Cancer and Nutrition were analyzed. Discrimination for the 4Kscore and total PSA was assessed using the AUC with 95% confidence intervals (CI) via bootstrapping.Results:For high-grade tumors, AUCs were 0.69 (95% CI, 0.66–0.72) for the 4Kscore and 0.75 (95% CI, 0.73–0.78) for total PSA. For advanced-stage disease, AUCs were 0.71 (95% CI, 0.66–0.75) for the 4Kscore and 0.77 (95% CI, 0.73–0.80) for total PSA. Similar findings were observed for other aggressive cancer endpoints. Among men with PSA >2 ng/mL, the 4Kscore had better discrimination than PSA for overall prostate cancer, high-grade disease, and prostate cancer death but only in men <60 years at recruitment.Conclusions:In this large European study, the 4Kscore did not significantly improve the prediction of clinically significant prostate cancer compared with total PSA, except in younger men with elevated PSA.Impact:The findings underscore the limited utility of the 4Kscore in improving medium- to longer-term risk prediction over PSA, with potential benefits restricted to younger men with elevated PSA.

ABSTRACTIntroductionWe report a case in which triplet therapy demonstrated efficacy for multiple metastatic recurrences following radical prostatectomy.Case PresentationA 70‐year‐old man with relapsed metastatic castration‐sensitive prostate cancer (mCSPC) following radical prostatectomy (Gleason 9, pT3bN1M0) presented with rectal involvement and extensive lymph node and bone metastases, as evidenced by a markedly elevated PSA level of 59.57 ng/mL. He received triplet therapy consisting of androgen deprivation therapy (ADT) with degarelix, darolutamide (1200 mg/day), and docetaxel (70 mg/m2). This combination led to a complete PSA response, dropping below the detection limit (< 0.006 ng/mL). At 24 months post‐treatment, the patient remained in a stable condition without any signs of PSA recurrence.ConclusionThis case highlights the potential of triplet therapy as a highly effective treatment strategy for high‐risk mCSPC patients who experience recurrence after initial local therapy.

Background/Aim: Staging in prostate cancer is essential for determining the right treatment approach and its execution. This study assessed the staging effectiveness of multiparametric prostate magnetic resonance imaging (MpMRI) compared to prostate-specific membrane antigen (PSMA) positron emission tomography – computed tomography (PET-CT) and examined the preoperative information that they provide. Methods: We collected data from patients diagnosed with prostate cancer who visited our clinic between June 2020 and November 2022. The results from MpMRI performed prior to biopsy were compared to those from PSMA PET-CT conducted after diagnosis, alongside the outcomes of pathological evaluations. Results: There was no significant correlation between MpMRI and PSMA PET-CT findings and the final pathology results regarding extraprostatic extension. However, both imaging techniques showed a significant correlation with the final pathology in evaluating pelvic lymph-node metastasis and seminal vesicle invasion. In terms of lesion localization, no significant correlation was found between the final site of the pathological lesion and MpMRI, while a significant correlation was noted with PSMA PET-CT. Patients with positive surgical margins had significantly elevated serum PSA levels, size of the index lesion identified in MpMRI, and maximum standardized uptake values (SUV max) of PSMA. Conclusion: Although both imaging methods offer important staging insights, further research is needed to clarify their respective limitations and benefits. In the future, these techniques may have additional roles in predicting surgical margin positivity before surgery.

Prostate cancer is the second most common malignancy in males, primarily associated with risk factors such as age, ethnicity, obesity, and family history. While metastases commonly involve lymph nodes, bones, and the liver, ureteral metastasis is exceedingly rare. Ureteral obstruction due to metastatic prostate cancer can lead to hydronephrosis, often requiring ureteroscopy for diagnosis and management. However, persistent symptoms may necessitate exploratory surgery. An 82-year-old Arab male with a history of Gleason 4 + 4 = 8 prostate adenocarcinoma (initially managed with hormonal therapy and surgical castration) presented with right back pain. Imaging revealed stage 4 hydronephrosis, initially attributed to a ureteral stone. Ureteroscopy identified obstructing ureteral tumors instead, with biopsy confirming well-differentiated adenocarcinoma of prostatic origin. Due to persistent obstruction and confirmed malignancy, a right nephroureterectomy was performed. Histopathology demonstrated extensive ureteral involvement (16 cm) with vascular and perineural invasion but no distant metastasis on postoperative PET-CT. This case underscores the diagnostic challenge of ureteral metastasis in prostate cancer, often mimicking benign conditions like ureteral stones. Despite successful local surgical control, the tumor's aggressive features necessitate long-term surveillance and continued hormonal therapy. High clinical suspicion for metastasis is crucial in high-risk prostate cancer patients presenting with obstructive uropathy, even in the absence of significantly elevated PSA. This report highlights the importance of a stepwise diagnostic approach and the need for prompt intervention in such rare presentations.