Editor’s Note: The following is from the June 2025 issue of The Journal of Urology^®. Visit The Journal of Urology Current Issue page to access these articles. Reprinted with permission from Siemens DR. Editor’s Choice. J Urol. 2025;213(6):679-680. doi:10.1097/JU.0000000000004518

Finessing Prostate Cancer Risk, Best Cystectomy Approach, and Reducing Low-Grade Bladder Cancer Recurrence

Bacillus Calmette-Guérin vs Gemcitabine for Low-Grade Intermediate-Risk Bladder Cancer

Bladder cancer research seems to be having its moment. The development of novel therapies with decisive efficacy for both high-grade nonmuscle invasive bladder cancer (NMIBC) and more advanced disease is truly exciting. Investigators have not ignored the management of low-grade disease.¹ In this issue of The Journal of Urology®, Khene et al² provide insight into 2 common management options for treatment-naïve, low-grade, intermediate-risk NMIBC. In this retrospective cohort, they show that while both bacillus Calmette-Guérin (BCG) and gemcitabine have similar risk of disease progression (albeit low), BCG was superior in reducing recurrence rates. These findings suggest that BCG may be the preferred intravesical therapy of the two for intermediate-risk NMIBC. However, the reduced adverse event profile of gemcitabine suggests it still is a viable alternative and emphasizes the need for individualized treatment approaches, balancing efficacy and toxicity for these patients.

Lessons Learned From the Randomized RAZOR Trial

The urological oncology community has done an admirable job over the last decade completing randomized surgical trials for muscle-invasive bladder cancer. Although a clear winner between robot-assisted radical cystectomy and open radical cystectomy is arguably elusive,^3,4 important lessons have been underscored. In this issue of The Journal, Venkatramani et al⁵ reinforce the equivalence of robot-assisted radical cystectomy and open radical cystectomy in terms of major complications and readmission rates from the multicenter RAZOR trial. With no significant differences between the 2 surgical approaches at both 90 days and 1 year postoperatively, the findings support the use of either technique based on institutional expertise. Furthermore, the authors show that frailty (rather than surgical approach) will predict how our patients fare, reiterating the primacy of careful patient selection and preoperative optimization to improve outcomes for patients with muscle-invasive bladder cancer.

Redefining Prostate Cancer Risk: Volume of Pattern 4

It can be a difficult conversation with our patients describing localized prostate cancer (PCa) grading while also fundamentally recognizing it is likely the total volume of more aggressive disease in the gland that is associated with prognosis. In this issue, Scuderi et al⁶ nicely demonstrate the significance of absolute pattern 4 volume, showing it can provide superior predictive value for advanced-stage disease and biochemical recurrence compared with International Society of Urological Pathology Grade Group and pattern 4 percentage. These findings are provocative and suggest that incorporating absolute pattern 4 volume into risk stratification models could improve communication and decision-making for our patients. Alongside the paper, read the accompanying editorial for some insightful thoughts on what this could look like in the future.

When Can We Omit Systematic Biopsy When Targeting MRI-Detected Prostate Lesions?

The expanding use of MRI to inform diagnostic approaches for localized PCa has resulted in an important technical concept: Can we omit systematic biopsies when targeting MRI-detected lesions? Ahdoot et al⁷ add important and practical insight in their study demonstrating the potential role of PSA density as a stratification tool to help guide this decision. The authors’ findings show a clear correlation between increasing PSA density and higher detection rates of clinically significant PCa, with systematic biopsy contributing minimal additional value in men with PSA density > 0.2 ng/mL/cm³. These results support a more selective biopsy approach, potentially reducing biopsy passes and their additive morbidity while maintaining diagnostic accuracy. 

1. Prasad SM, Shishkov D, Mihaylov NV, et al. Primary chemoablation of recurrent low-grade intermediate-risk nonmuscle-invasive bladder cancer with UGN-102: a single-arm, open-label, phase 3 trial (ENVISION). J Urol. 2025;213(2):205-216. doi:10.1097/JU.0000000000004296
2. Khene ZE, Bhanvadia R, Attia S, et al. Gemcitabine vs bacillus Calmette-Guérin for intravesical therapy in treatment-naïve low-grade intermediate-risk nonmuscle-invasive bladder cancer. J Urol. 2025;213(6):730-738. doi:10.1097/JU.0000000000004472
3. Bochner BH, Kamat AM, Bivalacqua TJ. Open vs robotic cystectomy: case closed?. J Urol. 2024;211(3):473-475. doi:10.1097/JU.0000000000003828
4. Gill IS, Desai MM, Cacciamani GE, Khandekar A, Parekh DJ. Robotic radical cystectomy for bladder cancer: the way forward. J Urol. 2024;211(3):476-480. doi:10.1097/JU.0000000000003829
5. Venkatramani V, Reis IM, Gonzalgo ML, Swain S, Svatek RS, Parekh DJ. Comparison of complication and readmission rates between robot-assisted and open radical cystectomy: results from the randomized RAZOR clinical trial. J Urol. 2025;213(6):684-692. doi:10.1097/JU.0000000000004497
6. Scuderi S, Tin AL, Klug J, et al. The absolute volume of Gleason pattern 4 on radical prostatectomy is more strongly associated with advanced stage and biochemical recurrence than Gleason grade groups. J Urol. 2025;213(6):722-729. doi:10.1097/JU.0000000000004484
7. Ahdoot M, Naser-Tavakolian A, Heard JR, et al. Prostate-specific antigen density to select magnetic resonance imaging–targeted vs combined biopsy for prostate cancer diagnosis: a secondary analysis of the Trio study. J Urol. 2025;213(6):693-701. doi:10.1097/JU.0000000000004480