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How do American Urological Association (AUA) and EAU define undetectable PSA after prostatectomy in 2024–2025?
Executive Summary
The American Urological Association (AUA) and the European Association of Urology (EAU) continue to anchor the clinical definition of biochemical recurrence (BCR) after radical prostatectomy at a PSA threshold of ≥0.2 ng/mL, typically requiring a confirmatory measurement, while both societies and contemporary practice treat PSA values below the conventional assay limits—commonly <0.1 ng/mL—as “undetectable” for routine decision‑making [1] [2]. Contemporary research and specialty meeting reports in 2024–2025 note growing use of ultrasensitive PSA assays with detection limits an order of magnitude or more lower (e.g., <0.01 ng/mL), and investigators argue those assays redefine “undetectable” for prognostic and early‑intervention studies even though guideline definitions remain tied to standard assay thresholds [1] [3]. This analysis synthesizes available guideline-aligned statements and recent literature to show where AUA/EAU practice thresholds stand and how ultrasensitive testing is changing clinical interpretation and practice patterns [4] [5].
1. Why the 0.2 ng/mL threshold still drives action in post‑surgery care
Both guideline bodies continue to use PSA ≥0.2 ng/mL (with confirmatory testing) as the operational definition of biochemical recurrence after radical prostatectomy, a cutoff that drives salvage‑therapy decisions and trial eligibility. The historical AUA consensus and recent summaries cited in 2024–2025 literature maintain this threshold as the trigger for defining BCR and for recommending consideration of further imaging and treatment [5] [1]. Guideline language stops short of formally defining “undetectable” in a single universal numeric value; instead, the societies rely on assay performance characteristics and on the pragmatic convention that PSA below the standard assay detection limit (~0.1 ng/mL) is clinically undetectable. This approach preserves consistency across centers where standard assays remain most common while acknowledging confirmatory testing before labeling recurrence [1] [6].
2. What the EAU explicitly states about early post‑op PSA and persistent PSA
The EAU’s contemporary guidance and APCCC Diagnostics discussions in 2025 articulate that biochemical failure can be identified either as persistent PSA ≥0.1 ng/mL within 4–8 weeks after surgery or as two consecutive rises after a previously undetectable value, effectively implying that “undetectable” is a PSA <0.1 ng/mL for early postoperative assessment [4]. That framing recognizes persistent detectable PSA in the early postoperative window as biologically and prognostically different from later recurrence. The EAU emphasis on the 0.1 ng/mL standard for early persistence reflects both assay realities and outcome data linking early persistent PSA to higher recurrence risk; the society thus operationalizes undetectable status relative to that common assay threshold rather than an absolute ultralow value [4] [2].
3. How AUA practice and consensus panels treat undetectable PSA in 2024–2025
AUA‑aligned literature and prior consensus statements continue to define BCR as PSA ≥0.2 ng/mL with confirmatory elevation, and do not set a single mandated numeric definition of undetectable beyond stating that values below the assay’s detection limit are considered undetectable in clinical practice [5] [1]. Recent reviews and studies note that AUA guidance relies on conventional assay thresholds (~0.1 ng/mL) when guiding routine surveillance and salvage decisions, while acknowledging that ultrasensitive assays are increasingly used in research and specialized centers [2]. The AUA’s practical stance preserves comparability of outcomes and triggers for intervention but leaves space for clinicians to incorporate ultrasensitive PSA data with caution because guideline‑level evidence linking ultralow cutoffs to improved long‑term outcomes remains maturing [1] [5].
4. Ultrasensitive PSA: changing the meaning of “undetectable” in research and practice
Multiple 2024 studies and diagnostics panels highlight that ultrasensitive PSA (usPSA) assays detect levels below 0.1 ng/mL, often down to 0.01 ng/mL or lower, and research teams define “undetectable” at these ultralow values to study earlier biologic recurrence and to refine timing of salvage radiotherapy [1] [3]. Investigators report that usPSA thresholds such as <0.01 ng/mL or detection at 0.03–0.05 ng/mL show prognostic signal for eventual recurrence and may influence earlier imaging or treatment decisions in select high‑risk patients. Guideline documents and consensus meetings note this growing evidence but caution that society definitions and treatment‑trigger thresholds have not uniformly shifted to match ultrasensitive cutoffs because of limited standardized assay harmonization and incomplete outcome data across populations [3] [6].
5. Practical implications for clinicians and patients navigating “undetectable” results
Clinicians should interpret postoperative PSA in the context of the assay’s limit of detection, timing after surgery, and patient risk factors: EAU practice effectively treats <0.1 ng/mL as undetectable in the early postoperative period, while AUA frameworks tie action to confirmed PSA ≥0.2 ng/mL even as ultrasensitive testing informs risk stratification [4] [5]. Patients receiving ultrasensitive tests may see detectable readings at very low levels that do not meet guideline BCR definitions; physicians must explain that an ultrasensitive detectable PSA does not automatically equal guideline‑defined recurrence but may prompt closer surveillance or earlier imaging in specific contexts. The current landscape in 2024–2025 therefore combines guideline stability around the 0.2 ng/mL BCR cutoff with evolving clinical use of ultralow assay thresholds, and clinicians should document assay type and detection limits when communicating “undetectable” results [1] [2].