An 89-year-old man was diagnosed with prostate cancer 7 years ago and is status post radical retropubic prostatectomy. At the time of diagnosis, he had Gleason 3 + 4 = 7 disease with perineural invasion but negative margins on resection, no disease outside of the prostate on imaging, and an initial prostate-specific antigen (PSA) level of 5.2 ng/mL. Following surgery, PSA became undetectable, but began to rise 2 years after surgery. The patient then received definitive radiation therapy to the prostate bed with an initial downtrend in PSA. However, 2 years after receiving radiation, his PSA once again began to rise. Restaging scans were negative for metastatic disease. He was started on leuprolide injections and bicalutamide, and his PSA subsequently dropped. However, after 8 months of therapy, the PSA began to rise from a nadir of 0.9 ng/mL to 1.3 ng/mL in 12 months. In the next 12 months, the PSA increased to 2.1 ng/mL. Restaging scans are negative for metastatic disease, and his serum testosterone level is 3 ng/dL. The patient has no urinary symptoms.