Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you choose which LHRH agonist or antagonist to prescribe for ADT in patients with prostate cancer?
The choice of LHRH agonist or antagonist depends on patient factors. Most patients receive some form of leuprolide or goserelin since these allow longer intervals between injections (as compared to degarelix). Goserelin is used more for those on anticoagulation or with bleeding disorders since it is...
Is long term ADT now the standard of care with salvage prostate bed RT?
The dreaded hormone question...After 40 years of embarking on extremely well designed randomized trials, we still are confused about the who, what, when of ADT. Will RTOG 9601 create a new care standard? As @Dr. First Last said, I think we will see increased utilization. I have been using bicalutami...
In light of the recent data indicating increased late grade 3 to 5 toxicities after hypofractionated salvage radiation therapy, will you continue to offer these regimes to patients?
Prior Literature: Prior non-randomized studies seem to suggest excess toxicity with hypofractionated PORT (e.g., Cozzarini et al., PMID 24985964, Tandberg et al., PMID 29559284). In part for this reason, a phase III, randomized controlled non-inferiority trial, NRG-GU003, was conducted (Buyyounouski...
What do you tell patients that opt for High-intensity focused ultrasound (HIFU) for favorable intermediate risk prostate cancer over AS (Active Surveillance), RP (Radical Prostatectomy), EBRT (External Beam Radiation Therapy), or brachy?
There are currently no published trials that specifically address this question, which is a very good one.My general discussion is that ablation therapies (not specifically HIFU) will have less negative impact on quality of life factors such as preserving erectile function, avoiding urinary incontin...
How do you select patients for prostatic artery embolization over standard surgical options for BPH (benign prostatic hyperplasia)?
Assuming that the patient is proceeding with prostate artery embolization (PAE) after failed medical management, choosing PAE depends on a few factors: Patient's prostate characteristics: size, shape, and whether there is bleeding related to the patient's prostate Patient comorbidities: PAE is les...
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Presently, the main categories of actionable DNA based alterations in advanced prostate cancer are 1) alterations in homologous repair enzymes like BRCA2, and 2) microsatellite instability (MSI high status, mismatch repair gene deficiency). These are actionable as they can lead to the use of a thera...
How do you stage patients with testicular cancer who may have CSIS disease?
This always looks easy, but you have to be careful and have patience. Some mistakes occur because providers use the PRE-orchiectomy markers or immediate post-orchiectomy markers before they have a chance to normalize. Also, providers sometimes react to low abnormal stable markers which often are fal...
What are the treatment options for a patient with unfavorable intermediate risk PCa who desires future child bearing?
The best option for such patients would be sperm banking prior to treatment, whether they undergo RT+ADT or surgery. See this prior post on this forum regarding the impact of RT on fertility. Given the expected internal scatter dose to the testes during a course of fractionated RT, it would not be s...
In light of recent updates on neoadjuvant enfortumab vedotin plus pembrolizumab for muscle-invasive bladder cancer showing benefit, how should a trimodality bladder-preservation strategy be contextualized?
The treatment of muscle-invasive bladder cancer. has evolved quickly. Neoadjuvant EVP is absolutely the standard of care in all patients who can receive it. The clinical trials (EV-303/304) used cystectomy as the bladder-directed therapy, and this is the standard of care. Having said that, many pati...
Is there a role for DDR gene mutation or tumor mutation burden/load in predicting response to immunotherapy in urothelial cancer?
Our recent work showed that urothelial cancers harbor high rate of alterations in DDR (DNA damage repair and response) genes, with 25 – 29% rate of deleterious alterations and up to 25% with variants of unknown significance – considering the genomic complexity of urothelial cancers, it is not un...