Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
In a patient with stage 1 mixed germ cell tumor who cleared tumor markers post-orchiectomy but with subsequent rise to borderline abnormal within 6 weeks, would you treat with 3 cycles BEP as for S1 disease?
Several points to begin with. My strong preference is to recommend active surveillance for all well documented clinical stage 1 nonseminoma whether or not there is embryonal predominance or lymphovascular invasion present. Second, I do not make treatment decisions based on borderline abnormal normal...
How does urinary obstruction impact your choice of therapy for metastatic or locally advanced prostate cancer?
Bladder outlet obstruction due to locally advanced prostate cancer is typically due to bladder wall and ureteral orifice invasion and T4 disease. These patients can suffer from pain and urinary obstructive symptoms for long periods of time despite the use of ADT, ADT plus AR inhibition, or ADT plus ...
Do you treat de novo metastatic hormone sensitive prostate cancer presenting with a paraneoplastic syndrome more aggressively?
For these patients, I will likely add a GnRH antagonist early on to drop testosterone quickly. Depending on performance status and other patient characteristics, we still go through the discussion of adding docetaxel, abiraterone, enzalutamide, and apalutamide (I generally add about 3-4 weeks after ...
Do you measure testosterone in men who will be receiving ADT?
I do check before starting ADT. I make sure to check after ADT completion as well. A post-treatment low PSA level in the setting of a low testosterone has a different meaning than a low PSA in the setting of a recovered testosterone. It also gives you a potential explanation for a slight temporary P...
Would you offer adjuvant chemotherapy to a patient with high grade pT1 bladder cancer with concurrent pT2 prostatic urethral stroma involvement?
I would adopt the data from the CheckMate 274 trial. If the patient is post-neoadjuvant cisplatin-based chemotherapy, I would consider adjuvant nivolumab, especially if the tumor PD-L1 is high and/or post-op ctDNA is positive for minimal residual disease. If the patient has not received neoadjuvant ...
What are your top takeaways in GU Cancers from ASCO 2022?
1. Bladder cancer. Potential new non-muscle invasive bladder cancer immunotherapy with N-803, an IL-15 superagonist plus BCG. Abstract 4508. Demonstrated striking complete and durable remissions (70%), bladder preservations over 1-2 years of follow up (>90% cystectomy free survival), favorable toxic...
In metastatic/recurrent clear cell carcinoma with a solitary site of metastasis to the bone when, if ever, do you consider local therapy adequate and hold systemic therapy?
If I have a patient with a treated solitary metastatic site in RCC (bone or otherwise), I generally give local therapy and historically would not give systemic therapy. A point of discussion would be use of adjuvant pembro in this setting. While bone mets were not included in KEYNOTE-564 resected M1...
Do you utilize surgical and medical treatments when treating patients with erythroplasia of queyrat, bowenoid papulosis or giant condyloma acuminatum?
Bowenoid papulosis can remit spontaneously (especially in those who are <35 and immunocompetent) so initial management is typically conservative with locally destructive methods. I prefer treatment with cryotherapy and/or topical treatment with Aldara or Efudex 5% cream. Other options include electr...
How would you manage a low risk patient with a negative fusion prostate lesion by biopsy but MRI shows apparent advanced disease?
Assuming that the patient has NCCN low-risk features and MRI findings of EPE (which is the most common situation), I would think about this situation in two different subcategories: (1) active surveillance (AS) is still under consideration, and (2) the patient has decided he would like to proceed wi...
What is the earliest time to check PSA after prostatectomy?
The half-life of PSA in the circulation is about 3 days, so there is no point checking PSA within the first 15 days (5 half-lives) as any detectable PSA at that point may just represent residual PSA that has yet to be cleared. Most surgeons I have worked with generally wait 4-6 weeks, which should b...