Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach a prostate cancer patient with oligomet disease on PSMA PET?
I think there is a spectrum of 'PSMA-PET Avid lesion suspicious for metastasis'. In some locations, such as ribs, I worry more about false positives. For lesions with PET avidity without CT correlate, I worry about false positives and may advocate for a biopsy if it will change the treatment plan. S...
Do you always obtain PSMA PET as initial staging for high risk and very high risk localized prostate cancer patients?
I do obtain a PSMA PET/CT or PET/MRI in all patients with high risk localized prostate cancer. However, when this is not available due to insurance coverage issues or lack of access to PSMA PET, it is still acceptable to stage with bone scan and CT or MRI. I prefer PSMA PET because it has better per...
Is prior TURP a contraindication to SpaceOAR placement?
It's worth a try. Most of the time, I haven't had an issue. Occasionally, a TURP or other procedure can lead to more fibrosis in the rectoprostatic space that can make it hard to hydrodissect. But typically, it is not an issue.
Do you change your monitoring strategy for a high risk prostate cancer after XRT if the initial PSAs have never been very high?
In general, a patient whose volume of cancer is out of proportion to their PSA makes me nervous. So, I'm much more worried about the patient with a PSA of 5 and multiple cores positive for high volumes of Grade Group 4-5 cancer than I am about the patient with a PSA of 5 and a single positive core s...
How would you manage stable/slightly enlarged pulmonary metastasis from non-seminoma testicular cancer after receiving 3 cycles of BEP, which resulted in a mixed responses on chest CT but normalized AFP?
This is a patient with nonseminomatous germ cell tumor, with presumably pulmonary metastases at start of BEP X 3. I am also assuming that his abdominal CT scan was either normal baseline or it reverted to normal post BEP. The issue now is a mixed response in the lungs, implying some lesions are smal...
Do you recommend surveillance for secondary malignancies of the rectum and bladder after prostate XRT?
I think it's important to be sure that patients are up to date with screening for colorectal cancer before beginning a course of prostate XRT. I have had an occasional patient who was found to have a colorectal cancer on colonoscopy performed pre-treatment because they were out of compliance with sc...
Would you prescribe ADT or AR inhibitors for a patient with moderate to severe dementia who has biochemical recurrent, non-metastatic prostate cancer, but otherwise good physical performance status and prognosis >5 years?
I would discuss with their caregivers. They are the ones who have to manage the patient's moderate to severe dementia daily and presumably are acting as the patient's medical power of attorney. Practical consequences to typically routine therapies can be serious. Substantial declines in cognition, m...
How do you approach imaging in patients with M0 castration-resistant prostate cancer with rising PSA on an ARSI?
I do not use molecular imaging (e.g., PSMA-PET/CT) for patients with CRPC (including both mCRPC and nmCRPC) except as a screening tool for Pluvicto eligibility for three reasons. Most patients have metastasis already. In one study that used molecular imaging in patients with nmCRPC, they identified ...
How do you approach ADT in a post-prostatectomy patient who had higher Gleason score on biopsy but a lower Gleason score on final pathology?
I would only base my decision on the pathology of the final prostatectomy specimen, and ignore the prior biopsies.
Would you change AR signaling inhibitor in a patient with high volume metastatic castration-sensitive prostate cancer who started darolutamide with initial plan for docetaxel but in whom chemotherapy was eventually deferred?
The ARASENS trial showed a survival benefit for the combination of ADT with chemotherapy and Darolutamide in mHSPC. In a patient with high-volume disease who has been initiated on Darolutamide but in whom chemotherapy was planned but then deferred, I would continue with Darolutamide if the patient i...