Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach a patient with prostate cancer with sclerotic/lytic lesions found on a CT scan but not seen on a bone scan or PET-PSMA?
This can be a tough situation, as sometimes healthy individuals can have sclerotic or lytic foci in various bones for reasons unrelated to any type of malignancy. The first thing I would try to do is compare the CT scans to any prior imaging if possible. If these lesions are completely unchanged fro...
How would you approach adjuvant therapy for a patient with a single lymph node positive in the peri-prostatic fat without pelvic lymph node dissection?
I would favor treating like node positive prostate cancer adjuvantly with long term ADT and RT. Presuming post op PSA is undetectable.
Does a transperineal approach to prostate biopsy change your treatment plan compared to transrectal?
The short answer is no. The typical scenario in which I have seen transperineal biopsies done is a patient with multiple negative transrectal biopsies in whom there is still a concern for clinically significant prostate cancer and an MRI has not identified a target to biopsy. In these cases, multipl...
What systemic therapy do you recommend for prostate cancer pelvic nodal recurrence on PSMA PET-CT after prostatectomy and salvage radiation?
If the LNs are not measurable on conventional imaging and can be covered in the radiation fields, then for now I treat as high risk salvage setting. Usually suggest 2 years ADT and radiation. If the LNs cannot be covered in the radiation fields, or are measurable, then would also escalate AR-targete...
When will you recommend enfortumab vedotin plus pembrolizumab as first-line treatment of metastatic urothelial carcinoma for cisplatin-ineligible patients?
This is a timely question given the US FDA approval of the pembro/EV combination on 4/3/2023. Currently, the label is for patients with locally advanced or metastatic urothelial carcinoma who are ineligible for cisplatin-containing chemotherapy. There are a variety of definitions for cisplatin ineli...
How would you treat a patient with a low grade Follicular lymphoma and Gleason 6 adenocarcinoma of the prostate?
There are too many unstated particular clinical parameters to provide a specific answer to this question, but general principles are that neither of these malignancies necessarily require intervention. The very long natural history of each condition should guide us. Stage, symptoms, functional statu...
Does the presence of ductal adenocarcinoma change how you risk stratify or treat patients with localized prostate cancer?
Ductal adenocarcinoma (DAC) of the prostate is a distinct, but rare (< 1%) subtype of prostate adenocarcinoma. DAC originates from primary periurethral prostatic ducts or in the peripheral prostatic ducts. Because of its predominantly periurethral location, it may present with hematuria, urgency, an...
Do you continue ADT/Lupron in all patients with castrate resistance prostate cancer?
It is recommended to continue ADT in patients with castration-resistant prostate cancer. Some mechanisms of castration-resistance include upregulation of androgen receptors and autocrine testosterone production, so a castration-resistant cancer is not necessarily a "hormone resistant" cancer.
What is your approach to systemic treatment of de novo metastatic hormone-sensitive prostate ductal adenocarcinoma with lung only metastases?
Nearly all patients with mHSPC/mCSPC deserve combination therapy based on multiple phase III clinical trials. There are very few exceptions to this. Even frail patients should be considered for intensified therapy since the published data suggests minimal to no worsening in HRQoL over ADT monotherap...
Would you use adjuvant pembrolizumab for bilateral ccRCC with R1 resection?
It would depend on the pathology of each resected tumor, but my initial thought is that I would not. My concern would be that renal function is likely reduced and nephritis (although rare) could have significant consequences. Certainly, genetic counseling should be considered for all bilateral tumor...