Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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...
How do you manage a muscle-invasive bladder cancer patient who received neoadjuvant cisplatin-based chemotherapy but has a positive margin post-operatively?
While no trial has tested adjuvant RT plus nivolumab in margin-positive post-cystectomy bladder cancer, and this remains an extrapolation, I would consider adjuvant pelvic RT as radiation alone (cystectomy bed/pelvic nodes 45–50.4 Gy, boost the involved margin to 54–60 Gy), consistent with how NCCN ...
How do you approach treating bladder outlet obstruction and urinary retention prior to undergoing radiation for prostate cancer?
Prior to radiation, I evaluate any meaningful lower urinary tract symptoms with the IPSS, uroflow, and PVR. The goal is to identify bladder outlet obstruction or impaired emptying before radiation. If significant obstruction is present, I prefer to address it before SBRT whenever feasible, so the pa...
What first-line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
For patients presenting with brain metastases, I always do local therapy, usually SBRT, before systemic therapy. I am nervous about starting immune-based therapy or a TKI in patients with uncontrolled CNS metastases. There are small series using TKIs such as cabozantinib in this setting, but since S...
What is your next step in management for patients who develop sexual side effects on an SSRI (anorgasmia, low libido, etc.) but are responding well to therapy?
Managing side effects from SSRI medications is a key component of treating patients in the outpatient setting who are suffering from depression and/or anxiety. This is doubly true given the fact that primary care is often the most accessible, and often most trusted, source for patients to make their...
What is your preferred second-line treatment for erectile dysfunction refractory to PDE5 inhibitors after radiation therapy for prostate cancer?
When PDE5i's fail after XRT for prostate cancer, my usual progression is to offer a duplex ultrasound to evaluate penile vascular integrity and to see if the response to Trimix is adequate and one that would be acceptable to the patient. If not, the other options would include VED and IPP.
How do you counsel a man with nonobstructive azoospermia and a normal FSH on his odds of successful sperm retrieval?
Such a nuanced question. Will assume 46 XY, no Y micro deletion, no varicocele to fix that would suggest late maturation arrest which may respond to varicocele repair. I would offer them testis mapping depending on testis volume. Say they want to go to mTESE without mapping—would discuss donor sperm...
Is there any data on the use of PARP inhibitors in patients with metastatic urothelial carcinoma with deleterious DDR mutations?
Urothelial cancers harbor high rate of deleterious DDR alterations. Based on clinical data from other tumor types, especially TOPARP-A in metastatic castration-resistant prostate cancer where responses to olaparib monotherapy were observed especially among men with defective DDR genes, the use of PA...
How do the results of KEYNOTE-B15/EV-304 influence your preferred treatment for cisplatin eligible MIBC?
The management of urothelial cancer has undergone major changes in the last decade.We have seen a number of new drugs approved for relapsed BCG-refractory superficial bladder cancer. Additionally, we have seen a number of new approaches for the management of muscle-invasive bladder cancer (MIBC) or ...