Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Why is there a benefit of ADT for high risk prostate cancer treated with radiation, yet no large trials describing benefit of adjuvant ADT after radical prostatectomy?
From a high level, the magnitude of the benefit of ADT with radiation seems proportional to the aggressiveness of the disease (i.e. low risk has no significant benefit, int risk weighs risk features and cardiac health, and high risk the benefit of ADT can trump cardiac risk). In that context, we hav...
Does the presence of cribiform histology at biopsy in prostate cancer affect your management in an otherwise intermediate-risk prostate cancer?
There have been no trials on this specific question, so there is room for debate and more science (hoping our recent grant submission in this area gets funded...). Here is my current thinking. This is for generally healthy patients with long life expectancy (≥10 years, but especially if ≥15 years). ...
How do you approach prostate cancer patients who have hypertestosteronism on pre-treatment labs?
This is rare and full disclosure - I have not personally experienced this situation and this answer is based on discussion with colleagues. I suspect whatever the true incidence is, it is likely detected in only a fraction of patients as ADT is often initiated without drawing testosterone levels, an...
For a patient treated with abiraterone for first line metastatic prostate cancer, would you still use a combination of abiraterone/olaparib at a subsequent progression?
No, there is no evidence for this, and in the absence of benefit, I would use single agent olaparib in HRD+ patients only, particularly BRCA2 patients. Ongoing trials like the CASPAR trial will address this question. In addition, there are ongoing trials testing PARP/AR combinations in men with mHSP...
Would you ever recommend testosterone replacement for men with incomplete T recovery after ADT for prostate cancer?
I have been hesitant to agree to supplemental testosterone after prostate cancer treatment, especially within the first few years. Prostate biopsies during that time often show atypical cells that are suspicious or adenocarcinoma with treatment effect. Androgens are pro-survival and the full effects...
How do you define cisplatin ineligibility for muscle invasive bladder cancer?
We traditionally have been using the "Galsky criteria" published in 2011 based on consensus. We have looked into possibly lower threshold for estimated GFR, e.g. 50 ml/min, and possibly cisplatin "split dose" on a per patient basis if otherwise a patient is fit: Koshkin et al., PMID 29576445.Sometim...
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience wi...
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
What duration of ADT do you recommend for a patient with locally treated prostate cancer who undergoes metastasis-directed radiation therapy to a single oligometastatic bone lesion?
While I agree with @Dr. First Last that very small studies like STOMP and ORIOLE suggest that a small subset of men can delay the need for ADT by 1-3 years, this is not level 1 evidence. Most men with oligometastatic HSPC will still progress with metastasis directed therapy alone over a short time h...
Are patients with MIBC and bladder neck involvement good candidates for bladder preservation with chemoradiation after maximal, but not complete, TURBT?
Both BCON and BC2001 suggest that a complete TURBT may not be essential for bladder preservation. Incomplete TURBT is a surrogate for a higher stage and predicts poorer outcomes irrespective of the modality used for treatment.Elumalai et al., PMID 36517194