Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you recommend adjuvant ADT instead of neoadjuvant ADT with prostate RT?
If ADT and RT are synergistic rather than additive, then the sequencing of therapies should matter. Neoadjuvant: ADT has been shown to reduce proliferation and cell cycling (increase radioresistance) and decrease hypoxia (increase radiosensitivity). However, tumor hypoxia is not a major driver of ou...
For a patient post-prostatectomy with a high PSA (>1), a negative MRI pelvis, and a negative PSMA PET scan, do you pursue any other imaging?
The sensitivity of PSMA scan for PSA above 1 is about 75-90%. I would proceed with salvage RT plus ADT like we did in the era when PSMA was not available.
Is it appropriate to re-consider bladder preservation in patients with bladder muscle-invasive cancer (T2) who were initially poor candidates for BP (multifocal disease, etc.) but had complete response after neoadjuvant chemotherapy?
It is perfectly appropriate. There are many ways to achieve a complete response to T2 bladder cancer. It can be reached with radiation, an aggressive local resection, or chemotherapy. The issue is whether or not it is durable. None of these therapies alone have a great track record, although chemoth...
Do you recommend neoadjuvant and concurrent ADT vs concurrent ADT for salvage post prostatectomy radiation?
I do both neoadjuvant and concurrent. The strategy used is typically dictated by patient schedule/convenience.While GETUG-AFU 16 used a concurrent approach, SPPORT utilized a 2-month neoadjuvant strategy for ADT.
Do you recommend delaying spot urine protein quantification testing until after nephrostomy tube removal in a patient with obstructive uropathy?
Yes, if the tubes are coming out. Would not want to make treatment decisions under these circumstances. Not an emergency usually.
Would you rely on virtual crossmatch alone to proceed with a kidney transplant?
Yes. We switched to virtual crossmatch prior to transplant. We still do the actual cross match as well, but the results of that often come when the patient is in the OR.
Do you ever consider intermittent ADT for metastatic prostate cancer?
In general, I recommend continuous ADT for men with metastatic disease based on the OS difference from the Intergroup 0162 trial. I do agree, however, that this trial was a noninferiority design and the difference is not large, therefore in men with very limited disease who display intolerance to AD...
Why are patients getting enzalutamide s/p prostatectomy not candidates for salvage radiation therapy?
Although there have been other efforts to profile the role of enzalutamide (e.g., SALV-ENZA, Tran et al., PMID 36367998) or other second generation androgen axis inhibitors (e.g., FORMULA-509) in conjunction with salvage RT, EMBARK (Freedland et al., PMID 38320501) was designed to test the efficacy ...
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
How do you choose between initiating long-term therapy with mTOR inhibitors versus opting for interventional treatments such as embolization or surgery in a patient with tuberous sclerosis, experiencing flank pain, and with renal angiomyolipomas larger than 4 cm?
I have very limited experience, but mTOR has been a game changer for my (2) TS patients. Why would you wait for bleeding, pain, and embolization if you can prevent it?