Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you treat metastatic large cell neuroendocrine carcinoma of prostate with undetectable PSA, who had the treatment related transformation while on ADT monotherapy?
Treatment-emergent (or extra-pulmonary) high-grade neuroendocrine carcinoma (sometimes labeled HG-NEC or EP-NEC) is an increasingly seen phenomenon with the more widespread use of ARSI in the first-line setting. This is a distinct entity from prostate adenocarcinoma with neuroendocrine differentiati...
Do you offer adjuvant pembrolizumab post metachronous oligometastatic resection of RCC beyond the first year of diagnosis?
For patients with recurrence beyond 1 year of initial nephrectomy, I would not offer post metastasectomy pembrolizumab. Such patients would usually belong to the IMDC favorable risk category at the time of recurrence and could have a continued disease free interval post metastasectomy based on sever...
What is your preferred approach to low volume unresectable/metastatic favorable risk RCC?
For good-risk metastatic RCC patients, who are considered not a candidate for cytoreductive nephrectomy, systemic therapy with one of the IO/TKI combinations is indicated, taking into consideration the patient’s comorbidity and tolerance to the regimen. (For non-clear cell metastatic RCCs, systemic ...
How would you approach subtotal resection of a sarcoma of the scrotum/groin with grossly positive margin at the base of the penis?
These are clinically challenging situations. I would image to see if there is gross vs. microscopic disease. I would also have a surgical colleague evaluate to see if re-resection is possible to remove gross disease if present and obtain negative margins. With respect to adjuvant radiation, histolog...
How do you approach prevention of kidney stones in patients with an ileal diversion and recurrent nephrolithiasis?
My first step, is to perform a kidney stone analysis. Kidney stones are not a "monolithic" disorder; rather they are "symptoms" of a diverse group of renal mineral metabolism and acid-base disorders. my next step in this case would be to obtain a 24-hour urine supersaturation study. I would be parti...
What is your approach to weight loss interventions for patients with recurrent nephrolithiasis and obesity?
Obesity tends to be a little more common in stone formers. Integrating weight loss with stone prevention features can be tricky. We are fortunate to have a dietitian dedicated to our Stone Clinic and I rely heavily upon her expertise. More fluid, preferably water, and a diet tailored to the patient’...
Has use of PSMA PETCT revealed increased local failures than previously known after definitive prostate EBRT with biochemical failure?
Prior to the advent of PET imaging, the published rates of local recurrence (LR) after definitive RT vary widely in phase III trials from ≈ 1% (e.g., PCS IV) to ≈ 30% (e.g., PROG 9509). The heterogeneity is likely explained by several factors including (1) differences in baseline risk of local recur...
Is TURP a contraindication for prostate cancer SBRT?
I have not done it, but Georgetown experience recently published here: Pepin et al., PMID 32432033A recent informal Twitter poll shows many are comfortable with SBRT after TURBT: https://twitter.com/TylerSbrt/status/1323315130990432256?s=20I'm interested if any have further insight.
What are your top takeaways in GU Cancers from ASTRO 2024?
The Presidential Symposium was outstanding. Dr. Brandon Mahal’s presentation hit on a top priority for the field, in my view: how do we improve/accelerate the implementation of advances like focal microboost for prostate cancer? RCT evidence of benefit to dose escalation is rare in rad onc. The FLA...
How would you treat a patient with synchronous node positive prostate cancer (T3bN1M0) and oligometastatic rectosigmoid cancer (T4aN1M1) with a solitary liver metastasis?
I reached out to my colleague, Dr. @Dr. First Last, a radiation oncologist and co-director of the Prostate Cancer Center at Dana Farber, who has expertise in both genitourinary and gastrointestinal cancers for his thoughts on this question. Here is his answer: Recognizing that the rectal cancer is l...