Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
For unfavorable intermediate prostate cancer in elderly patients, would you consider radiation without ADT?
This is a great and highly clinically relevant question that I view has 4 important inter-related points.First, I will take the liberty of rephrasing the question as I believe the real question is... for a man with a good enough life expectancy to warrant curative intent RT, does age and comorbid co...
When do you initiate androgen deprivation therapy for biochemical relapse of prostate cancer following primary therapy?
There is no right or wrong answer here. The Johns Hopkins approach is to always recommend a clinical trial for the nonmetastatic BCR population. In the absence of a trial, our group does not believe that early ADT is justified in men with PSADT >9 months, where metastasis-free survival approaches 10...
For patients with seminoma testicular cancer who are Stage II (positive retroperitoneal lymph nodes), what factors do you consider when choosing between radiation versus chemotherapy?
I usually look at the size of the retroperitoneal adenopathy, the age of the patient and the anticipated tolerance of chemotherapy. Disease > 3cm in the retroperitoneum is most often treated with chemotherapy. Less than 3 cm, it becomes a clinical judgement. Older patients probably have lower risk o...
What is your preferred treatment for Stage IIA seminoma or IIB seminoma with LN <3 cm and normal tumor markers after orchiectomy?
Para-aortic nodal disease <5 cm is well treated with radiotherapy to PA+pelvis with boost tot eh nodes with high cure rates and minimal toxicity. >5cm best treated with BEP or EP chemotherapy. No role for RPLND in seminoma.
When following active surveillance paradigm, what PSA increase will trigger prostate biopsy?
When using PSA to aid in the decision to re-biopsy a patient on active surveillance, I think you have to consider that the non-malignant prostate tissue also contributes to the rise in the PSA and that there are limits to the accuracy of the test. In patients not known to have prostate cancer, a PSA...
Do you routinely do restaging imaging before surgery for a patient who completed neoadjuvant treatment for MIBC?
Clinical staging of MIBC is suboptimal despite the advent of multiparametric (mp)-MRI. However, routine radiographic restaging following neoadjuvant chemotherapy and before radical cystectomy is prudent in patients with baseline cT2-T4aN0 MIBC and is generally required in clinical trials. It is know...
Would you treat a patient with prostate biopsy (and or MRI) suspicious for extraprostatic extension as high risk if they otherwise have IR disease factors?
Men in the intermediate risk category are a heterogeneous group, and clinical factors can be a useful way to further stratify risk in this group. In our practice, because of an institutional outcomes study, we primarily use % positive cores > 50% as a means to select men for the more aggressive ther...
Do you recommend a patient with recurrent nephrolithiasis who is performing a 24 hour urine collection add a urine preservative or keep the specimen refrigerated?
We always add a preservative that will not interfere with any of the analytes to be measured. Additionally, we recommend refrigeration of the specimen. Stephen B Erickson, MD
What would you recommend for pTa, stage 0a papillary urothelial carcinoma of the distal ureter?
I think a lot would rest on the grade (and presumably upper tract imaging was otherwise negative) – if low grade could do endoscopic resection and monitor, if high grade could consider neoadjuvant therapy with ureterectomy vs nephroureterectomy. …also depending on age, comorbities, etc.
In asymptomatic patients with unfavorable intermediate risk prostate cancer and a PSA <10, how helpful/reliable and clinically useful is bone imaging?
Bone scans amazingly are still something we discuss, and I imagine when we look back in 5 years at this question (at least I hope), people would think it is unthinkable to order a bone scan for intermediate risk with PSA <10 (let alone in localized PCa) instead of MRI and/or PSMA PET/CT.10 years ago...