Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you incorporate absolute percent pattern 4 (APP4) into your risk stratification, specifically your recommendation for ADT for intermediate prostate cancer?
Summary: The short answer is that APP4 is unlikely to improve risk prognostication to the extent to which other advanced biomarkers (GC, MMAI, etc.) do. It is also unlikely either alone or in combination with standard clinical factors to serve as a predictive biomarker. Nevertheless, it is certainly...
Based on the VESPER trial data, do you recommend the full 6 cycles or 3-4 cycles of ddMVAC for neoadjuvant muscle invasive bladder cancer treatment?
For clinically node negative MIBC: I give 4 cycles of neoadjuvant chemotherapy either (preferably) dose dense MVAC with G-CSF or Gemzar/Cisplatin. For cN+ MIBC: I tend to restage after 3 cycles and consider up to 6 cycles for patients who can tolerate induction chemo and do not have interim progress...
Do you routinely transition patients with recurrent calcium based kidney stones off of hydrochlorothiazide and onto chlorthalidone or indapamide for optimal control of hypercalciuria?
Yes, I do as they are longer acting thiazides and thus have better control over hypercalciuria. I generally start with Indapamide 1.25 mg daily and will titrate up if necessary. I prefer that as opposed to Chlorthalidone as to start with 12.5 mg Chlorthalidone, you need to cut it in half, which is n...
How do you decide between internal versus external decompression of malignant obstruction of the ureter (MUO)?
The decision between ureteral stenting and percutaneous nephrostomy placement is, by definition, an interdisciplinary one with my urologic oncology colleagues. If a ureteral stent is feasible, that typically is my preference as patients typically prefer this approach. Ultimately, the impact of local...
How should the outcomes and QOL results of the ProtecT Trial be interpreted?
The trial is a masterpiece. Quality assurance on the treatments, complete follow-up, careful cause-of-death ascertainment, pristine and long term quality of life data.My conclusions:1. The vast majority of men with low-risk and low-intermediate risk disease do not benefit from immediate treatment. I...
How do you approach salvage of a local-only recrurrence of prostate cancer after definitive external beam radiation?
We continue to prefer "zero margin" whole gland "HDR-like" SBRT for this circumstance for prior external beam RT cases, *34 Gy/5 fx, though would exclude any patient that has preexisting grade 2 or higher toxicity from their original RT course (otherwise, no specific exclusions, if the metastatic w/...
If a patient with non-metastatic prostate cancer is found to have a BRCA mutation, should this influence treatment recommendations for local therapy?
While there are no randomized trials to address this question, one prospective, non-randomized study of BRCA2 carriers with localized prostate cancer suggested improved outcomes with lower relapse rates in men treated with radical prostatectomy as opposed to radiation therapy. See: Castro et al., Jo...
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...