Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What can prostate patients do for sexual function while on ADT?
While libido drops for most men on ADT, sexual function is still an important component for many, and educating on what to expect will help prevent disappointment or confusion. First, some men can get an erection with testosterone suppressed, but it is less common and not as firm an erection as wha...
Should prostate cancer genomic classifiers, such as Decipher, be used in all high risk post-prostatectomy patients to risk stratify patients to adjvant RT vs PSA observation and possible salvage RT?
I think that the data are hypothesis generating and can assist in physician decision making. Additional analysis from other independent cohorts substantiate the findings from the JCO paper whose publications will be forthcoming. It is important to discuss the findings, including the limitations, wit...
Do you have your patients with recurrent nephrolithiasis stop supplements such as turmeric?
That is a good question and a hard one to answer since supplements may contain a variety of ingredients of unknown quantity or impurities. I think it also depends on the stone type. For example, excessive amounts of vitamin D, as were advised by some "practitioners" during COVID, can cause or aggrav...
Would you recommend ADT in a patient receiving salvage post-prostatectomy radiation with PSA <0.5 and a high Decipher score?
Certainly, this is an area of evolving management. Here’s what we know about the use of ADT in the salvage setting: RTOG 9601: 2 years of bicalutamide improved 12y OS but PSA at the time of salvage was a significant interaction term with PSA <0.7 receiving no benefit. 2 years of bicalutamide was ass...
Do you alternate CT stone scans and renal ultrasounds for stone monitoring in your patients with recurrent nephrolithiasis with the goal of limiting radiation exposure?
No. Although I share your concern about radiation and expense, the purpose of monitoring kidney stone patients is to detect small differences in stone burden from year to year. Ultrasound is less accurate than CT for this purpose. Avoiding contrast views decreases CT radiation exposure and is my mon...
Would you use belzutifan in metastatic renal cell carcinoma with somatic mutation in VHL (VHL p.q73) without having germline VHL and/or other manifestations of VHL syndrome?
Currently, there is no proven role for belzutifan use in somatic VHL mutation RCC. However, phase III clinical trial in advanced pretreated RCC randomizing to everolimus or belzutifan is currently ongoing. Phase II trials conducted in advanced RCC have reported promising results with belzutifan ther...
How do you counsel NCCN low and very low risk prostate cancer patients who receive a high risk DECIPHER score?
I do not order Decipher in NCCN low or very low risk. I'm not sure very low risk is even a relevant category in modern practice. The 15-year results from ProtecT demonstrate excellent outcomes for those on the active monitoring arm. Critically, those patients were mostly diagnosed in the pre-MRI era...
Would you offer definitive chemoRT for bladder cancer in a patient who had previously received prostate radiation?
It has to be individualized based on location in the bladder. Bladder neck may be harder with significant overlap from previous RT field but other locations can be done with reduced volume and avoiding including prostatic urethra in volume
When do you refer patients for TURP prior to prostate radiotherapy?
Good question - my experience for both brachy and EBRT prostate cancer patients - has been the clinical narrative. That is - for patients with significant LUTS - who are already on alpha blockade prior to RT, and who are still having issues of urine flow - is to see if there is a mechanical reason -...
What is your management strategy for patients with positive lymph nodes after radical prostatectomy?
There is a good retrospective study from Milan that shows considerable benefit to postoperative radiation therapy for node postive patients. DaPozza et al published this in "European Urology 55 (2009) 1003–1011". Their conclusions state: "Our data showed excellent long-term outcome for node-positi...