Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...
Would you treat a patient who failed cryotherapy?
There is published data (small series), showing reasonable efficacy and good tolerence of salvage EBRT for cryotherapy failure and we have treated a few patients with this approach.
In a low volume prostate cancer (2 of 12 cores, low percentage) with a GS 4+4=8, how long does ADT need to be administered?
The role of ADT for high-risk disease continues to evolve, with new data emerging annually. While guidelines typically recommend 2-3 years for any high-risk patient, not all have the same risk of failure and/or benefit from ADT. Initial phase III studies from the RTOG & EORTC that showed OS benefits...
For patients with high risk prostate cancer, is there data to support increased morbidity, such as increased urethral strictures or cystitis, when given postprostatectomy XRT as opposed to definitive XRT?
This is a very relevant question that commonly comes up in practice - should a man with high risk prostate cancer have a prostatectomy, when the chance of him needing post-op RT is reasonably high, if he could have RT/ADT only and possibly avoid the risks associated with surgery? The discussion must...
If one decides to use a mpMRI to stage a pt with low-risk prostate cancer, how do you work up a focal lesion suspicious for higher grade GS 7-10 disease?
Even though modern mpMRI is sensitive (>90%) at detecting occult GS ≥4+3 cancers that are missed by blind systematic TRUS biopsies, it is not 100% specific. Almost all radiologists will occasionally over-call a radiographic abnormality when it is still only GS 6. When decisions to be made from this ...
Do you forgo adjuvant radiotherapy for men with pT3 prostate cancer who have significant urinary incontinence?
I agree that early salvage may be reasonably effective and thus one might carefully observe patients who are not ideal candidates for adjuvant RT. Both the RADICALS study and the RAVES study will examine this issue (timing of post-op RT further). Here's a recent summary of the RAVES trial: BJU Int....
For intermediate risk prostate cancer do you recommend short-term complete androgen blockade or LHRH agonist alone?
This is a good question with little data specifically addressing it. Anthony D'Amico et al. did a retropsecitve study of this issue in a cohort of high-risk patients who were treated with IMRT+brachy and showed complete blockade was associated with better prostate cancer specific mortality (Red J, 2...
When is the best time to start denosumab in men with metastatic prostate cancer?
The data supporting the use of bone modifying agents (BMAs) such as denosumab or zoledronic acid are certainly the most solid for men with castration-resistant prostate cancer (i.e. progresion of disease through inital LHRH analog therapy) (Saad, JNCI 2004; 94: 1458–68; Fizzazi Lancet Oncol 2011; 37...
Is weekly Cisplatin considered a valid alternative to Cisplatin cycles every 3 weeks as part of definitive chemo-radiation for muscle invasive bladder cancer?
None of the RTOG trials had this approach, but extrapolating from head and neck cancer (cisplatin 30mg/m2) or cervical cancer (40mg/m2), people in the community are using weekly cisplatin. As far as data, there is a phase II study from Australia utilizing cisplatin 35mg/m2 weekly for 6-7 cycles show...
What is the best approach to management of newly diagnosed intermediate or high risk prostate cancer in a patient with high grade non-muscle invasive bladder cancer?
Perhaps the term "Best Approach" should be eyed with skepticism in the field of genitourinary radiation oncology. Is there extensive disease in the bladder, focal recurrences, or no visualizable lesions? The maintenance BCG element of the question suggests the patient has minimal measurable disease ...