Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is bilateral hearing loss requiring hearing aids an absolute or relative contraindication for neoadjuvant cisplatin in MIBC?
For this “curative intent” neoadjuvant therapy setting, a detailed discussion with the patient is very helpful and should include the pros/cons of cisplatin based chemotherapy based on phase 3 trials data and a meta-analysis showing OS benefit as well as possible side effects, including hearing loss...
Is it safe to administer cabazitaxel to a patient with mCRPC who developed grade 3 pneumonitis from docetaxel?
In general, the answer is yes, as these are distinct therapies with distinct toxicities. Both are formulated in TWEEN80 solvent and can cause allergic reactions and anaphylaxis, and this is the only adverse event that I would strongly consider avoiding cabazitaxel if this event was experienced in a ...
Are there other therapies such as SGLT2 inhibitors or alpha lipoic acid that you are offering your patients with cystinuria who continue to have active stone disease despite conservative therapy and thiol-based agents?
I am not aware of quality trials for new agents being advocated for the treatment of cystinuria. I do not prescribe them. Generally, the failure to respond to standard therapy reflects a failure of the patient to follow the appropriate diet and titrate the usual medications as regards urine pH and c...
When would you use PSMA PET over conventional imaging for prostate cancer?
So far, most (but not all) prospective data for molecular imaging has been obtained in the setting of biochemical recurrence and that is where I have used it most outside of trials.In the primary disease setting, some trials examined the utility to detect nodal and distant disease (like OSPREY publi...
How do you counsel patients with high risk prostate cancer treated with RT + long term ADT who want to allow their testosterone level to rise above castration before receiving their next Lupron injection?
I would not support this strategy unless the patient is on longer term ADT for biochemical recurrence after prior local therapy. In that setting, intermittent ADT is a viable option supported by literature and could be considered. Otherwise, once ADT is stopped, there's no basis for resuming. The co...
How do you manage favorable intermediate risk prostate cancer patients that have a PIRADS 5 lesion that was most-likely missed in the template biopsy?
Yes, I'd suggest a repeat biopsy before treatment. In the case of radiation +/- ADT, a repeat biopsy may impact the dosimetry of radiation, whether or not ADT is used, and how long ADT is used as part of treatment.
How do you manage an elderly, high risk prostate cancer patient who refuses any local therapy?
In general, for patients who refuse treatment, I try to understand their goals and their fears. Often, elderly patients state that they are ready to die, and don't want to prolong their lives. If I think that treatment is likely to significantly improve the quality of their lives, I will explain why...
What is your criteria for undetectable PSA value after prostatectomy?
In the era of ultra-sensitive PSA, reading below threshold of .2 ng/ml also reflects biochemical recurrence especially in the right context. That being said, if values are low like above, we generally repeat PSA to see the trend rather than act on treatment on single value.
Are there any scenarios in which you would consider use of PARPi in the upfront mCSPC setting rather than reserving for CRPC?
The FDA approved talazoparib plus enzalutamide for HRRm metastatic CRPC in June 2023. NCCN panel recommends talazoparib plus enzalutamide as a category 1 treatment option for patients with metastatic CRPC and a pathogenic mutation (germline and/or somatic) in one of certain HRR and other DNA repair ...
How would you treat a patient presenting with de novo metastatic prostate cancer and baseline low testosterone?
By definition, progressive disease despite castrate levels of testosterone is CRPC. This is a very rare situation in the de novo setting, and more likely one may encounter a patient with only slightly low testosterone, which would not be considered CRPC. Patients with de novo metastatic prostate can...