Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is there any data to support the use of hormone therapy with RT in the adjuvant post-prostatectomy setting?
Unfortunately, randomized data remains limited. Although pT3/N1 pts were included in RTOG 8531 (www.ncbi.nlm.nih.gov/pubmed/15817329), the majority of the pts included in this trial were treated with definitive radiation. At ASTRO 2011, Shipley et al reported the results of RTOG 9601 (www.redjournal...
Which patients with intermediate and high risk prostate cancer should not receive androgen deprivation therapy?
Based on randomized trials that didn't exclude patients with cardiac risk factors, an overall survival benefit has been observed for intermediate and high risk localized prostate cancer. Review of RTOG studies has not detected an increase in cardiovascular events. That said, appropriate management o...
Do you decrease the duration of hormones in a man with high risk prostate cancer and cardiac risk factors?
I do consider a shorter course of ADT in the setting of a patient with significant cardiac disease, but usually only after speaking with the patient's cardiologist to first determine if there may be other mitigating risk factors that are more readily modifiable. If the patient is older than 75 or ha...
For patients with high risk prostate cancer, is there data to support prostatectomy, as opposed to upfront RT?
In 2010, MSKCC published a study in JCO which suggested surgery was better than 81 Gy IMRT for high risk prostate cancer. The study had many limitations including selection bias of higher stage patients. in the RT group, there was only short term androgen ablation, lack of salvage or delayed salvage...
How should I interpret a Gleason 7 prostate cancer (4+3 or 3+4) with tertiary grade 5?
The scoring system adopted by 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma specified that in a prostate biopsy, the two numbers should be the primary pattern and the highest grade (not the second most common type as was done...
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 ...