Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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?
I also like to do the combined androgen ablation with RT to stay consistent with the majority of the randomized studies done. There is a subset analysis of Anthony D'Amico's 206 patient study in which PSA recurrence rates were analyzed according to whether combined androgen blockade was received (as...
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 ...
What is the appropriate management of Stage 0 (testicular intratubular neoplasia) of the testicle?
For patients with ipsilateral TIN, usually one performs orchiectomy. This may be diagnosed as part of an infertility work up, as these patients often have primary infertility and atrophic testis. The issue of RT comes for patients with previous orchiectomy and then develop contralateral TIN. For the...
What is the best toxicity data to quote to patients for prostate IMRT vs nerve-sparing prostatectomy?
The surgery vs. RT question is a common one during a “2nd opinion†consultation with radiation oncology. More and more comparative data are being published regarding disease outcomes but many fewer exist regarding toxicity. I often hand out a copy of Sanda et al, NEJM 2008, which reports on qual...
At what PSA do you start calculating doubling time post-prostatectomy?
The problem you describe, I think, also applies to standard assays when values are at or near the limits of detectability. Is an increase from 0.1 to 0.2 in 3 months really indicative of a rapid rise? If you are seeing small changes at low PSA values, and you're not inclined to treat the patient, yo...
How do you manage high risk prostate cancer patients with well controlled Crohn's disease?
My first choice would be to manage them without the use of radiation therapy. A minority of patients with high risk disease are curable with surgery, and the population with inflammatory bowel disease is one that I tend to steer away from radiation therapy. Despite the adverse prognostic features of...
How long should the duration of hormones be in post-prostatectomy patients receiving salvage RT?
That depends upon why you are giving the ADT. If you think it is just to improve local control in the prostate bed then 6 months should be more than enough. If it is to address micrometastatic disease, then to be consistent with other precedents, it should be two years. An RTOG trial looking at salv...