Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How to you treat patients with germ cell tumors that progress during treatment with first-line platinum-based chemotherapy (i.e. platinum-refractory disease)?
This is extremely uncommon and a common mistake is to label someone as cisplatin refractory who really isn't. I would have to see the pattern of markers over the course of treatment and be assured that sanctuary sites have been ruled out prior to formally declaring someone as cisplatin refractory. T...
How do you counsel men with prostate cancer on the cardiovascular risks of androgen deprivation therapy?
This is a complex issue and depends on the specific setting (concurrent with XRT), the risk of the patient, and the specific CV risks of that patient. In the metastatic setting, there is almost never a contraindication to hormonal therapy given that prostate cancer is the likely cause of death in th...
How do you manage musculoskeletal pain in men receiving androgen deprivation therapy for non-metastatic prostate cancer?
This a very good question. Because bone pain can be a symptom of "benign" bone health issues without bone metastasis and because of the patient population demographics including risk factors, we obtain baseline bone health screening on most patients who must undergo Androgen Deprivation Therapy (ADT...
When do you use high-dose IL-2 for metastatic renal cell carcinoma?
In general, as an academic investigator, I always prefer clinical trials over standard of care. However, most of the front line registration trials in mRCC with immunotherapy have recently completed accrual, with results currently awaited. I continue to offer the option of high dose Interleukin-2 (H...
For patients who develop oligometastatic renal cell carcinoma amenable to local therapies (i.e. ablation, radiation therapy, or surgery), how do you integrate systemic therapy, if at all?
With full disclosure that the answer to this question is in the relm of a data free zone, for patients with oligometastatic disease not on systemic therapy, the answer is of course dependent upon site of disease i.e. CNS vs bone vs liver etc. That said if the solitary site of disease is managed with...
Would you offer salvage RT to a patient with adverse features after prostatectomy if his post-operative PSA was highly elevated (for example >10 ng/mL), but his metastatic work-up was negative?
The benefit in a patient like this with salvage RT is very limited if at all and I would not offer RT. This persistent elevation of more than 10 after surgery is from occut metastatic disease and local RT would not help with the outcome. Ga68 PSMA PET if available may pick up some of the disease tha...
What adjuvant therapy (chemotherapy, radiation) do you recommend for incidentally found focus of small cell prostate cancer at time of radical prostatectomy?
This is an interesting question. Extrapolating from the relatively recent data on surgery for early SCLC, the local therapy for an incidental focus of small cell histology has been completed after RP. If there is tumor that penetrated through the capsule, I'd look at the amount of tumor that broke t...
Do you see a role for adjuvant sunitinib after resected RCC?
The role of VEGF-R inhibitors as adjuvant therapy in RCC is an evolving field. As you point out, ASSURE was negative but S-TRAC was positive. Each study has to be interpreted on it own while also trying to reconcile the different results. S-TRAC was different in that it was clear cell only, a higher...
In the era of MRI and other advanced imaging, do you still routinely perform a digital rectal exam on every prostate cancer patient?
Having started my career in the era when the latest in advanced imaging was a first generation CT scan, I still perform DRE on every patient at consultation (unless they refuse). There are several reasons for this approach. First, the information you get from DRE is needed for staging purposes, whic...
How do you approach prostate cancer patients with persistent obstructive lower urinary tract symptoms after primary radiation therapy?
If the persistent LUTS is due to radiation treatment, and medical therapy is not sufficient -- then I would refer the patient to urology for consideration of a channel TURP. Patients with metastatic cancer can have local (prostate) disease progression and experience significant obstructive symptoms ...