Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is there any role for re-challenge with enzalutamide or abiraterone after prior failure in metastatic castrate-resistant prostate cancer?
Returning to a therapy on which a patient with mCRPC had previously progressed can be done with docetaxel (Bracarda et al, Future Oncol. 2015;11(22):3083-90; Di Lorenzo et al, Medicine (Baltimore). 2016;95(14):e2754), where a patient may derive clinical benefit to a re-challenge. Typically, the pati...
In a patient with a history of treated stage II seminoma with rising bHCG while on surveillance, do you routinely recheck the bHCG with a different assay?
In this setting, it depends a lot of the confidence you have in the treatment and the degree of HCG elevation. It also depends to some degree on whether the patient had an HCG elevation when he presented with stage II disease. In most of these cases these are very low level HCG elevations that bounc...
What is your approach to treating metastatic prostate cancer with primary resistance to GnRH analogues or early CRPC?
There is no one correct answer for every patient. In general, patients who are primarily resistant to GnRH or who develop early CRPC and who have not received docetaxel in the hormone-sensitive setting, would be good candidates to receive docetaxel. For those who are elderly or frail, I would consi...
How would you manage positive surgical margins after partial nephrectomy for kidney cancer?
If feasible, I would recommend re-excision. This is not always feasible however, and in that case, I would observe. Patients with positive margins do not always recur and thus could spare the patient some toxicity.
What challenges and adverse effects have you encountered with SpaceOAR injection?
Only situation in our limited experience where we have encountered a problem is in a patient with inflammatory bowel disease that had a j pouch where the scarring limited optimal placement of the SpaceOAR and the separation between the rectum and prostate was not as desired.
Do you offer bladder-sparing approaches as an alternative to cystectomy for surgery-eligible patients with muscle-invasive bladder cancer?
We have a bladder cancer multispecialty clinic at SCCA/UWMC in which we also see patients with localized MIBC and we balance carefully risks vs benefits, rationale, data, details & logistics of options. Overall, cisplatin-based chemotherapy (for fit patients) ->radical cystectomy with PLND, OR maxim...
Is there a role for a salvage lymph node dissection in patients who present with a biochemical failure after prostatectomy?
It's an important question without randomized data to support an answer. Even this question will evolve as we bring on-board more advanced imaging such as Fluciclovine PET/CT, PSMA PET, etc. These scans are continuuing to introduce new challenges as we start to resolve the location of lesions and so...
How would you approach adjuvant therapy for a finding of carcinosarcoma in a prostatectomy specimen?
Pure "carcinosarcoma" a biphasic neoplasm with both epithelial adenocarcinoma with second component which is a clearly recognizable type of sarcoma is of course extremely rare, thus my comments must be considered in the data free zone from which they eminate. Both local recurrence and systemic failu...
What is your preferred second-line agent for treatment of metastatic urothelial carcinoma?
Great question, currently only atezolizumab and nivolumab are FDA-approved in this setting. Overall, there are several parameters to take into account (by the way, I suggest a recent review on ASCO "value-based care", which is creating a framework and parameters for the evaluation of cancer drugs ut...
How do you approach non-metastatic castration-resistant prostate cancer?
The two recent placebo controlled trials comparing apalutamide and enzalutamide in M0CRPC (SPARTAN and PROSPER) have shown sizeable and consistent effects on various outcome measures, clearly met the primary study endpoints and hence satisfied FDA regulatory criteria for drug approval in this space....