Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is a fluciclovine (Axumin) PET scan an adequate imaging modality for prostate cancer re-staging after a biochemical failure?
Fluciclovine (Axumin) [FACBC] PET scan was FDA approved in May 2016 for recurrent prostate cancer – FDA approval was based on high accuracy of PET uptake when correlating with biopsy. As with any diagnostic imaging test, Axumin has higher diagnostic yield with increasing PSA. While Axumin can assist...
Would you consider a trial of anti-PD-1 therapy following disease progression through anti-PD-L1 therapy for advanced urothelial carcinoma?
This is a great question and should be answered in a clinical trial setting. We need trials in patients with progression on anti-PDL1 or anti-PD1 agent; currently we don't have data to answer this question of cross-resistance
What surveillance strategy do you use for patients after resection of localized renal cell cancer?
Surveillance depends on the pathological stage of the patient. For T1a disease I follow annually. For T1b disease and higher I follow q 6 mos with MRI imaging if abdimen and low dose Ct of chest. I do not perform imaging of bones or brain without a clinical indication. For LN positive disease i star...
When do you consider for first-line atezolizumab for metastatic bladder cancer?
I see these patients in 2 groups, "cisplatin-ineligible" or "chemotherapy-ineligible”. In the “cisplatin- ineligible” group one may consider a carboplatin-based regimen (carboplatin plus gemcitabine or carboplatin plus taxol) or atezolizumab. In “chemotherapy-ineligible”, I consider both performanc...
Does a transitional zone vs. peripheral zone location of low risk prostate cancer affect your recommendation for active surveillance?
All other things being equal, the location of the cancer would not impact my recommendation for active surveillance. Transitional zone tumors tend to have a better prognosis than peripheral zone cancers. They are typically found in men who have had an elevated PSA and a prior negative biopsy, which ...
How do you manage a patient with a history of non-seminomatous germ cell tumor who has a rising AFP after primary chemotherapy without any imaging evidence of recurrence?
It would depend on the timing of the rise of AFP after chemotherapy, how elevated it is, whether they were good or poor risk patients at the time of chemotherapy, whether they had liver disease and whether the AFP was definitively elevated prior to chemo In most cases, we sort of ignore AFP < 25 or ...
In patients with good performance status, metastatic clear cell kidney cancer, and minimal metastatic disease, would you consider nephrectomy or partial nephrectomy if there are mets to brain?
Debulking nephrectomy has a clear role in the management of metastatic RCC, based on prospective trials showing an OS benefit. Patient selection, however, is critical for optimal benefit and minimizing risk. Brain metastases often portend a more aggressive systemic disease, and such patients often d...
How do you approach a solitary pelvic nodal recurrence following definitive radiation therapy to the prostate/SV?
Briefly, I agree with @Dr. First Last and I occassionally offer treatment to solitary nodal disease, most commonly seen in the postprostatectomy, post-salvage RT setting. I'm generally not offering SBRT to nodal disease, since I think of the nodal basin needing RT (like 45 Gy with SIB to nodal disea...
How do you interpret and utilize PSA values in patients on dialysis?
There appears to be no clinically relevant impact on total serum PSA, whereas free PSA and % of total can be impacted in a membrane type-dependent manner to where % free PSA is of less utility for screening. Thus, total serum PSA seems reasonable to continue as marker of biochemical control post-tre...
How do you incorporate NaF bone scan in the initial workup of prostate cancer?
At this point, I think the field is still learning how to make use of these tests and trying to determine which patients are the best candidates. We clearly need better imaging to detect early metastatic disease and lymph node involvement, as these findings would change how we would approach the pat...