Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What do you use for post-treatment follow up for prostate cancer patients whose cancers make little to no PSA, such as very high Gleason grade/neuroendocrine tumors?
We can probably separate the question into two categories: the rare prostate cancers that make absolutely no PSA and those that make relatively little PSA. For those that make zero PSA, then I've generally followed them with imaging similar to how one might follow a small cell cancer of any primary ...
What combination of clinical and pathologic features would lead you to be comfortable recommending active surveillance in a Gleason 7 prostate cancer patient?
Active surveillance (AS) is an important option for prostate cancer patients, especially for low risk prostate cancer. For intermediate risk prostate cancer, the risk of AS increases somewhat but the benefits of AS remain. To keep the risk of AS acceptable, one should select intermediate risk patien...
How would your management change for high-risk prostate cancer in a patient who is not a surgical candidate (due to age or medical comorbidities) and had prior pelvic irradiation?
Thank you for your question. Indeed, much of the data on re-irradiation in the pelvis corresponds to recurrent disease in GI or GYN malignancies. Historically, many physicians would recommend androgen deprivation alone as management in the setting of high risk prostate cancer with prior pelvic RT. H...
How would you manage a patient with low risk prostate cancer on active surveillance who develops high risk features but absolutely refuses a repeat biopsy?
In the setting of a suspicious mpMRI lesion, we start by acknowledging the patient's likely negative experience with their transrectal biopsy. We ask if they are referring to the one where they were rolled on their side, had a probe inserted in their rectum, and heard a bunch of loud CLICKs. We empa...
How would you manage a cN0 penile cancer with a moderate risk of nodal metastasis?
Pathologic nodal stage is such a strong prognostic factor that patients with moderate or high risk of nodal involvement, even if cN0, should have surgical nodal staging. This includes those patients with MD and PD tumours, and T1b or higher. PET-CT cannot show microscopic involvement. If the patien...
What alternative therapies would you consider for a patient with metastatic castration-sensitive prostate cancer who declines GnRH analogues?
This situation is fairly uncommon, particularly in the metastatic setting, where these therapies are nearly universally effective and toxicities generally manageable. The alternatives of bicalutamide at high dose (150 mg/d) and enzalutamide also have toxicities and much less evidence to support thei...
Do you find the measurement of ultra-sensitive PSA provides clinical benefit in a patient with biochemical recurrence after radical prostatectomy compared to non ultra-sensitive PSA measurement?
Yes- for patients post prostatectomy uPSA should be ordered. The outcome of salvage RT is tied to PSA levels and the lower the PSA better the outcome.
Would you offer prostate specific PET imaging (e.g. Axumin or PSMA PET) in a post-RT prostate cancer patient that has a rising PSA that has not yet met failure criteria?
Maitre et al., PMID 35189154 This study shows a high pick up rate with PSA not meeting failure criteria and many of them had focal relapses which are potentially salvageable.
When do you offer salvage prostate bed RT to patients who have a biochemical recurrence >5 years after RP?
While retrospective data consistently suggest that biochemical outcomes (and possibly also distant metastases and prostate cancer specific mortality) are better when salvage radiation is delivered at lower PSA values, there is no absolute cut-point to trigger treatment. Many factors must be taken in...
Is antiandrogen monotherapy a reasonable option for a patient with high-risk disease getting IMRT (+/- BT boost) who refuses GNRH modulators?
I do use anti-androgen monotherapy as a compromise for patients who refuse LHRH agonists. Many patients walk out the door when LHRH agonists are mentioned. The PSA nadir is not as low with biclutamide as with LHRH agonists. There is experience with biclutamide at 150 mg both in non randomized report...