Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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...
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 ...
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.