Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you manage patients with locoregional lymph node recurrence after radical cystectomy for muscle invasive bladder cancer?
Recurrent bladder cancer is typically a systemic disease. I would start with cisplatin based chemotherapy first and then add consolidative radiotherapy. There is a small body of literature on surgical consolidation as well. In our single instiution experience patients did very well following radioth...
How would you approach management of a large retroperitoneal mass that shows seminoma on biopsy?
Cure rate should be 90-95% with BEP X 3 ( EP X 4 if over age 50) . No need to consider a mixed tumor. Postchemo, he with be in P.R. and would then just observe residual mass with serial CT scans.
For patients with high-risk metastatic castration-sensitive prostate cancer who have completed upfront ADT + docetaxel, would you consider starting abiraterone or enzalutamide in addition to ADT while the disease is still castration-sensitive?
No. In patients with castration-sensitive disease on ADT who have completed six cycles of docetaxel as per the CHAARTED data (Sweeney et al. NEJM 2015), there is no good evidence that adding abiraterone after docetaxel while still castration-sensitive is warranted. Abiraterone has potential harm and...
Is ADT alone appropriate for high risk prostate cancer patients without evidence of metastasis and limited life expectancy?
I disagree with ADT alone as an option for any patient with non-metastatic prostate cancer. For high-risk patients, 2 randomized trials have compared ADT alone vs ADT+RT. In the MRC UK PR07 trial (Mason MD et al, JCO 2015), RT improved overall survival and disease specific survival. Notably, the dis...
Is there a role for any non-cisplatin based adjuvant therapy or radiotherapy (in absence of platinum sensitizer) for muscle-invasive, node-negative bladder cancer after radical cystectomy?
This is a very clinically relevant question that we often wrestle with the optimal management. In the adjuvant space, multiple investigators have looked at alternative adjuvant chemotherapy regimens for patients after cystectomy and deemed cisplatin-ineligible. The most ideal would be carboplatin-ba...
What palliative systemic treatment options (if any) may be considered for metastatic adenocarcinoma of the rete testis?
There is no known effective therapy for metastatic rete testis cancer. I presume the patient is not a candidate for resections of metastatic deposit(s). If we were seeing here we would do NGS to see if there is anything that could be therapeutically exploited. Sorry.
Are prostate PET scans (axumin, PSMA, etc.) still useful for patients on androgen suppression therapy?
The detection rate with this radioisotope is a function of PSA level with sensitivity improving with increased level of PSA. I don't think androgen ablation by itself would affect detection rate unless disease is under control with the therapyThis is good review article in PRO comparing sensitivity ...
How would you approach locally advanced bladder cancer in a patient on hemodialysis?
It depends on "locally advanced" setting; resectable or unresectable tumor?If resectable and not metastatic may consider radical cystectomy and LN dissection in good surgical candidates; however bladder preservation approach can be considered in well selected patients, e.g. small unifocal tumors wit...
In a medically inoperable, elderly, frail patient with muscle invasive, node negative bladder cancer, would you consider combining immunotherapy with radiotherapy instead of chemotherapy?
Maybe but what about using low dose Gemcitabine ( 27mg/M2 twice weekly) with daily XRT as in NEG 0712? This seems much better to me! WS
For a patient with metastatic castration-resistant prostate cancer to the bones with rising PSA but no evidence of radiographic or symptomatic progression, would you continue with the same treatment or change therapy based on biochemical progression?
This question emphasizes the importance of radiographic monitoring while on treatment for mCRPC. In a recent study from the PREVAIL trial of enzalutamide in chemo naive men with mCRPC, we found that radiographic progression occurred in about 1 out of 4 men (25%) without evidence of formal PSA progre...