Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you manage adjuvant hormonal therapy in a patient with high risk prostate cancer who already received prolonged neoadjuvant ADT prior to being referred for radiation?
For the purpose of answering this question, I will assume that the patient has a stable or declining PSA and has not shown signs of castrate resistance. In general, I am more concerned with the response to ADT prior to beginning radiation, rather than the duration of ADT before RT. Retrospective dat...
How do you approach local control in intermediate risk bladder rhabdomyosarcoma in very young (<24 months) children ?
These two approaches are probably equivalent in qualified hands (cystectomy / prostatectomy or definitive RT) in terms of local control. This issue is balancing morbidity. The surgical approach in many cases will require a full cystectomy, necessitating the creation of a neobladder or some other re...
Would you use AR-V7 testing to decide second-line androgen receptor-axis-targeted therapy vs chemotherapy for patients who with metastatic castration-resistant prostate cancer?
In our PROPHECY multicenter AR-V7 validation trial, we compared the JHU AR-V7 CTC RNA test against the Epic/Genomic Sciences nuclear protein CTC AR-V7 test. Both tests, when positive, were strongly associated with lack of PSA response, short PFS, and short OS in men with mCRPC receiving abiraterone ...
What approach would you take for patients with metastatic castration-resistant prostate cancer with marked PSA response (undetectable) on docetaxel, but radiographic progression in bone metastases?
As a first step I would confirm that the patient has truly had radiographic progression of his bone metastases. Prostate cancer can often demonstrate what has been termed a "healing flare" following response to systemic therapy, and radiographic progression in bone requires a follow up bone scan (us...
How do I convince urologists to send patients for a discussion of adjuvant radiation after prostatectomy?
Howard's advice is spot on as usual.For the residents and even faculty reading this, I think there has been an unnecessary rivalry between radonc and uro-onc that predominately only negatively impacts patients. We are a team and I think if we approach the care of our patients as a team we will provi...
In light of the recently published CARMENA trial, is there still a role for cytoreductive nephrectomy in metastatic RCC patients?
Several features of CARMENA make the data not applicable to all mRCC patients with primary in place. These include a large percentage of poor risk/poor PS patients, lack of receiving intended protocol therapy, including delayed nephrectomy in almost 1 of every 5 patients, and a primary tumor burden ...
If a patient develops intermittent painless hematuria during standard prostate RT do you attribute this to cystitis or would you work it up further?
While acute mucosal deepithelialization may be to blame, painless hematuria may unfortunately mark the beginning of a conundrum. It's good medicine to always develop a broad DDx and remember that radiation injuries are waste basket diagnoses. It's also wise to start with a UA/UCx, and if negative do...
How do you approach a patient with a non-castrate testosterone level and rising PSA despite receiving LHRH agonist therapy?
This is a good question. It is always good to check on the testosterone value in men on LHRH agonist therapy in order to ensure the level truly is within castrate range. I assume this patient has been on therapy for a number of months (i.e. the testosterone has had time for full suppression). If so,...
What is your preferred first-line therapy for patients with newly diagnosed intermediate- or poor-risk metastatic clear cell RCC?
For intermediate and poor risk advanced clear cell renal cell carcinoma, combination therapy is the standard of care with 4 different regimens showing an improvement in overall survival vs sunitinib: nivolumab/ipilimumab, pembrolizumab/axitinib, cabozantinib/nivolumab, and pembrolizumab/lenvatinib. ...
Can bicalutamide be used instead of LHRH agonist in intermediate to high risk prostate patients receiving EBRT who want to preserve erectile function?
The short answer is yes, BUT with some serious reservations: 1. This is not considered standard of care in this patient population, so patients should be made aware of that fact and that conversation should be documented in the medical record; 2. There are data to indicate that bicalutamide plus EBR...