Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you treat patients with muscle-invasive urothelial carcinoma of the bladder with small cell and sarcomatoid differentiation?
Muscle-invasive urothelial carcinoma "with small cell and sarcomatoid differentiation" could represent an inexperienced pathologist failing to recognize a variant of pure urothelial cancer or it might be a stem-cell tumor with variable differentiation. I would start by having the pathology reviewed ...
In a patient who requires prostate cytoreduction prior to EBRT or brachytherapy, do you include a 5-alpha reductase inhibitor in your ADT regimen?
This is a great question. Although 5-aplha reductase inhibitors do shrink the prostate, there is little data reporting on its use prior to RT. Jethwa et al (J of Contem Brachytherapy 2016 Oct; 8(5): 371–378.) evaluated factors that impacted decrease in prostate volume and the initial prostate volu...
Is treating high-risk prostate cancer with trimodality therapy safe for a patient who remains on anti-PD1 therapy for metastatic melanoma?
More important question is do we need to treat patient with triple modality for high risk disease if they have metastatic melanoma as outcome would be dictated by metastatic disease
What morphologic criteria do you use to call prostate cancer N1 on imaging?
Good question. By old CT standards from the 90s that include not only prostate but NSCLC as well, the criteria for positive LNs was a short axis LN diameter of 1cm or greater. Some have used CT with MRI imaging and lowered to as low as 5-7 mm, too.Source: The diagnostic accuracy of CT and MRI in the...
How do you decide between abiraterone or docetaxel for first line treatment of newly diagnosed metastatic prostate cancer?
Abiraterone (LATITUDE and STAMPEDE trials) and docetaxel (CHAARTED and STAMPEDE trials) both have level 1 evidence supporting their use in men with metastatic hormone-sensitive prostate cancer. However, a pre-planned subset analysis from the CHAARTED study demonstrated that docetaxel only appeared t...
Would you recommend starting treatment for a renal cell carcinoma patient with new low-burden, asymptomatic sub-centimeter bilateral pulmonary nodules that arise after a short disease-free interval (<6 months) after nephrectomy for stage I disease?
This patient generally fits the phenotype of someone I would consider for initial observation. Usually if you look closely at prior scans, such nodules were present but unappreciated. There are prospective data supporting such an approach. Having said that, it also depends on the age and performance...
In patients who initially received chemo-hormonal first-line therapy for metastatic prostate cancer followed by abiraterone/enzalutamide for castration-resistant disease, would you re-challenge with docetaxel?
As we all know, very few things regarding therapeutic sequencing in prostate cancer are straightforward. Retreatment with docetaxel was used relatively commonly in the past in patients with mcrpc, especially in those with good initial responses primarily for want of other agents. In this setting, re...
What adjuvant treatment would you use for a cisplatin ineligible, node positive, upper tract urothelial cancer patient after radical nephroureterectomy?
Based on the recent POUT trial, there is no benefit in substituting cisplatin with carboplatin. In fact, node positive patients tended to do worse even with chemotherapy. I routinely consider adjuvant IO trials for these patients like AMBASSADOR. If patient is not able to participate in trials, it m...
Are you using prostate PET imaging for any newly-diagnosed prostate cancers?
December 2021 Update:In 2 years since this original post, a lot has changed. Two different PSMA PET/CT companies have gained FDA approval with broad indications that include the use in newly diagnosed men at risk for harboring metastatic disease. Distribution is well underway with many centers now h...
Would a history of receiving green light laser therapy for BPH change your management of newly diagnosed prostate cancer?
Your intervention will depend on his prostate cancer risk group, if he has a 'huge' prostate still, and bothersome LUTS. It will also depend on if you are in the private sector, or in institutional / academic setting, too. For some, the risk of prior "TURP" like procedures are a contraindication for...