Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach treatment for high-risk prostate cancer in patients who need clearance for organ transplant listing?
Our initial approach for these patients is to engage their transplant physician to understand the barrier for organ transplant listing. For some patients, the presence of a detectable PSA is the rate limiting factor, while for others having untreated disease is the main issue. The difference between...
Would you use apalutamide in high risk non-metastatic castrate resistant prostate cancer?
I would consider using apalutamide for the appropriate patient, which I would define as meeting the entry criteria for the study i.e. PSA DT 10 months or less. The label for the drug is broad i.e. any castration resistant PSA only patient, which I beleive is too far to inclusive, many of these folks...
Given the biochemical failure definition of PSA nadir+2 ng/mL, how do you approach a PSA bounce of magnitude 2 ng/mL or higher?
ASTRO definition of biochemical failure has high specificity (about 80%) and high negative predictive value ( 90%) but lower sensitivity and positive predictive value (40% or so) . It is good for reporting to avoid incorrect reporting. A PSA bounce can effect the less than 2 years reporting numbers....
How would you treat a patient with high-volume metastatic prostate cancer who has asymptomatic biochemical relapse after having a good response to upfront docetaxel?
If the patient is asymptomatic or minimally symptomatic and now castrate-resistant, I would start with sipuleucel-T. Based on the PSA quartile data (Schellhammer et al 2013) and in line with current NCCN guidelines and supportive clinical and preclinical data, immunotherapy should be used as early a...
Would you de-escalate therapy for a prostate cancer that is barely high risk and has only 1 of 12 cores positive?
First let’s discuss high risk for cancer at the low-end of that category (example a T1c PSA6 1-2 core GS 8). Current standard of care for radiation management is to provide at least 18mo of ADT based on PCS-IV. This is somewhat of a dose de-escalation of hormonal therapy compared to EORTC regimen. ...
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...