Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you approach a patient with Gleason 9 prostate cancer and regional lymphadenopathy as well as inguinal lymphadenopathy (M1a) but no bone metastases?
Definitely warrants a balanced discussion. Systemic therapy as the mainstay is definitely the right answer--long-term ADT for sure, at minimum. I think offering to treat the prostate with RT is fair, based on STAMPEDE. For a fit patient with good life expectancy, I would explain to the patient that ...
How would you manage prostate cancer with isolated presacral nodal metastasis?
Unfortunately, we can't really use RTOG 0521 to guide us here, as men with involved nodes detected by imaging were excluded. Also, according to the AJCC 8th edition staging manual, pre-sacral nodal involvement would be considered N1 rather than M1a, so although this man is at high risk for subsequen...
How would you manage a locally advanced TNBC and a malignant appearing renal mass suspicious for a synchronous renal cell carcinoma?
The answer to this question (in my view) depends largely on the extent of the renal cell carcinoma. Historically, renal cell carcinoma is still managed largely by up front surgical resection. If the suspected second primary were small and the oncologist felt like close observation was possible, one ...
What is a safe time interval from completion of hormones and external beam radiation to TURP in patients who develop refractory obstruction?
Great question. Ordinarily, in my past experience, if a patient had real LUTS >14 AUA score that was not relieved with alpha blockers, and/or had a large median lobe, we would prefer the TURP be done upfront and / or chemical debulking with ADT too. In these instances, we found we had less LUTS then...
For localized prostate cancer patients, do you routinely give antiandrogen therapy for patients receiving LHRH agonist therapy?
Although studies have given anti androgen for variable period of 4 weeks to 6 months, we use it only to suppress testosterone flare.
What is your approach to imaging for localization of biochemical relapse of prostate cancer after radical prostatectomy?
This is a complex question without a short answer. Men with a very low PSA of less than 0.5 have clear benefits from salvage RT after prostatectomy, particularly if they have T3 disease or positive margins; and these patients rarely have PET positive disease, even with PSMA or Axumin imaging. Thus t...
When treating a patient definitively for high risk prostate cancer, how would you interpret the interval development of sclerotic bone lesions that appeared during neoadjuvant ADT?
It most likely reflects treated metastatic disease but can be very difficult to prove, as bx yield is low since it has been treated. Would not change management and complete planned treatment. Stampede also showed benefit of local RT for limited bone mets
Which patients with metastatic hormone sensitive prostate cancer would you treat with enzalutamide or apalutamide (instead of abiraterone or docetaxel)?
Current studies in mHSPC combining docetaxel or abiraterone or enzalutamide or apalutamide suggest that the standard of care for patients who present with de novo high volume metastatic disease has now changed from single ADT (gonadal androgen suppression) to one of the combinations. At this point i...
What duration of ADT do you recommend for patients with high risk or very high risk prostate cancer who undergo radical prostatectomy, adjuvant RT, and adjuvant docetaxel?
Locally advanced prostate cancer remains a significant clinical challenge. The role of "adjuvant" docetaxel to follow patients receiving primary radiotherapy plus ADT has been tested in at least 5 randomized studies, with RTOG 0521 the only one to my knowledge showing survival benefit (albeit a smal...
How long after biopsy is it safe to place rectal spacer when treating a patient definitively for prostate cancer?
Depends on the method of biopsy. Transperineal, think it would be safe to do this immediately. Transrectal biopsy I would be more concerned about infection and would wait 3 days.