Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you treat a patient who develops metastatic prostate CA while on enzalutamide or apalutamide for originally M0 CRPC?
Most patients in this setting actually have mCRPC but very low volume disease. Occasionally this can be local/regional only but most PET imaging studies suggest that M0 CRPC is comprised of metastatic disease below the limits of detection of conventional CT and bone scan imaging. Thus I manage these...
Would you consider cystectomy in a patient who acheived radiologic and cystoscopic CR from chemo-radiation for oligometastatic urothelial carcinoma originating in the bladder if remains disease free > 6 months?
For this patient, I would currently recommend 4-6 cycles of cisplatin based chemotherapy followed by avelumab switch maintenance therapy. I would strongly consider radiation or chemoradiation after the combination chemo directed at the bladder and lymph node, followed soon after by avelumab. I think...
In a patient with newly diagnosed high risk prostate cancer, how do you work up a bone scan showing suspicious areas of radiotracer uptake?
This a great question. In the setting of abnormalities on the bone scan, I would take 2 actions. First, I would certainly get local imaging of the abnormal site, with a CT, MRI or X-ray, depending on the location. I would also use the patient's clinical scenario and treatment response to help in the...
Is the presence of STUMP (Stromal tumor of Uncertain Malignant Potential) after prostatectomy an indication for adjuvant radiation?
Based on limited data there is no role of adjuvant RT for STOMP
How much emphasis do you place on anti-AR therapy in a patient with metastatic castration resistant prostate adenocarcinoma with progressive neuroendocrine differentiation?
While most prostate cancers are adenocarcinomas, there is a histologic spectrum that includes neuroendocrine and small cell tumors -- with the later typically arising in response to chronic androgen deprivation therapy. Often times we are faced with mixed histologies, which can be challenging to man...
Is there any role for neoadjuvant therapy in urothelial Tis refractory to BCG therapy?
No clear role of systemic chemotherapy prior to radical cystectomy. The latter alone is the SOC in this setting; clinical trials should be certainly considered especially in patients who either refuse or can’t tolerate radical cystectomy for BCG unresponsive high risk NMIBC.
Would you prefer FGFR inhibitor or second line immunotherapy in a patient with metastatic urothelial cancer of the bladder with FGFR mutation?
I would clearly prefer immunotherapy specifically with the use of pembrolizumab. I would measure the PDL1 CPS expression, where the impact is much greater. Phase 3 data clearly shows significantly improved survival compared to chemotherapy or BSC. This is the first positive trial in the second-line ...
Do you offer adjuvant chemotherapy or abiraterone for patients with high and very high risk prostate cancer with still detectable PSA after radical prostatectomy and lymph node dissection?
I will recommend reimaging outside conventional CT and bone scans. The goal of imaging is to rule out metastatic disease and (hopefully) identify localized residual disease in prostatectomy bed or pelvic LN and consider early salvage RT. Fluciclovine PET is now commercially available and also PSMA P...
How do you manage androgen deprivation in a patient with oligometastatic prostate cancer in which the primary and all known metastatic sites have been treated with curative intent radiation and PSA remains undetectable?
A great question and one that we don't have data for yet! In the absence of data, we can fall back on what we know about prostate cancer and its response to radiation and hormonal therapy, and remember the goals of treatment. Studies in the localized setting combine ADT with RT for 3-26 mo, with len...
Is there any role for regional lymph node dissection with radical nephrectomy for patients with early stage RCC?
Patients with early stage RCC without unfavorable clinical pathologic features and clinically positive nodes have a low incidence of nodal metastasis. LND is unnecessary in these patients. Furthermore, renal lymphatic drainage is unpredictable.