Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is there a lung metastasis size cut-off do you suggest for selecting between BEP and VIP as initial chemotherapy in advanced testicular cancer?
I do not use a size cut off to select initial chemotherapy regimen for advanced testicular cancer. I rather use the International Germ Cell Cancer Collaborative Group (IGCCCG) model for initial risk stratification. Irrespective of risks, BEP is considered standard initial regimen. Nevertheless, for ...
In patients with metastatic RCC who have had a complete response to pembrolizumab and axitinib and undergone a nephrectomy, how long would you continue therapy post-operatively?
This is a great question and increasingly relevant. The larger question is about duration of IO-based therapy in general, especially when patients are at maximal response (CR or deep and stable PRs). The honest answer is that nobody knows. My sense is that the decision is based on pt preference and ...
How does the presence of active rheumatoid arthritis on rituxan impact your decision to proceed with prostate radiation?
I am always concerned about irradiating a patient with an active chronic inflammatory condition, as these people may be more prone to toxicity, both acute and late. In the case of a patient with both prostate cancer and rheumatoid arthritis, the latter being treated with rituximab, the fact that he ...
Would you offer a patient with pT4 renal urothelial cancer adjuvant RT for a positive margin if re-excision is not possible?
Adjuvant radiation therapy for upper tract urothelial cell carcinoma (UTUC) has historically been performed, but is currently not recommended by most cooperative guideline groups (NCCN, European Association of Urology,...). Due to the relative scarcity of this disease, there is no randomized data. L...
In practice, do you discuss the role of Oncotype Dx before ordering the test?
We do discuss the role and implication of Oncotype Dx or any other genomic assay with patients, before ordering it. I make patient aware, how the results will guide us help decide between chemotherapy Vs. No chemotherapy. As a group, we have created an agreed upon criteria for ordering Oncotype Dx, ...
Should systemic therapies be added to ADT and salvage RT in patients with PSAs >2 ng/mL after RP?
The question is asking for patients who underwent RP, and the PSA either was persistently elevated to ~2.0 ng/mL, or was observed until it was 2.0 ng/mL, what is the standard of care. The only salvage RT trial that really enrolled men at a PSA of 2 or higher was RTOG 9601 (GETUG-16 allowed up to 2.0...
Would you treat a patient with ESRD on hemodialysis and penile cancer with neoadjuvant ifosfamide?
I do not have a particular expertise in penile cancer. My sense is that neoadjuvant therapy in general is not of proven value in penile cancer and, in someone like this with ESRD, likely to be more toxic than beneficial. The immunotherapy question is interesting, but there are no data to support suc...
What are the current recommendations for androgen blockade for patients undergoing salvage radiation after prostatectomy with PSAs between 0.6 and 1.5?
Just be a little careful here. Although Dr. Spratt did an amazing analysis and thorough presentation of the subgroups, one shouldn't look at PSA <=0.6 as a "cutoff". As Dr. Spratt pointed out in his presentation, the population on RTOG 9601 was mixed in terms of prognostic features.. Would you reall...
How would you treat a patient with poorly differentiated carcinoma with squamous differentiation of the kidney following nephrectomy with metastatic retroperitoneal adenopathy?
Depending on the patient’s age and performance status I would determine if retroperitoneal dissection is an option (assuming that’s the only site of metastatic disease) If possible, send the pathology specimens out for a second or third opinion. I would also consider next-generation sequencing, as ...
In a patient with intermediate risk castration sensitive prostate cancer S/P prostectomy and now with biochemical recurrence + regional lymph node involvement 8 months post RP, would you do hormonal therapy (ADT or ADT+Abiraterone) with or without EBRT?
Yes, node positive (N1 M0) patients such as this were eligible for the STAMPEDE trial of ADT +\- abiraterone even in the relapsed setting after local therapy. These patients have both a disease free and overall survival advantage with abiraterone. See NCCN guidelines 2019.