Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you manage pelvic pain and hematuria due to recurrent high grade transitional cell bladder cancer who had received 70 Gy to bladder and is not a chemotherapy or surgical candidate?
It depends whether these symptoms are caused by radiation, recurrence, or both. One might not be able to distinguish. For hematuria I think a cystoscopy and focal fulguration if that is available to the patient, or else consider hyperbaric oxygen therapy, which may also improve pain (I don’t think h...
Would you skip adjuvant RT in post prostatectomy patients?
I suspect that once the paper is published and we get a chance to review the data that we may begin to hold off on routine use of adjuvant RT for prostate cancer patients after radical prostatectomy with higher risk features. That said, it should be noted that the study did randomize to early salvag...
Would you recommend salvage RT in a patient who previously had prostatectomy for high risk prostate cancer who is no longer tolerating his intermittent hormonal therapy?
Why was hormone therapy started. BCr or adjuvant ? if adjuvant doesn’t need any treatment and just psa surveillance
Do you offer ADT in patients with intermediate risk prostate cancer who receive hypofractionated EBRT?
There is no good evidence that with different radiotherapy dose/fx or other RT modalities that the relative benefit of ADT is any different. This applies also to SBRT, brachy, and combo-brachy. The basic evidence and logic is as follows:1. ADT improves MFS and OS in multiple RCTs using lower dose co...
Should you offer radiation therapy to a low risk prostate cancer patient on active surveillance so that he may receive testosterone supplementation?
Great question. In my experience I can recall at least 3 or 4 patients who were subsequently dx'ed with PC after starting a testosterone supplementation.So, serious treatment and future considerations must be the matter of both doctor and patient in terms of the potential for tumor progression while...
What is the optimal duration of ADT for cN1 disease with EBRT?
Unfortunately there are no prospective data to guide management for cN1 prostate cancer treated with EBRT. The NCCN guidelines do not comment on the optimal duration of ADT in this setting. While 18 months may be considered for some patients with high risk cN0 prostate cancer as per the PCS IV trial...
What is your preferred neoadjuvant chemotherapy regimen for muscle invasive bladder cancer, adequate performance status and preserved kidney function?
I agree, to date there is a lack of published randomized phase 3 data to date (though this is ongoing with NCT01812369) Several retrospective analyses such as one by Peyton et al JAMA Oncol 2019 found that neoadjuvant dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) produced...
For prostate cancer, when do you pursue a biopsy for metastatic disease to the bone found on imaging study?
Presuming the patient has undergone curative care for his prostate cancer, and had become undetectable via PSA, who now presents with bone metastases, when would I consider a bone biopsy? So, if he was treated for cure, and had an undetectable PSA on his most recent follow up visit, my question beco...
How would you treat a patient with newly diagnosed advanced urothelial cancer?
The current standard of front line systemic therapy for advanced urothelial cancer is cisplatin based combination chemotherapy: cisplatin/gemcitabine or ddMVAC, for cisplatin eligible patients. For cisplatin ineligible patients, pembrolizumab (Keynote 052), atezolizumab (IMvigor 210) or carboplatin/...
Do you offer adjuvant chemotherapy to patients with urachal adenocarcinoma and at least one high risk feature?
In the absence of data in this space, I would offer adjuvant chemotherapy applying similar principles from colon adenocarcinoma for patients with T4 or node positive disease. FOLFOX/CAPOX for 3 to 6 months is reasonable in this situation. This regimen has the most reliable and reproducible data in t...