Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you treat a patient with testicular cancer stage I, pure seminoma on orchiectomy, but with high bHCG (in 1000s) as seminoma or as non-seminoma?
It would depend on what happens with the HCG of 1000 after orchiectomy. If it normalizes, I would proceed with active surveillance. If it persists or plateaus at a high level post orchiectomy, I would treat them the same way I would with a CSIS non seminoma typically BEP X 3. I would also review the...
How do you sequence ADT relative to radiation for a low volume M1 prostate cancer?
Start with radiotherapy, carry on hormone therapy for up to two years.
Would you treat unfavorable intermediate risk prostate cancer in the setting of recently resected NSCLC?
This greatly depends on the stage of the lung cancer. If stage IIIA resected NSCLC, I would not treat the prostate cancer immediately, and effectively enter them into active surveillance until the patient is 2 years free of NSCLC on follow-up imaging. If they recur from NSCLC within 2 years, they ha...
Would you offer neoadjuvant chemotherapy for a patient with low-grade upper tract/renal pelvis urothelial carcinoma with concurrent bladder drop-metastasis?
This question has several aspects. How commonly does a low-grade urothelial tumor metastasize? Is the described lesion in bladder truly a drop metastasis from upper tract? How can concurrent lesions in upper urinary tract and bladder be approached?Underestimation of staging and grading is a problem ...
Is orchiectomy necessary for a patient with primary retroperitoneal seminoma and calcifications seen on testicular ultrasound (but no primary testicular mass)?
For me, it depends. If the mass has a "sidedness" to it, I often recommend an ipsilateral orchiectomy. If the mass is midline and there is no dominant testicular mass, I just watch both testicles closely. In either case, I would incorporate exam and occasional testis ultrasound in followup.
Do you modify your neoadjuvant considerations for patients with micropapillary histology and pT2 urothelial carcinoma and no distant neoplastic disease?
No. The prognostic significance of this histology is uncertain (EAU Systematic Review, Veskimae et al., Eur Urol Onc 2019). Prospective well powered studies with overall survival as the primary outcome and which incorporate disease classifiers that are more accurate than histology (e.g. a molecular ...
How do you think through the various treatment options for patients with unfavorable intermediate risk prostate cancer?
The first thing I do is make sure that I have plenty of time blocked off for this consultation, because these tend to be long encounters, and may require follow-up visits and/or phone calls to address all of the patient's questions. I think these are the most complex of all GU consults. The next thi...
Do you recommend MRI pelvis/prostate in a patient with biochemical recurrence after XRT and negative axumin PET scan?
This is a difficult question to answer as the context is very important. If this is a younger patient with fast doubling time that warrants aggressive treatment, the answer will be different than in an older patient with a slow doubling time. The patient's particulars (co-morbid conditions, prior tr...
How do you think about management options in a patient with a minute focus of Gleason grade 4 (4+4) on 1 core from needle biopsy along with only Gleason 3+3 disease in other biopsy cores and PSA<10?
This patient has "Favorable High Risk Prostate Cancer", and has outcomes similar to an intermediate unfavorable risk patient, rather than a true high risk patient. See here.I would offer this patient at least 6 months of ADT with IMRT. It would not be wrong to offer a longer course of ADT (24 mo), b...
What length of ADT do you recommend in a patient with a very low risk prostate cancer who otherwise has a PSA >20?
I would start by confirming that I feel comfortable with their biopsy results:1) ensuring that there appears to be adequate sampling of the prostate on biopsy,2) obtaining an MRI to make sure there is not a concerning appearing lesion that was not sampled (for instance, anterior disease),3) would al...