Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you manage TKI induced secondary polycythemia in a patient with RCC?
Fortunately this is fairly rare, although this has been described especially with axitinib. Polycythemia can also be RCC-related. I usually will engage my benign Heme colleagues who can help with the work up to ensure there are no other causes, and also direct phlebotomy as needed. I'm not aware thi...
What duration of ADT do you recommend for a patient with otherwise favorable intermediate risk features but a mpMRI showing gross extracapsular extension?
All of the responses so far are reasonable to me. I am assuming the patient is Gleason 3+4 with PSA <10 ng/mL. I am wary of applying a new technology to categorize patients to older trials (i.e., T3 on mpMRI and assuming that is the same as clinical T3 prior to MRI). That said, I can't call a patien...
Do you alter your management of ADT in a patient with high-risk prostate cancer who is a transwoman receiving estradiol hormone therapy?
We published a case report several years regarding a transwoman who developed prostate cancer who had been on estradiol therapy in JAMA. She presented with a PSA of over 100. She continued on her estradiol therapy. We did not use LHRH since she had a bilateral orchiectomy for her transition. She was...
Would you give abiraterone in the post-prostatectomy setting to patients with positive nodes detected at surgery?
This clinical scenario of N1 but resected disease post-RP represents an area where there is not sufficient evidence to recommend abiraterone or any potent AR inhibitor. While there is evidence to support ADT in this adjuvant setting for N1 resected patients based on the older Messing ECOG trial, sim...
Does your recommendation for ADT change in an elderly patient with dementia and high risk prostate cancer?
Thank you for this question. There have been publications that have shown the association of ADT and cognitive decline. Probably one of the most robust studies was published in 2017 (Nead et al., PMID 27737437) in which the effect of ADT on dementia risk was assessed using propensity score-matched m...
What oral alternatives would you recommend as opposed to injectable GnRH agonists for those who do not wish to come to clinic due to COVID-19?
Casodex is an option. Due to liver toxicity, they would need LFTs checked before and at a future interval, effectively requiring them 3 visits to a health care facility—labs, pharmacy, labs. A single 6 month injection seems like a better proposition.
Would you consider a cisplatin-based regimen with hypofractionated radiation for bladder cancer?
Yes, with bladder only RT almost any chemo regimen is acceptable, including cisplatinum, Gemzar, or 5FU and MMC.
Would you offer immunotherapy for a patient with a history of kidney transplant on immunosuppression who has clear cell RCC in the native kidney?
While data to address this question remains retrospective in nature, a number of small series suggest a very high solid organ rejection rate (37-41%) and worrisome morality rates in the 40+% range. Fully understanding the potential for survival benefit from ipi/nivo or pem/axi, I would be inclined t...
What is your treatment approach for metastatic squamous carcinoma of the prostate?
There are limited data to guide the management of metastatic squamous cell cancer of the prostate. Outside clinical trials, I have typically treated patients extrapolating from squamous cell cancer of the lung /head and neck literature and have seen responses with gem and cisplatin, 5 FU, pembrolizu...
How do you approach a patient with ATM mutation with prostate cancer?
This is a good guide for a radiation oncologist suggesting no contraindication to RT, with a possible small increase in second cancer (most data based on breast cancer).