Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
In practice, do you discuss the role of Oncotype Dx before ordering the test?
Yes, I always discuss checking Oncotype Dx first with the patient prior to sending the test. I think it is important to discuss the clinical relevance of the test upfront, as well as the potential implications that may occur as a result of the findings. If a patient is not willing to be administered...
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?
Unfortunately outcomes for patients with pure squamous cell carcinoma of urothelium do poorly with approaches that target urothelial type histologies. If surgical resection can render pt disease free with reasonable morbidity than may make sense. I agree with sequencing the tumor to identify perhaps...
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.
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...