Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Which of the androgen blocking agents have the best CNS penetration for someone with metastatic CRPC with brain metastases?
There is no direct prospective clinical evidence to really answer this question, unfortunately. My approach to patients with CNS metastases (including epidural disease) from prostate cancer is to provide metastasis-directed therapy such as surgery or stereotactic radiation depending on a range of fa...
How would you manage a locally advanced prostate cancer with positive pelvic nodes, incidentally found at the time of radical cystectomy for bladder cancer?
A growing body of retrospective data suggests a benefit to the addition of pelvic radiation in addition to ADT in men with node-positive prostate cancer. The decision to treat, in this case, has to be balanced by the competing risks related to the bladder cancer. If the patient's prognosis from the ...
How do you balance short-course ADT in unfavorable intermediate risk prostate cancer patients with cardiac comorbidities?
One paper that addresses the topic was published in the Red Journal in 2016 (Rose et al., PMID 27788950). This retrospective analysis attempted to answer the question of which patients would derive disease-specific mortality benefit from the addition of ADT. Patients included in this analysis were f...
How would you treat an older patient with stage IIC nonseminoma who is unfit for platinum chemotherapy due to comorbidities?
These are difficult questions to answer. The definition of a patient unsuitable for cisplatin in an elderly patient varies from oncologist to oncologist. Cisplatin + etoposide for 4 courses is the “standard“ therapy for patients over the age of 50. For elderly patients with poor performance status f...
Are TKIs safe for a patient with metastatic renal cell carcinoma and a transplanted kidney?
No contraindications from my experience, and does not look like there are any known interactions or interactions with metabolism. It is helpful to make sure the treating nephrologist is aware of the diagnosis and therapy in order to monitor immunosuppression levels. Often we will change the immunosu...
Would you treat a patient with refractory, metastatic castrate resistant prostate cancer who has somatic ATM mutation with a PARP inhibitor?
Yes, I would consider Olaparib (not Rucaparib), but only after they have received at least two AR-targeting drugs and at least one taxane drug, and only if an ATR inhibitor trial was not available. And I would set the expectations really low: PSA response rate of 5-10%, PFS of 4-6 months.
How would you approach multiply recurrent prostate cancer in a patient who has had both LDR and salvage HDR?
Very carefully! The risk of GU and GI toxicity from any salvage therapy after both LDR and salvage HDR is very high. If there is a focal lesion identified on MR/PSMA that is distant from the bladder, urethra, and rectum, then maybe you can try a focal treatment. I'd be very careful because the risk ...
Would you offer neoadjuvant chemotherapy to a patient with high risk non-muscle invasive urothelial carcinoma for whom cystectomy is planned?
Short answer is no in NMIBC. If there is pT3/4 and/or pN+ path Stage at radical cystectomy, would consider adjuvant therapy options, e.g. cisplatin-based chemo or clinical trial.
How does presence of MMR deficiency/Lynch syndrome affect your recommendation on peri-operative chemotherapy for high-grade upper tract urothelial cancer?
The presence of MMR deficiency does not really alter my recommendation regarding peri-op chemo for high-grade upper tract UC. Firstly, I don't personally think the MMR deficiency data are ready for prime-time use in chemo-prescribing; I do think this connotes for a higher likelihood of resistance, b...
How do you treat locally advanced choriocarcinoma of the urinary bladder?
This is a very rare site and a rare subset of germ cell tumor. I assume the pathology has been reviewed and full scans including ultrasound of testes if a male and HCG/AFP have been performed. Is the patient in the typical age range for germ cell tumors? If this is confirmed and the patient has a ty...