Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach a patient with metastatic urothelial carcinoma who has progressed on maintenance avelumab?
This patient would be in the 3rd line so options include Enfortumab vedotin (based on EV-201, cohort 1, published data, and EV-301 press release) or Erdafitinib (if FGFR2 or FGFR3 activating mutation or fusion based on BLC2001 trial published data) or clinical trial. Outside the US, without access t...
What is your preferred choice and timing of systemic therapy in a patient with high risk oligometastatic prostate cancer undergoing metastasis directed therapy to all sites of disease, including the prostate?
Metastasis-directed therapy (MDT) is an option for patients with oligometastatic prostate cancer who wish to delay initiation of ADT, based on STOMP (Decaestecker et al., PMID: 25223986) and ORIOLE (Phillips et al., PMID: 32215577) trials. In the STOMP study, 61% of patients (3 or fewer metastases) ...
How would you manage a patient with localized prostate cancer treated with radical prostatectomy and found to have a single involved pelvic lymph node on final pathology and a detectable postoperative PSA?
This patient is now in the salvage setting with PSA recurrence after RP and with PSA persistence and node-positive disease. This is a grey area of medicine without level 1 evidence from RCTs but there are some sources of data to help guide optimal outcomes. This patient is at high risk for further m...
How would you treat a patient with recurrent malignant perivascular epithelioid cell neoplasm (PEComa) arising from the kidney and metastatic to lungs?
At our institution, first-line systemic therapy would be with mTOR inhibition.
Would you use maintenance avelumab for a patient with metastatic urothelial carcinoma who progressed on first-line pembrolizumab, then had stable disease after at least four cycles of second-line carboplatin plus gemcitabine?
Great question. I would suggest that if the patient progressed on prior PD-1/PD-L1 inhibition, the standard would be observation (as challenging as that may be in clinical practice!). At progression, would probably not offer checkpoint inhibitor and would instead favor novel therapies like enfortuma...
What is your preferred treatment approach for a patient who has prostate cancer with disease only in retroperitoneal nodes, experiencing rapid biochemical progression on abiraterone, and who was previously treated with an androgen receptor inhibitor while non-metastatic?
I would consider a non hormonal option for this patient. I advise germline/somatic testing to evaluate for DNA repair mutations that are present in 15-20% of the patients. If these are present, it identifies PARP inhibitor as an option. Rarely next generation sequencing may identify MSI-high disease...
For persistent localized muscle-invasive bladder cancer following chemoradiation in patients who are not surgical candidates, what is an appropriate next therapy?
For this situation, optimal therapy is unclear. However, assuming the patient did not achieve clinical CR or recurred within a year, following maximal TURBT (which can achieve remissions in up to 15% of untreated patients), systemic therapy may be considered while tailoring therapy based on previous...
Can hydrogel, SpaceOAR, placed interstitially for prostate cancer embolize to the lung?
I doubt that this could happen as the Precursor and Accelerator solidify rapidly. Moreover, when injected between the rectum and prostate as indicated, there would not be a clear vascular route for it to reach the lung. However, if the Precursor alone containing undissolved polyethylene glycol (PEG)...
For a patient on dialysis with metastatic clear cell renal cancer, what regimen would you use after front line immunotherapy?
For patients with ESRD on dialysis, prior data showed that pharmacokinetics of VEGF-TKIs in subjects with severe renal impairment were similar to those with normal renal function (Khosravan et al. 2010, Chen et al, 2016, Nguyen et al, 2016). Also, other retrospective studies showed safety of VEGF-TK...
How do you treat patients with newly diagnosed metastatic MiT Family Translocation Renal Cell Carcinoma?
The AREN1721 clinical trial is accepting patients of all ages with unresectable or metastatic TFE/translocation renal cell carcinoma (RCC). The tumors must have either TFE3 expression by immunohistochemical staining or evidence of a TFE3 or TFEB translocation. The three arm trial compares nivolumab,...