Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Does diffuse high grade PIN in a low risk prostate cancer patient affect your recommendation for surveillance?
No. If the patient otherwise has low-risk prostate cancer, surveillance is appropriate. The diffuse high-grade PIN might raise the chance of occult cancer (that could be higher grade), but not more so than a widespread Gleason 3+3 disease, which is not, by itself, a contraindication to active survei...
What do you tell men with low but detectable PSA who have completed ADT and RT?
Several analysis have shown that patients who do not achieve undetectable PSA levels after 6 months of ADT have worse outcomes. This is a bit of a moving target and the definition of undetectable has changed over the decades. An important question is - are these patients failing due to incomplete lo...
How would you approach a new pelvic mass in a patient with history of mixed germ cell tumor but normalized tumor markers?
By the type of treatment received, I assume this was likely a post-pubescent male, probably under 18? In my view, this sort of patient should be managed identically to what we do in the much larger populations of non-seminoma seen between 18-40. Clinical and biological evidence is mounting that post...
What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?
Risk of bladder cancer following cyclophosphamide treatment can be associated with oral therapy and likely also related to cumulative dose (1). Risk of bladder cancer with intermittent IV cyclophosphamide has been reported in some observational studies, but has not been consistently reproduced (2). ...
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.