Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you treat a patient with urothelial cancer and 25% plasmacytoid variant who has a solitary recurrence in rectum 1 year after neoadjuvant chemotherapy and radical cystectomy?
Plasmacytoid urothelial carcinoma has a very high tendency to develop peritoneal carcinomatosis. And although on scan there could be solitary occurrence, on exploration, may be able to see more peritoneal involvement. Thus, systemic therapy would be a more appropriate strategy to treat. Diamantopoul...
Would you consider single agent TKI for patient with metastatic renal cell carcinoma who developed biopsy proven giant cell arteritis days after starting immunotherapy?
Clinicians are not infrequently in situations where we need to help guide patients along a decision pathway for which we have little data. The vasculitis in this patient obviously was a pre-existing condition. The first question I would ask is does the patient's RCC need treatment now? If favorable ...
Which patients with mCRPC on ADT + advanced anti-AR do you treat with bisphosphonates or denosumab?
Men with bone-metastatic CRPC face a relatively high rate of fractures due to bone loss as a result of potent AR inhibition and ongoing ADT but also due to lytic and sclerotic bone metastases which create focal weakening of the bone matrix despite the pathologic bone formation. The fracture rate was...
In addition to ADT, how would you treat Gleason 8, pure ductal prostate adenocarcinoma with oligometastatic disease?
Based on the available data and knowledge, it is difficult to answer this question definitively.Although prostate ductal adenocarcinoma (PDA), was first described more than 50 years ago and its behavior as an aggressive variant is increasingly being recognized, evidence-based management of PDA is no...
Would you give adjuvant therapy for a urothelial carcinoma T2 on TURBT but pTis at margins on cystectomy?
No, this patient would be followed by active surveillance based on NCCN guidelines, e.g. visits, labs, urine cytology, CT chest, CT IVP; would pay attention for any symptoms to upper tract and urethra that may trigger further evaluation. Would discuss with Urologist & Pathologist about the case, the...
How do you treat localized prostate cancer with neuroendocrine differentiation?
Most hybrid or pure NEPC tumors lack PSMA expression as only 1/3 of metastatic NEPC tumors are PSMA PET+ and expression is typically very heterogeneous. For this reason, an FDG PET/CT would likely be a better staging test for this aggressive variant of prostate cancer. If this is also N0M0, RP is my...
Will you consider adding an AR targeted agent to ADT for a patient thought to have isolated pelvic nodal recurrence of prostate CA if next generation imaging reveals additional non-regional disease not seen on conventional imaging?
There are no formal prospective trials addressing the question of timing (i.e. initiation of systemic therapy) based on metastasis identified on molecular only imaging. The best data available is based on the three trials in non-metastatic castration-resistant prostate cancer (PROSPER, ARAMIS, and S...
How would you approach definitive treatment of intermediate-risk prostate cancer with baseline severe (AUA >25) urinary dysfunction and severe rheumatoid arthritis?
This case presented has a number of possible variables. First, does intermediate risk in this case, Gleason 7, 3+4, or 4+3 or some other set of variables making the case intermediate risk? That might change management in terms of use of ADT use, etc. However, the question's focus appears to ask for ...
How would you manage a patient with favorable intermediate prostate cancer patient who obtains a high Decipher test score at the end of their RT course?
Would favor adding 4-6 months of ADT.
How would you approach low grade non-invasive urothelial carcinoma arising from seminal vesicle and ejaculatory ducts with invasion into prostate?
Primary urothelial carcinoma of seminal vesicle is extremely rare. There is some skepticism whether this is a true entity. More common is the secondary spread from bladder primary. This can happen as a result of direct invasion through bladder wall or via mucosal spread. Formal is staged as T4 disea...