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 metastatic RCC and significant baseline proteinuria after progression on immunotherapy?
- Tough situation no doubt. I would look for actionable genomic aberrations on NGS though limited in ccRCC. - Consult with a nephrologist and depending on severity of proteinuria, closely monitor proteinuria (urine checks as well as serum protein/albumin levels) with use of VEGFRi (short-acting ones...
Would you give EP to a patient with Stage I testicular nonseminoma with risk factors (LVI and 90% embryonal), who is not a candidate for bleomycin?
Personally, I would not and there are no strong clinical data supporting that approach in CSI NS. First if given, adjuvant chemotherapy for CSI NS with high risk features is BEP X1 if you ask what approach has the largest database, most mature results, and reporting of relapse and toxicity. (SWENOTE...
How would you treat a patient with new isolated enlarged lymph node <6 months after RPLND with prior pT2NX non-seminoma treated with orchiectomy then RPLND within 1 year due to nodal metastases?
If the patient were marker negative and the node was relatively small, I would probably just repeat imaging in 8 weeks to see what was happening. If the markers were definitively rising, I probably would proceed with BEP X 3. I do not typically recommend a re-do primary RPLND. Also, a lot would depe...
What treatment would you consider for small cell neuroendocrine carcinoma of the bladder with a metastatic recurrence within 3 months of neoadjuvant cisplatin/etoposide followed by radical cystectomy (ypT0N0)?
Very poor prognosis with early recurrence in a very aggressive histology despite pCR in the primary tumor reflecting tumor heterogeneity and implying platinum resistance in the recurrence tissue. Would evaluate NGS for potential “actionable” genomic alterations and also consider clinical trials (e.g...
How soon after completion of salvage RT to the prostate bed do you allow urethral dilation?
In my experience, anastomotic strictures do not resolve spontaneously or with treatment interruptions. In part, the answer to this question depends on how symptomatic the patient is and how close you are to the end of treatment. If the patient is totally obstructed or close to it, you're probably go...
How would you approach local control in a patient with extra-osseous metastatic Ewing sarcoma of the kidney?
I would follow general guidelines for Ewing sarcoma – if the tumor is completely resected, no RT. If spread outside post surgery, then would follow Ewing Sarcoma dosing guidelines.
How do you manage patients with oligometastatic renal cell carcinoma after nephrectomy and metastatectomy?
Patients with oligometastatic renal cell carcinoma after nephrectomy and metastatectomy or M1 NED represent a challenging subset of patients given the heterogeneous nature of this subset and outcomes vary with the location and timing of metastatectomy.Prior VEGF-TKI studies after metastasectomy for ...
When discussing prostate cancer treatment options, how do you address that surgery side effects are considered acute and radiation side-effects are long lasting?
Stress urinary incontinence as well as ED can last a lifetime after surgery. So, both have acute and late effects. Also since urologists don’t typically (never in my experience) order an MRI prostate, they can expose patients to additional surgical and adjuvant radiation toxicity. If I see a patient...
Would you change chemotherapy to VIP in a young patient with stage IIIB intermediate risk non-seminomatous germ cell tumor with borderline DLCO after one cycle of BEP?
The term “borderline DLCO” needs to be taken into context. The test is not completely reliable and one needs to consider the DLCO result in the clinical setting - has the patient been a heavy smoker, does he have known respiratory disease, does he have any limitation in effort tolerance, and who/whi...
When staging prostate cancer, does MRI pelvis/prostate replace CT A/P?
The NCCN guidelines and recent NRG protocols allow for either CT or MRI to stage the pelvis. Assuming the MRI includes imaging of the pelvic LNs, I am not aware of an added benefit of a CT. With the increasing use of novel imaging for staging such as PSMA PET (which can be more sensitive at detectin...