Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you manage a low risk patient with a negative fusion prostate lesion by biopsy but MRI shows apparent advanced disease?
Assuming that the patient has NCCN low-risk features and MRI findings of EPE (which is the most common situation), I would think about this situation in two different subcategories: (1) active surveillance (AS) is still under consideration, and (2) the patient has decided he would like to proceed wi...
What is the earliest time to check PSA after prostatectomy?
The half-life of PSA in the circulation is about 3 days, so there is no point checking PSA within the first 15 days (5 half-lives) as any detectable PSA at that point may just represent residual PSA that has yet to be cleared. Most surgeons I have worked with generally wait 4-6 weeks, which should b...
How do you treat a rectoprostatic fistula after prostate SBRT?
This is a difficult problem to manage, regardless of whether it occurs after SBRT or any other type of prostate radiation. It will require close cooperation between multiple specialists. Early involvement of a gastroenterologist and a colorectal surgeon is imperative as this is likely to require a d...
What is your PSA threshold for obtaining PSMA PET for biochemical failure after RP?
I typically order a PSMA PET after ~0.20. Sometimes lower if there are multiple aggressive features or poor prognostic factors (i.e. SVI with no lymph node dissection and persistently positive PSA of 0.15 after RP). This approach seems to be a reasonable threshold to me based on two considerations: ...
Do you recommend ADT for a high risk prostate cancer patient who had SBRT?
SBRT doesn’t mitigate benefit of ADT and the type and duration have to be the same as with EBRT or EBRT plus brachytherapy.
Do you hold ADT prior to biopsy of possible prostate cancer metastatic disease?
ADT can affect the ability to assign a Gleason score, but I am assuming this is not an issue here. We biopsy new sites of metastatic disease in people on ADT all the time to confirm progression and to get tissue to identify potentially actionable targets. The only time I would deliberately hold ADT ...
How would you manage a patient with PSA relapse 10 years after salvage radiotherapy with PSA doubling time<6 months?
Depending on PSA, would image with PSMA PET - typically, will do around PSA 0.5 or higher (given most insurances will not cover multiple PETs in a short timespan, and detection rates of ~50% at PSA 0.5-1 per CONDOR). If no targetable (by XRT) disease on that, would discuss ADT given increased risk o...
Would you recommend biopsy of a bone met noted on PSMA PET after definitive prostate radiation?
There is no simple answer to this. The following are some relevant considerations: What was the original risk category? What was the Gleason score? What was the pre-treatment workup? Was there anything noted there previously? Was or is the patient on ADT? Pre-treatment and current PSA values? How l...
Are there instances where you would offer erdafitinib instead of avelumab for maintenance therapy for FGFR3 mutated metastatic bladder cancer after stable disease on cisplatin/gemcitabine?
The short answer is 'no'. There are no data for supporting FGFR inhibition in a maintenance first-line setting for those with stable or responding disease on platinum-based chemotherapy and FGFR2/3 activating alterations. There are contrasting data suggesting that the activity of PD1/L1 inhibitors m...
What treatment would you offer for a patient with prior primary prostate radiation, with a biochemical progression to PSA >1.0 and negative PSMA scan?
I’m assuming the patient has already received a prostatectomy and received prostate bed radiation, with a rising PSA. First, in terms of imaging, you may want to consider a contrasted pelvic MRI, which may reveal a small lesion in the prostate bed which may have been obscured by PET activity from t...