Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach a local failure with a rising PSA following prostate SBRT?
I would obtain an MRI if not already done to help delineate local disease extent. A variety of salvage options are available (RP; HIFU; cryotherapy; and re-irradiation with brachytherapy or focal SBRT). A recent systematic review and meta-analysis of local salvage therapies was published by a group ...
When do you consider the insertion of nephrostomy tubes for gynecologic malignancies without fistulas?
Indication of nephrostomy for gyn cancer depends on the stage of cancer and renal function. If creatinine is normal range, nephrostomy may not be needed but if abnormal, nephrostomy is indicated. In the early stage of cancer, nephrostomy is more likely indicated than late stage of cancer.
How does a diffusely positive PSMA in the prostate affect treatment planning in a patient with MRI and biopsy showing only one area of disease?
There are three parts to my answer: First, mild to moderate PSMA uptake can be seen in benign conditions, including BPH and prostatitis (e.g., reviewed by Satapathy et al., PMID 32755196). Second, I don't see how the discrepancy between PSMA PET and MRI/biopsy would affect radiation treatment planni...
How would you approach second line treatment for prostate adenocarcinoma with diffuse neuroendocrine features?
Men with NEPC (histologic evidence of small cell carcinoma) face a poor prognosis and are typically refractory to all hormonal interventions, and in fact transformed NEPC much more typically evolves after potent AR inhibition than present de novo at diagnosis. Autopsy series and biopsy series sugges...
How would you manage an older, frail ECOG 2 patient with stage II muscle-invasive bladder cancer with other competing risk of death?
Conceivably, treatment options are extremely limited for older, frail patients with localized muscle-invasive bladder cancer, who are not candidates for cystectomy or radiation. TURBT is a common practice in this patient population (Trulson et al., PMID 23817891), but without any improvement in outc...
For a patient with localized high risk prostate cancer with high risk Decipher score receiving ADT and abiraterone, is there any value of continuing ADT and abiraterone beyond two years?
Since the trial (STAMPEDE) stopped abi at 2 years, that is the longest duration that I use.In the mHSPC setting, we are seeing many patients stay on their first-line treatment for many years (often longer than 2 years). This has made me more cognizant of the long-term effects of abi/prednisone (acce...
In a patient with otherwise low-risk prostate cancer, does presence of a small component of Grade Group 3 disease up-stage to unfavorable intermediate?
I agree with Dr. @Dr. First Last's response and will just add a couple of additional thoughts. There are many things that go into making a decision about whether treatment is necessary, and what type of treatment is performed. In this case, it's important to consider patient factors (i.e. age, co-mo...
What is the best treatment for pT2 cN1 seminoma with mild elevation of B-HCG (~100)?
I would recommend making sure that the pathology is seminoma (with either review of the orchiectomy specimen and making sure there are trophoblastic elements or a biopsy of the retroperitoneal lymph node) as the beta hCG level is getting close to the upper end of what I would expect from a seminoma....
After definitive prostate RT, when do you prescribe ADT for local salvage (EBRT, HDR, LDR)?
For patients with localized recurrence after definitive radiotherapy, re-irradiation without ADT is a reasonable course of action and the one I usually favor. There are no current clinical trials that have been reported to demonstrate the benefit of ADT in this setting, but this practice is consiste...
Do you routinely obtain next generation sequencing for patients with metastatic renal cell carcinoma and if so, what is your approach to incorporating these results into treatment decision making?
Currently, I do not routinely send NGS for patients with metastatic clear cell RCC as we do not have level 1 evidence that these results should guide treatment decisions. We do not have "actionable mutations" that would change or guide our treatment of choice. IMDC still remains our best risk strati...