Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you prescribe ADT or AR inhibitors for a patient with moderate to severe dementia who has biochemical recurrent, non-metastatic prostate cancer, but otherwise good physical performance status and prognosis >5 years?
I would discuss with their caregivers. They are the ones who have to manage the patient's moderate to severe dementia daily and presumably are acting as the patient's medical power of attorney. Practical consequences to typically routine therapies can be serious. Substantial declines in cognition, m...
How do you approach imaging in patients with M0 castration-resistant prostate cancer with rising PSA on an ARSI?
I do not use molecular imaging (e.g., PSMA-PET/CT) for patients with CRPC (including both mCRPC and nmCRPC) except as a screening tool for Pluvicto eligibility for three reasons. Most patients have metastasis already. In one study that used molecular imaging in patients with nmCRPC, they identified ...
How do you approach ADT in a post-prostatectomy patient who had higher Gleason score on biopsy but a lower Gleason score on final pathology?
I would only base my decision on the pathology of the final prostatectomy specimen, and ignore the prior biopsies.
Would you change AR signaling inhibitor in a patient with high volume metastatic castration-sensitive prostate cancer who started darolutamide with initial plan for docetaxel but in whom chemotherapy was eventually deferred?
The ARASENS trial showed a survival benefit for the combination of ADT with chemotherapy and Darolutamide in mHSPC. In a patient with high-volume disease who has been initiated on Darolutamide but in whom chemotherapy was planned but then deferred, I would continue with Darolutamide if the patient i...
How do you approach a patient with prostate cancer with sclerotic/lytic lesions found on a CT scan but not seen on a bone scan or PET-PSMA?
This can be a tough situation, as sometimes healthy individuals can have sclerotic or lytic foci in various bones for reasons unrelated to any type of malignancy. The first thing I would try to do is compare the CT scans to any prior imaging if possible. If these lesions are completely unchanged fro...
How would you approach adjuvant therapy for a patient with a single lymph node positive in the peri-prostatic fat without pelvic lymph node dissection?
I would favor treating like node positive prostate cancer adjuvantly with long term ADT and RT. Presuming post op PSA is undetectable.
Does a transperineal approach to prostate biopsy change your treatment plan compared to transrectal?
The short answer is no. The typical scenario in which I have seen transperineal biopsies done is a patient with multiple negative transrectal biopsies in whom there is still a concern for clinically significant prostate cancer and an MRI has not identified a target to biopsy. In these cases, multipl...
What systemic therapy do you recommend for prostate cancer pelvic nodal recurrence on PSMA PET-CT after prostatectomy and salvage radiation?
If the LNs are not measurable on conventional imaging and can be covered in the radiation fields, then for now I treat as high risk salvage setting. Usually suggest 2 years ADT and radiation. If the LNs cannot be covered in the radiation fields, or are measurable, then would also escalate AR-targete...
When will you recommend enfortumab vedotin plus pembrolizumab as first-line treatment of metastatic urothelial carcinoma for cisplatin-ineligible patients?
This is a timely question given the US FDA approval of the pembro/EV combination on 4/3/2023. Currently, the label is for patients with locally advanced or metastatic urothelial carcinoma who are ineligible for cisplatin-containing chemotherapy. There are a variety of definitions for cisplatin ineli...
How would you treat a patient with a low grade Follicular lymphoma and Gleason 6 adenocarcinoma of the prostate?
There are too many unstated particular clinical parameters to provide a specific answer to this question, but general principles are that neither of these malignancies necessarily require intervention. The very long natural history of each condition should guide us. Stage, symptoms, functional statu...