Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Does the presence of ductal adenocarcinoma change how you risk stratify or treat patients with localized prostate cancer?
Ductal adenocarcinoma (DAC) of the prostate is a distinct, but rare (< 1%) subtype of prostate adenocarcinoma. DAC originates from primary periurethral prostatic ducts or in the peripheral prostatic ducts. Because of its predominantly periurethral location, it may present with hematuria, urgency, an...
Do you continue ADT/Lupron in all patients with castrate resistance prostate cancer?
It is recommended to continue ADT in patients with castration-resistant prostate cancer. Some mechanisms of castration-resistance include upregulation of androgen receptors and autocrine testosterone production, so a castration-resistant cancer is not necessarily a "hormone resistant" cancer.
What is your approach to systemic treatment of de novo metastatic hormone-sensitive prostate ductal adenocarcinoma with lung only metastases?
Nearly all patients with mHSPC/mCSPC deserve combination therapy based on multiple phase III clinical trials. There are very few exceptions to this. Even frail patients should be considered for intensified therapy since the published data suggests minimal to no worsening in HRQoL over ADT monotherap...
Would you use adjuvant pembrolizumab for bilateral ccRCC with R1 resection?
It would depend on the pathology of each resected tumor, but my initial thought is that I would not. My concern would be that renal function is likely reduced and nephritis (although rare) could have significant consequences. Certainly, genetic counseling should be considered for all bilateral tumor...
How would you treat a metastatic pure urethral adenocarinoma?
The treatment of rare or unusual urologic tract tumors remains an area of active investigation to optimize approaches. In general, most practitioners would utilize a GI malignancy-focused regimen for a metastatic urothelial tract pure adenocarcinoma (mucinous/or enteric type) such as FolFox off of a...
What is your approach to elevated urine uric acid levels in a recurrent calcium based stone former?
There was good evidence from controlled trials supporting the use of allopurinol in hyperuricosuric calcium stone formers. That said, the trials are now pretty old and I would tend to treat other risks first (unless there was another reason to lower the uric acid like gout). In general, a lower anim...
Would you consider pelvic radiation in a patient with prostate cancer and myelofibrosis with mild cytopenias?
I would avoid prophylactic RT in this scenario as the absolute benefit has to be weighed against the worsening of cytopenia.
Do you ever initiate on degarelix and then switch to leuprolide for patients with prostate cancer and cardiac risk factors receiving ADT?
I do not believe that there is a major differential in cardiotoxicity between LHRH antagonists and agonists. The key issue is metabolic syndrome associated with long-term androgen deprivation. Randomized trials have not shown convincing evidence of a difference in cardiotoxicity between agonists and...
What are your top takeaways in GU Cancers from ASCO 2023?
THOR study. Improved overall survival (HR 0.64 p=0.005) and PFS (HR 0.58 p=0.0002) of the oral FGFR tyrosine kinase inhibitor erdafitinib in FGFR altered metastatic urothelial carcinoma over chemotherapy. Establishes a new standard of care in the second/third/fourth line setting after failure of ch...
Would you treat the prostate in a patient with widely metastatic disease who has CR to all metastatic sites after systemic therapy or ADT?
This is an interesting hypothesis, but requires further study before offering. The trials that define a benefit to prostate RT in the metastatic setting (HORRAD, STAMPEDE, and now PEACE-1) did not use response-adapted selection criteria. Therefore, we cannot say that radiation to the prostate in an ...