Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you counsel younger patients regarding long-term radiologic monitoring of non-functional adrenal adenomas?
I do not think biology is so black and white. The risk of malignancy in adrenal masses according to size is a spectrum and certainly not zero just because at one point in time it is less than 5 cm (how about 4.5 cm?). Unless the radiologist can confidently diagnose a myelolipoma I think clinical jud...
Do you give chronic antibiotic prophylaxis for recurrent UTIs, including Pseudomonas aeruginosa, in a patient with retained ureteral stents?
If the "recurrent UTIs" are symptomatic (fever is what I would be mostly concerned about), then the stents should be changed as feasible, (I assume this has been done) and the UTIs treated as appropriate. If the UTIs continue after the change, I would just try to treat the symptomatic events as best...
How do you manage PSA progression while a patient is on Xofigo or Pluvicto?
The tl;drPSA is very much an imperfect tool for these patients. The data show that PSA may initially increase over multiple cycles before decreasing, though this is a minority of patients. Most patients whose PSA increases early have resistant disease, and you should investigate further with imaging...
Should high risk prostate cancer patients be placed on more potent ADT (abiraterone or enzalutamide) in the upfront setting with definitive RT instead of the standard LHRH agonist?
With STAMPEDE suggesting improvement with the addition of abiraterone in very high risk N0 patients, this is certainly becoming a consideration. Duke is completing a trial of concurrent abiraterone/STADT/definitive radiation for intermediate and lower high risk prostate cancer. Results forthcoming. ...
If a patient diagnosed with seminoma after orchiectomy has margin positive disease noted in the spermatic cord and no overt metastasis on imaging and normal tumor markers, how should this patient be staged?
I believe that the staging would be pT3cN0M0S0 in this case. Margin-positive disease suggests continuous rather than discontinuous spermatic cord invasion. In case this was felt to be discontinuous, NCCN v1.2024 now has a note on staging such patients as pT3 (high-risk stage I) and not as M1 (stage ...
Would you avoid starting potassium citrate in a patient with recurrent calcium oxalate nephrolithiasis and hypocitraturia if they have metabolic alkalosis?
If the metabolic alkalosis was from hypokalemia and/or thiazide, as is common in stone formers, I would not hesitate, as the potassium would be beneficial in reducing the excess renal ammonia excretion. If from other causes, everything would depend on the cause.
Why is there a benefit of ADT for high risk prostate cancer treated with radiation, yet no large trials describing benefit of adjuvant ADT after radical prostatectomy?
From a high level, the magnitude of the benefit of ADT with radiation seems proportional to the aggressiveness of the disease (i.e. low risk has no significant benefit, int risk weighs risk features and cardiac health, and high risk the benefit of ADT can trump cardiac risk). In that context, we hav...
Does the presence of cribiform histology at biopsy in prostate cancer affect your management in an otherwise intermediate-risk prostate cancer?
There have been no trials on this specific question, so there is room for debate and more science (hoping our recent grant submission in this area gets funded...). Here is my current thinking. This is for generally healthy patients with long life expectancy (≥10 years, but especially if ≥15 years). ...
How do you approach prostate cancer patients who have hypertestosteronism on pre-treatment labs?
This is rare and full disclosure - I have not personally experienced this situation and this answer is based on discussion with colleagues. I suspect whatever the true incidence is, it is likely detected in only a fraction of patients as ADT is often initiated without drawing testosterone levels, an...
For a patient treated with abiraterone for first line metastatic prostate cancer, would you still use a combination of abiraterone/olaparib at a subsequent progression?
No, there is no evidence for this, and in the absence of benefit, I would use single agent olaparib in HRD+ patients only, particularly BRCA2 patients. Ongoing trials like the CASPAR trial will address this question. In addition, there are ongoing trials testing PARP/AR combinations in men with mHSP...