Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
When using active surveillance for rising PSA after prostatectomy, at what level of PSA would you start ADT?
Given the EMBARK data (Freedland et al., PMID 37851874), I would typically treat with ADT + enzalutamide if the PSA level was between 2.0 and 5.0 ng/mL following maximal definitive local therapy (RP + adjuvant/salvage RT). This would apply only to patients with a PSADT of <9 months. For those with P...
Do you have specific waiting periods before a patient can be listed for a kidney transplant if they have a past history of malignancy?
The pair of articles by Al-Adra and colleagues (Al-Adra et al., PMID 32976703; Al-Adra et al., PMID 32969590) outlining expert consensus opinions on melanoma/hematological and solid organ malignancies in transplant candidates serve as the primary references for this issue at our center. The treatmen...
Do you recommend adjuvant ADT instead of neoadjuvant ADT with prostate RT?
If ADT and RT are synergistic rather than additive, then the sequencing of therapies should matter. Neoadjuvant: ADT has been shown to reduce proliferation and cell cycling (increase radioresistance) and decrease hypoxia (increase radiosensitivity). However, tumor hypoxia is not a major driver of ou...
For a patient post-prostatectomy with a high PSA (>1), a negative MRI pelvis, and a negative PSMA PET scan, do you pursue any other imaging?
The sensitivity of PSMA scan for PSA above 1 is about 75-90%. I would proceed with salvage RT plus ADT like we did in the era when PSMA was not available.
Is it appropriate to re-consider bladder preservation in patients with bladder muscle-invasive cancer (T2) who were initially poor candidates for BP (multifocal disease, etc.) but had complete response after neoadjuvant chemotherapy?
It is perfectly appropriate. There are many ways to achieve a complete response to T2 bladder cancer. It can be reached with radiation, an aggressive local resection, or chemotherapy. The issue is whether or not it is durable. None of these therapies alone have a great track record, although chemoth...
Do you recommend neoadjuvant and concurrent ADT vs concurrent ADT for salvage post prostatectomy radiation?
I do both neoadjuvant and concurrent. The strategy used is typically dictated by patient schedule/convenience.While GETUG-AFU 16 used a concurrent approach, SPPORT utilized a 2-month neoadjuvant strategy for ADT.
Do you recommend delaying spot urine protein quantification testing until after nephrostomy tube removal in a patient with obstructive uropathy?
Yes, if the tubes are coming out. Would not want to make treatment decisions under these circumstances. Not an emergency usually.
Would you rely on virtual crossmatch alone to proceed with a kidney transplant?
Yes, we have an excellent HLA director and have been proceeding with a virtual crossmatch for the past couple of years. Every organ offer that is accepted for transplant is reviewed by our HLA director, and we are advised whether or not there are any donor-specific antibodies of concern. This saves ...
Do you ever consider intermittent ADT for metastatic prostate cancer?
In general, I recommend continuous ADT for men with metastatic disease based on the OS difference from the Intergroup 0162 trial. I do agree, however, that this trial was a noninferiority design and the difference is not large, therefore in men with very limited disease who display intolerance to AD...
Why are patients getting enzalutamide s/p prostatectomy not candidates for salvage radiation therapy?
Although there have been other efforts to profile the role of enzalutamide (e.g., SALV-ENZA, Tran et al., PMID 36367998) or other second generation androgen axis inhibitors (e.g., FORMULA-509) in conjunction with salvage RT, EMBARK (Freedland et al., PMID 38320501) was designed to test the efficacy ...