Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Are there any special considerations to take into account when managing patients with recurrent nephrolithiasis who are found to have a horseshoe kidney?
Interesting question! Horseshoe kidneys are particularly susceptible to stones, primarily in the lower poles. Stones are typically composed of calcium oxalate. Renal embryology was a neglected topic during my medical education. The prometanephros are located near the fetal cervical spine. They subse...
How would you manage a patient with PSA persistence after RALP demonstrating metastasis in regional lymph nodes without further evidence of disease on bone or CT scans?
First, if possible, I would try to get a PSMA PET/CT. If that is negative, this patient should be started on long-term ADT. In terms of radiation, if they were a candidate for radical prostatectomy, the age/performance status question is probably not a major concern unless their health status has un...
Would you offer salvage radiation for prostate bed recurrence on PSMA PET in a patient with limited bone mets?
I don’t currently offer salvage post-op RT (PORT) to patients with osseous metastatic disease on PSMA-based PET/CT, which is consistent with the per-protocol treatment strategy on EMPIRE-1 (Jani et al., PMID 33971152). I would, however, be open to offering such a treatment on a clinical trial. An ex...
What is the appropriate timing of CRT after TURBT for bladder preservation in the treatment of bladder cancer?
Our typical timeframe is 3-6 weeks. If it has been >8 weeks, we would recommend at least an office cystoscopy to confirm no gross residual/recurrent disease. We typically perform 2 TURBTs (one from referring and one at our institution) prior to CRT.
Would you recommend adjuvant nivolumab for patients with upper tract urothelial cancer?
For any patient with upper tract UC who is eligible for cisplatin, adjuvant cisplatin based chemotherapy would be the preferred standard of care approach. This would be supported by results from the POUT trial where patients treated with cisplatin were deprived significant DFS benefit compared to su...
Would you offer adjuvant chemotherapy for platinum eligible patients with pT2pN0 urothelial carcinoma of bladder or UTUC who did not receive neoadjuvant chemotherapy?
I agree with both of my colleagues that adjuvant cisplatin-based combination chemotherapy is unproven for pT2N0 bladder cancer, although the POUT upper tract urothelial carcinoma phase III trial (which demonstrated significantly improved DFS) did recruit >=pT2N0 patients to evaluate adjuvant gemcita...
In high risk prostate cancer treated with RT with neoadjuvant/concurrent ADT, is adjuvant intermittent ADT reasonable instead of continuous ADT?
As an option in general, I say no. Given multiple phase III trials showing an overall survival benefit of adjuvant ADT, I would need a robust non-inferiority study of intermittent ADT to recommend it. If a patient refuses or cannot tolerate continuous ADT but can tolerate intermittent, this is proba...
Can abiraterone or enzalutamide be substituted for bicalutamide to prevent a flare when initiating ADT with a GnRH agonist for metastatic prostate cancer?
In theory, abiraterone or enzalutamide could potentially help by the mechanism to prevent or abrogate the testosterone flare when starting on GnRH agonists. In practice, however, abiraterone and enzalutamide are more difficult to obtain, need to be dispensed at specialty pharmacies, and require prio...
When administering adjuvant RT to the prostate bed with concurrent ADT, do you start concurrently or prefer to administer the ADT first?
In the absence of evidence I turn to first principles. If the ADT were short-term and aimed towards improving local control, then I would start the ADT a good few months ahead of the radiation to maximize the synergy. However, if it was a high-risk case with ADT planned for a few years and the radia...
Do you hold ADT before work up for prostate cancer when ordering advanced imaging such as PSMA PET?
The answer to this question is somewhat context dependent. The influence of ADT on a PSMA PET/CT is likely dependent on the clinical setting in which PSMA imaging is being considered, the duration of ADT prior to imaging, and how a provider plans to use the information to influence his or her treatm...