Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you recommend genetic testing for patients incidentally found to have nephrocalcinosis on imaging?
In general, yes, but it’s usually not my first step if my family history is negative for nephrocalcinosis. These patients typically have unusually alkaline urine and often pass calcium phosphate stones. I rule out primary hyperparathyroidism and incomplete distal RTA. I look for medications that can...
Can you/do you use an androgen receptor blocker alone in patients with metastatic hormone-sensitive prostate cancer who cannot tolerate GnRH-directed therapy?
Anti-androgen monotherapy for hormone-sensitive (M0 or M1) prostate cancer is not currently supported by FDA approvals or NCCN/AUA guidelines. Two recent studies that have explored enzalutamide monotherapy in patients with M0 and/or M1 hormone-sensitive prostate cancer are shown below. Enzalutamide ...
Would you offer adjuvant immunotherapy (pembrolizumab) for chromophobe RCC with R1 resection?
I have not experienced this situation yet in my own clinical practice but I would not offer adjuvant IO nor adjuvant radiation therapy for this patient. IO therapy has limited efficacy in this histology. This was shown best in the KEYNOTE-427 (monotherapy pembrolizumab in metastatic nccRCC, McDermo...
For HRRm prostate cancer, will you use olaparib alone or in combination with abiraterone?
The combination of a PARP inhibitor with a next-generation hormonal agent, including the combination of olaparib with abiraterone acetate, is not an FDA-approved combination and I do not recommend using it at this time. Both PROpel and MAGNITUDE showed a PFS benefit for the combination versus abirat...
When would you use PARP inhibitors in patients with refractory metastatic castrate resistant prostate cancer with somatic non-BRCA HRD mutations?
This is a very relevant question as clearly there is major heterogeneity in the outcomes with both olaparib and rucaparib in men with mCRPC based on their underlying germline or somatic tumor genomics. In addition, prior therapy and available alternatives including clinical trials with more or less ...
What is your general approach to treatment sequencing of available regimens in castration-resistant metastatic prostate cancer?
For mCRPC, my general approach with standard agents is a next-generation AR agent (typically started in the CSPC setting), followed by docetaxel, followed by Lu-PSMA. If disease is progressing slowly and is PSA producing, I will consider a switch from a first-line to a second-line hormonal agent, ty...
What can prostate patients do for sexual function while on ADT?
While libido drops for most men on ADT, sexual function is still an important component for many, and educating on what to expect will help prevent disappointment or confusion. First, some men can get an erection with testosterone suppressed, but it is less common and not as firm an erection as wha...
Should prostate cancer genomic classifiers, such as Decipher, be used in all high risk post-prostatectomy patients to risk stratify patients to adjvant RT vs PSA observation and possible salvage RT?
I think that the data are hypothesis generating and can assist in physician decision making. Additional analysis from other independent cohorts substantiate the findings from the JCO paper whose publications will be forthcoming. It is important to discuss the findings, including the limitations, wit...
Do you have your patients with recurrent nephrolithiasis stop supplements such as turmeric?
That is a good question and a hard one to answer since supplements may contain a variety of ingredients of unknown quantity or impurities. I think it also depends on the stone type. For example, excessive amounts of vitamin D, as were advised by some "practitioners" during COVID, can cause or aggrav...
Would you recommend ADT in a patient receiving salvage post-prostatectomy radiation with PSA <0.5 and a high Decipher score?
Certainly, this is an area of evolving management. Here’s what we know about the use of ADT in the salvage setting: RTOG 9601: 2 years of bicalutamide improved 12y OS but PSA at the time of salvage was a significant interaction term with PSA <0.7 receiving no benefit. 2 years of bicalutamide was ass...