Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you interpret PSMA/PET with focal prostate activity after XRT currently on ADT with stable PSA?
The most concerning element of the case presented is that the patient’s PSA continues to be ≈ 5 while on ADT with presumably castrate levels of testosterone, which should be verified. The current PSA is one order of magnitude greater than would be expected from the effect of ADT alone possibly indic...
How would you approach a patient with M0 castrate-resistant prostate cancer started on enzalutamide who continues to have increasing PSA levels without metastases seen on imaging?
This is an important question, given the new FDA approvals and NCCN guidelines in the M0 CRPC treatment space and likely increased use of apalutamide and enzalutamide in these men with PSA-only CRPC. In general, these studies continued treatment until metastatic progression (soft tissue or bone) was...
What adjuvant therapy, if any, is best for mucinous tubular and spindle cell carcinoma of the kidney?
Mucinous tubular and spindle cell carcinoma (MTSCCC) of kidneys is a rare RCC variant which was first described in WHO 2024 updates of the classification of RCC (Moch et al., PMID 35853783). Most cases are diagnosed incidentally and typically have an indolent course with good long-term prognosis (Ku...
What is your approach to solitary node positive bladder cancer (e.g. N1) in a patient who is otherwise a candidate for either bladder preservation or radical cystectomy?
This is a very intriguing question, with limited prospective data to guide us. I will frame my response on a patient with clinical node positive (based on imaging) bladder cancer and a candidate for bladder preservation or cystectomy. This patient is deemed metastatic yet there may be a subset of t...
What is your approach to lab and imaging monitoring in a patient with an elevated creatinine following a unilateral nephrectomy?
One should expect some elevation in serum creatinine after unilateral nephrectomy in the majority of patients. Hyperfiltration seems to be universal but is often not complete. Over time, the serum creatinine stabilizes and often improves some but likely not to baseline. I would repeat serum creatini...
Do you recommend initiating a potassium sparing diuretic in patients with recurrent nephrolithiasis who have hypercalciuria but do not tolerate thiazide diuretics?
No. The idea of using a thiazide diuretic as a preventive treatment for calcium-containing stones is its hypocalciuric effect. Potassium-sparing diuretics do not have this ability. Loop diuretics worsen hypercalciuria and, in general, are inappropriate for use in calcium stone formers. One could con...
How would you sequence PARPi vs pembrolizumab for a patient who has progressed on ARPI to mCRPC that has somatic PALB2 mutation and MSI-H?
MSI-high disease in men with mCRPC is uncommon, accounting for 3-5% of patients overall, and typically results in high TMB. MSI-high disease is usually a result of either germline MMRD (Lynch Syndrome, about 20% of MSI-high cases) or somatic MMRD (typically MSH2 or 6, MLH1, less commonly PMS2). The ...
Would you offer adjuvant immunotherapy in a patient with high risk RCC with new/worsening post-op renal dysfunction and CrCl<30?
My preference in situations like this is to stabilize the renal function first. I am comfortable treating the patient with adjuvant pembrolizumab with a CrCl <30 mL/min but it should be stabilized first. That will make it easier to diagnose potential irAEs as compared to starting adjuvant treatment ...
How do you work-up and manage a patient with prostate cancer and a borderline enlarged pelvic lymph node?
My approach in this case is to start patients on ADT(and abiraterone if possible) and monitor for LN response with a 3mo CT scan. If LN shrinks, I consider them to be N+ and treat the pelvis, boost the LN if it is still of adequate size to do so (typically >5mm), and continue ADT for 2 years before ...
Would you use olaparib after progression on an ARPI for a patient with somatic PALB2 mutated mCRPC?
Yes, I would consider using olaparib monotherapy in a sPALB2-altered patient who has previously received one or more ARPI agents. This is based on a recent meta-analysis conducted by the FDA. In that paper, in PALB2-mutated mCRPC patients (N total = 41) rPFS HR was 0.52 (0.23 to 1.17) and OS HR was ...