Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your approach for patients with recurrent nephrolithiasis who require daily use of acetazolamide for management of an unrelated chronic condition?
Acetazolamide, or other carbonic anhydrase inhibitors, typically increase urine pH into the low 7s. Normally, it is approximately 6.0. A mildly alkaline urine favors the formation of brushite and hydroxyapatite kidney stones. My first step is to contact the provider who prescribed the carbonic anhyd...
For what duration should abiraterone be used in a patient with biochemical and pelvic node recurrence (N1M0) who had prior definitive therapy with either RP or RT?
This is a similar but slightly different question than the one answered by Attard et al., PMID 34953525. This meta-analysis of randomized trials demonstrated a survival benefit with the addition of 2 years of Abiraterone + ADT compared to ADT in men who received definitive management for N1 prostate...
Would you consider adding abiraterone, in addition to ADT, for patients with less than very-high risk localized prostate cancer but high clinical-genomic metastasis risk after EBRT?
This is a very tricky area to be sure. The short answer is yes, I do in carefully selected patients.It is well established that genomics correlates with biology in the mHSPC and mCRPC settings. Now, there is emerging data that genomics correlates well with biology in the localized disease setting (e...
Would you use abiraterone or docetaxel in addition to ADT and radiotherapy for patients with very high risk, node-negative prostate cancer?
The most recent update from STAMPEDE's abiraterone arm in the M0 N0 very high risk setting was reported here: Attard et al., PMID 34953525 and strongly suggests that abi/ADT for 2 years plus radiation improves MFS and OS significantly and should be standard of care for men who are choosing RT in thi...
How would you manage sarcomatoid carcinoma of the prostate with poorly differentiated adenocarcinoma that is not amenable to surgery?
There is data on this rare histologic variant, albeit limited, and often in these situations we try to extrapolate from analogous areas with more data.It is believed that the pathogenesis of these tumors, the epithelial and sarcomatoid components, arise from a single cell of origin, rather than sepa...
Do you use denosumab for castration-sensitive prostate cancer with osseous metastases?
This is an important question but a complex one. Several issues are critical to consider: 1) bone anti-resorptive therapies like zoledronic acid have NOT been established to improve survival or reduce skeletal events in this setting of bone metastatic HSPC as compared to waiting for mCRPC. See CALGB...
How would you manage an elderly, medically inoperable patient with high-grade, muscle-invasive bladder cancer who has already received definitive prostate irradiation?
The more patients with prostate cancer we treat and the longer they live, the more likely this is to happen. While cystectomy is the right thing to recommend, it is often a very difficult operation as continent diversions are impossible, and the risk of bowel injury is high. If the patient is elderl...
How would you treat a young patient with a resected stage III chromophobe RCC?
Good question, while it is tempting to give adjuvant pembro given stage III we don’t know that chromophobes will respond. Wondering if there’s a specific trial for this. Adjuvant non-clear cell.
Do you advise Kegels/pelvic floor physical therapy to minimize urinary incontinence when irradiating the prostatic fossa?
I have not recommended Kegels/pelvic floor PT in asymptomatic patients, but if patients are symptomatic either before, during, or after RT, I will make this recommendation. My preference is to refer the patient to a Physical Therapist or pelvic rehab team with special expertise in this field, but if...
For non-metastatic MIBC patients with incomplete debulking TURBT, who are not surgical candidates for cystectomy or repeat TURBT, would you try chemoRT or proceed directly to systemic treatment?
Definitely chemoRT. I believe around 1/3 of patients on BC2001 had biopsy only or incomplete TURBT. No doubt maximal TURBT is preferred, but when it is not possible, that is not a contraindication to definitive treatment. If not a chemo candidate (though there are several options), I would recommend...