Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
When would you use PSMA PET over conventional imaging for prostate cancer?
So far, most (but not all) prospective data for molecular imaging has been obtained in the setting of biochemical recurrence and that is where I have used it most outside of trials.In the primary disease setting, some trials examined the utility to detect nodal and distant disease (like OSPREY publi...
How do you counsel patients with high risk prostate cancer treated with RT + long term ADT who want to allow their testosterone level to rise above castration before receiving their next Lupron injection?
I would not support this strategy unless the patient is on longer term ADT for biochemical recurrence after prior local therapy. In that setting, intermittent ADT is a viable option supported by literature and could be considered. Otherwise, once ADT is stopped, there's no basis for resuming. The co...
How do you manage favorable intermediate risk prostate cancer patients that have a PIRADS 5 lesion that was most-likely missed in the template biopsy?
Yes, I'd suggest a repeat biopsy before treatment. In the case of radiation +/- ADT, a repeat biopsy may impact the dosimetry of radiation, whether or not ADT is used, and how long ADT is used as part of treatment.
How do you manage an elderly, high risk prostate cancer patient who refuses any local therapy?
In general, for patients who refuse treatment, I try to understand their goals and their fears. Often, elderly patients state that they are ready to die, and don't want to prolong their lives. If I think that treatment is likely to significantly improve the quality of their lives, I will explain why...
What is your criteria for undetectable PSA value after prostatectomy?
In the era of ultra-sensitive PSA, reading below threshold of .2 ng/ml also reflects biochemical recurrence especially in the right context. That being said, if values are low like above, we generally repeat PSA to see the trend rather than act on treatment on single value.
Are there any scenarios in which you would consider use of PARPi in the upfront mCSPC setting rather than reserving for CRPC?
The FDA approved talazoparib plus enzalutamide for HRRm metastatic CRPC in June 2023. NCCN panel recommends talazoparib plus enzalutamide as a category 1 treatment option for patients with metastatic CRPC and a pathogenic mutation (germline and/or somatic) in one of certain HRR and other DNA repair ...
How would you treat a patient presenting with de novo metastatic prostate cancer and baseline low testosterone?
By definition, progressive disease despite castrate levels of testosterone is CRPC. This is a very rare situation in the de novo setting, and more likely one may encounter a patient with only slightly low testosterone, which would not be considered CRPC. Patients with de novo metastatic prostate can...
Is there any data to support the use of hormone therapy with RT in the adjuvant post-prostatectomy setting?
Unfortunately, randomized data remains limited. Although pT3/N1 pts were included in RTOG 8531 (www.ncbi.nlm.nih.gov/pubmed/15817329), the majority of the pts included in this trial were treated with definitive radiation. At ASTRO 2011, Shipley et al reported the results of RTOG 9601 (www.redjournal...
Which patients with intermediate and high risk prostate cancer should not receive androgen deprivation therapy?
Based on randomized trials that didn't exclude patients with cardiac risk factors, an overall survival benefit has been observed for intermediate and high risk localized prostate cancer. Review of RTOG studies has not detected an increase in cardiovascular events. That said, appropriate management o...
Do you decrease the duration of hormones in a man with high risk prostate cancer and cardiac risk factors?
Agree with all of @Dr. First Last's points. In the end, you often have to gauge the right thing to do based on the patient in front of you as much as on the literature. The truth of the matter is that I am often far more concerned about impacting negatively on bone mineral density (BMD) than cardiac...