Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
For patients with high risk prostate cancer, is there data to support prostatectomy, as opposed to upfront RT?
In 2010, MSKCC published a study in JCO which suggested surgery was better than 81 Gy IMRT for high risk prostate cancer. The study had many limitations including selection bias of higher stage patients. in the RT group, there was only short term androgen ablation, lack of salvage or delayed salvage...
How should I interpret a Gleason 7 prostate cancer (4+3 or 3+4) with tertiary grade 5?
The scoring system adopted by 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma specified that in a prostate biopsy, the two numbers should be the primary pattern and the highest grade (not the second most common type as was done...
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...
Would you treat a patient who failed cryotherapy?
There is published data (small series), showing reasonable efficacy and good tolerence of salvage EBRT for cryotherapy failure and we have treated a few patients with this approach.
In a low volume prostate cancer (2 of 12 cores, low percentage) with a GS 4+4=8, how long does ADT need to be administered?
The role of ADT for high-risk disease continues to evolve, with new data emerging annually. While guidelines typically recommend 2-3 years for any high-risk patient, not all have the same risk of failure and/or benefit from ADT. Initial phase III studies from the RTOG & EORTC that showed OS benefits...
For patients with high risk prostate cancer, is there data to support increased morbidity, such as increased urethral strictures or cystitis, when given postprostatectomy XRT as opposed to definitive XRT?
This is a very relevant question that commonly comes up in practice - should a man with high risk prostate cancer have a prostatectomy, when the chance of him needing post-op RT is reasonably high, if he could have RT/ADT only and possibly avoid the risks associated with surgery? The discussion must...
If one decides to use a mpMRI to stage a pt with low-risk prostate cancer, how do you work up a focal lesion suspicious for higher grade GS 7-10 disease?
Even though modern mpMRI is sensitive (>90%) at detecting occult GS ≥4+3 cancers that are missed by blind systematic TRUS biopsies, it is not 100% specific. Almost all radiologists will occasionally over-call a radiographic abnormality when it is still only GS 6. When decisions to be made from this ...
Do you forgo adjuvant radiotherapy for men with pT3 prostate cancer who have significant urinary incontinence?
I agree that early salvage may be reasonably effective and thus one might carefully observe patients who are not ideal candidates for adjuvant RT. Both the RADICALS study and the RAVES study will examine this issue (timing of post-op RT further). Here's a recent summary of the RAVES trial: BJU Int....
For intermediate risk prostate cancer do you recommend short-term complete androgen blockade or LHRH agonist alone?
I also like to do the combined androgen ablation with RT to stay consistent with the majority of the randomized studies done. There is a subset analysis of Anthony D'Amico's 206 patient study in which PSA recurrence rates were analyzed according to whether combined androgen blockade was received (as...
When is the best time to start denosumab in men with metastatic prostate cancer?
The data supporting the use of bone modifying agents (BMAs) such as denosumab or zoledronic acid are certainly the most solid for men with castration-resistant prostate cancer (i.e. progresion of disease through inital LHRH analog therapy) (Saad, JNCI 2004; 94: 1458–68; Fizzazi Lancet Oncol 2011; 37...