Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
In light of CHAARTED and STAMPEDE, should all men with newly-diagnosed, treatment-naive metastatic prostate cancer be treated with chemohormonal therapy?
This is an evolving answer but presently I do offer 6 cycles of docetaxel to men with M1 (not N1) CSPC who are initiating or who have recently initiated ADT. This would include men who present with M1 disease but also men with rapidly recurrent mCSPC who are hormone naive. There appears to be a grea...
Should bone-directed agents, such as denosumab or zoledronic acid, be given when patients are being treated with radium-223?
In ALSYMPCA, bisphosphonate use at study entry was associated with a delay in symptomatic skeletal events (Sartor, et al. Lancet Oncol 2014; 15(7) 738-46). Based on this, osteoclast-targeted agents (i.e. zoledronic acid and denosumab) should be offered to patients with mCRPC that will receive radium...
What chemotherapy regimen is best suited for patients with platinum-refractory metastatic bladder cancer who have good or excellent performance status?
I would try to get patient to a pd1/pdl1 study or try to get it off-label. Early results are promising for 1/3 of patients.
What is the optimal management of recurrent seminoma with small volume retroperitoneal disease initially managed with surveillance?
The question is how to manage pathologic confirmed CSII seminoma. If the nodal volume is on the larger side (> 3 or so cm), most experts would treat those patients with BEP X 3 with a very high cure rate, with very low likelihood of requiring any post-chemotherapy interventions. Most experts in the...
Without radiographic evidence for metastatic disease, is there a PSA value above which high risk localized prostate cancer should not be treated definitively?
The SPCG-7/SFUO-3 randomized trial randomized 875 patients to endocrine only therapy vs. endocrine therapy plus radiation therapy. 20% of the patients had a PSA > 30. The addition of radiation showed an overall survival benefit at 10 years (60.6% vs 70.4%), a prostate cancer specific survival benefi...
What treatment recommendations for a low or intermediate risk prostate cancer do you consider when treating patients with medical commodities such as ankylosing spondylitis and ulcerative colitis?
I do not think either of these would be a contraindication for radiotherapy. I have some experience with patients with ulcerative colitis, but not with ankylosing spondylitis. If there is any concern, either HDR or LDR brachytherapy are the most attractive options. The volumes for low and intermedia...
Is there a role for docetaxel for men with high risk prostate cancer receiving radiation and androgen deprivation therapy?
Standard of care for high risk localized prostate cancer remains radiation and long term androgen deprivation therapy. To date, there are no trials that have demonstrated an overall survival benefit with the addition of chemotherapy. Given the potential toxicity of adding chemotherapy, this should n...
When does a rising PSA after prostatectomy indicate growth just of normal prostate?
The concept of residual prostate tissue after prostatectomy has been around since the advent of the PSA. The idea that BPH could exist within this residual tissue has been suggested for nearly the same amount of time. Very little data exists regarding this concept. It has been demonstrated that resi...
Per 2016 NCCN guidelines, is the addition of 6 cycles docetaxel now the standard of care for all (NCCN) high and very-high risk prostate cancer patients receiving definitive XRT/ADT?
Last year, the results of RTOG 0521 were presented at ASCO and showed that adjuvant docetaxel led to a small improvement in overall survival for men with high risk prostate cancer. To briefly recap, 563 eligible subjects were randomized to standard-of-care external beam RT (72-75.6Gy, with 46.8 to r...
Does a rare histology prostate cancer, such as ductal or mucinous, change your typical management recommendations?
Intraductal cancers are often associated with Grade 4 prostate cancer and getting a mpMRI and performing a fusion TRUS/mpMRI bx of any PiRads 3, 4 or 5 cancer to r/o Grade 4 would be of value to recommend treatment as opposed to active surveillance in an otherwise Gleason score 6 PC. If Grade 4 is c...