Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you incorporate the recent proposed guidelines for using a prostate cancer "Grade Grouping" system (i.e. scores 1-5) into your clinical practice?
As theMedNet is a less formal venue for discourse I will do away with any pretense and answer the question honestly. I have no idea how I or anyone should incorporate this new system into practice. Although validated, the new system has not been used in randomized trials and one musn’t be overly dog...
For high risk, stage I, non-seminomatous testicular germ cell tumors, are there particular circumstances under which RPLND is clearly preferred over chemotherapy or surveillance?
There are few indications for primary RPLND in pure nonseminomatous CSI. The only one I can currently think of is someone who has a strong contraindication to ever receiving chemotherapy.... renal failure or the like. The only time I consider it general is for patients with high risk Leydig or Serto...
Given the results of the recently published GETUG 16 randomized trial, should all men undergoing salvage prostate radiotherapy receive concurrent hormone therapy?
I'm not surprised to see this question posted on The Mednet. GETUG 16 was recently published (Lancet Oncol. 2016 May 6.) and provides additional prospective information regarding the role of ADT in the managment of salvage prostatectomy cases. Not to nitpick over the article excessively, but I did n...
When should intermittent androgen deprivation vs continuous androgen deprivation be used for the treatment of prostate cancer?
I think the question posed and the patient example are really 2 different questions. To address the title question, let me call your attention to a recent article in the JCO 34: 280-5, 2016, and an accompanying editorial, which review this issue in detail. The authors point out that there are signif...
In patients who are medically poor surgical candidates, what are the treatment options available for bulbomembranous urethral cancer?
The evidence is thin, but these patients may be treated by chemo-radiation. Whether they are urothelial cancer or squamous cell carcinoma the aim would be to get in a worthwhile radiation dose, say 65-70Gy, with reasonable sensitizing chemotherapy if they have the kidneys to tolerate it. Sometimes t...
Is there a role for adjuvant docetaxel in patients with high-risk localized prostate cancer who elect for prostatectomy?
Currently, there is no data to support the use of adjuvant docetaxel following radical prostatectomy. Given that these are two entirely different treatments in different patient populations, there is no rationale for extrapolating the results from RTOG0521 to a post-surgical (even if high-risk) popu...
Are there any situations in which you would offer postoperative RT for node positive prostate cancer?
The textbook answer, based on Messing NEJM, is ADT for node+ patients post-prostatectomy, but this is certainly a moving target.As node+ patients were excluded from all adjuvant (EORTC, German, and SWOG) and salvage (RAVES, RTOG 0534) randomized trials, there is currently no level I evidence for XRT...
Following presentation of the PRINCE at ASCO 2016, should we be offering intermittent docetaxel to patients with metastatic castration-resistant prostate cancer?
The simple answer is no, as this study was dramatically underpowered to reach any conclusion. A couple of issues:1. This trial was designed after the TAX 327 data showed q3 week therapy to be the standard of care. This trial allowed weekly therapy anyway, likely because some of their docs wanted to ...
For castration-naive metastatic prostate cancer patients who you plan to treat with LHRH agonist monotherapy, how long do you treat with an anti-androgen therapy prior to and after initiating the LHRH-agonist?
I only use bicalutamide prior to starting LHRH agonist in patients with high risk of spinal cord compression or urinary obstruction. I will start bicalutamide for 7 days then start LHRH agonist therapy. In all other patients, I start LHRH agonist without combination with anti-androgen therapy.
Do you routinely offer AR-v7 testing to determine whether to treat with chemotherapy versus enzalutamide or abiraterone in metastatic castration resistant prostate cancer?
The short answer is no, not yet, and not outside of a research study. AR-V7 testing using a CLIA approved circulating tumor cell (CTC) assay, either Qiagen-Hopkins using the Adnatest RT-PCR platform or the EPIC-Genomic Health protein assay, appear very promising as negative predictors of the clinica...