Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is there a role for atezolizumab as a first-line agent for metastatic urothelial carcinomas?
The first question is whether the patient can tolerate cisplatin-based chemotherapy and whether or not they received (neoadjuvant or adjuvant) cisplatin-based chemotherapy within at least 1 year (if received peri-operative cisplatin-based therapy, it is a longer discussion regarding re-challenge tha...
Do you consider use of TIP as first-line therapy for poor-risk advanced germ cell tumors?
Unequivocally no. TIP seems clearly more toxic and achieves results no different than VIP or BEP given at high volume centers. TIP will not ever be compared to either and is going nowhere. In my view and the view of other testis cancer experts, the most important aspect is that these uncommon patien...
Do you counsel patients on the risk of dementia following androgen deprivation therapy for prostate cancer?
No, I generally do not counsel men about this risk. The two studies from the same investigator use a data warehouse search algorithm that may not be accurate enough to fully characterize who gets Alzheimer's disease or may not be able to correct for confounding factors that may be different between ...
How to you treat patients with germ cell tumors that progress during treatment with first-line platinum-based chemotherapy (i.e. platinum-refractory disease)?
This is extremely uncommon and a common mistake is to label someone as cisplatin refractory who really isn't. I would have to see the pattern of markers over the course of treatment and be assured that sanctuary sites have been ruled out prior to formally declaring someone as cisplatin refractory. T...
How do you counsel men with prostate cancer on the cardiovascular risks of androgen deprivation therapy?
This is a complex issue and depends on the specific setting (concurrent with XRT), the risk of the patient, and the specific CV risks of that patient. In the metastatic setting, there is almost never a contraindication to hormonal therapy given that prostate cancer is the likely cause of death in th...
How do you manage musculoskeletal pain in men receiving androgen deprivation therapy for non-metastatic prostate cancer?
This a very good question. Because bone pain can be a symptom of "benign" bone health issues without bone metastasis and because of the patient population demographics including risk factors, we obtain baseline bone health screening on most patients who must undergo Androgen Deprivation Therapy (ADT...
When do you use high-dose IL-2 for metastatic renal cell carcinoma?
In general, as an academic investigator, I always prefer clinical trials over standard of care. However, most of the front line registration trials in mRCC with immunotherapy have recently completed accrual, with results currently awaited. I continue to offer the option of high dose Interleukin-2 (H...
For patients who develop oligometastatic renal cell carcinoma amenable to local therapies (i.e. ablation, radiation therapy, or surgery), how do you integrate systemic therapy, if at all?
With full disclosure that the answer to this question is in the relm of a data free zone, for patients with oligometastatic disease not on systemic therapy, the answer is of course dependent upon site of disease i.e. CNS vs bone vs liver etc. That said if the solitary site of disease is managed with...
Would you offer salvage RT to a patient with adverse features after prostatectomy if his post-operative PSA was highly elevated (for example >10 ng/mL), but his metastatic work-up was negative?
The benefit in a patient like this with salvage RT is very limited if at all and I would not offer RT. This persistent elevation of more than 10 after surgery is from occut metastatic disease and local RT would not help with the outcome. Ga68 PSMA PET if available may pick up some of the disease tha...
What adjuvant therapy (chemotherapy, radiation) do you recommend for incidentally found focus of small cell prostate cancer at time of radical prostatectomy?
This is an interesting question. Extrapolating from the relatively recent data on surgery for early SCLC, the local therapy for an incidental focus of small cell histology has been completed after RP. If there is tumor that penetrated through the capsule, I'd look at the amount of tumor that broke t...