Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you see a role for adjuvant sunitinib after resected RCC?
The role of VEGF-R inhibitors as adjuvant therapy in RCC is an evolving field. As you point out, ASSURE was negative but S-TRAC was positive. Each study has to be interpreted on it own while also trying to reconcile the different results. S-TRAC was different in that it was clear cell only, a higher...
In the era of MRI and other advanced imaging, do you still routinely perform a digital rectal exam on every prostate cancer patient?
Having started my career in the era when the latest in advanced imaging was a first generation CT scan, I still perform DRE on every patient at consultation (unless they refuse). There are several reasons for this approach. First, the information you get from DRE is needed for staging purposes, whic...
How do you approach prostate cancer patients with persistent obstructive lower urinary tract symptoms after primary radiation therapy?
If the persistent LUTS is due to radiation treatment, and medical therapy is not sufficient -- then I would refer the patient to urology for consideration of a channel TURP. Patients with metastatic cancer can have local (prostate) disease progression and experience significant obstructive symptoms ...
Is there any role for re-challenge with enzalutamide or abiraterone after prior failure in metastatic castrate-resistant prostate cancer?
Returning to a therapy on which a patient with mCRPC had previously progressed can be done with docetaxel (Bracarda et al, Future Oncol. 2015;11(22):3083-90; Di Lorenzo et al, Medicine (Baltimore). 2016;95(14):e2754), where a patient may derive clinical benefit to a re-challenge. Typically, the pati...
In a patient with a history of treated stage II seminoma with rising bHCG while on surveillance, do you routinely recheck the bHCG with a different assay?
In this setting, it depends a lot of the confidence you have in the treatment and the degree of HCG elevation. It also depends to some degree on whether the patient had an HCG elevation when he presented with stage II disease. In most of these cases these are very low level HCG elevations that bounc...
What is your approach to treating metastatic prostate cancer with primary resistance to GnRH analogues or early CRPC?
There is no one correct answer for every patient. In general, patients who are primarily resistant to GnRH or who develop early CRPC and who have not received docetaxel in the hormone-sensitive setting, would be good candidates to receive docetaxel. For those who are elderly or frail, I would consi...
How would you manage positive surgical margins after partial nephrectomy for kidney cancer?
If feasible, I would recommend re-excision. This is not always feasible however, and in that case, I would observe. Patients with positive margins do not always recur and thus could spare the patient some toxicity.
What challenges and adverse effects have you encountered with SpaceOAR injection?
Only situation in our limited experience where we have encountered a problem is in a patient with inflammatory bowel disease that had a j pouch where the scarring limited optimal placement of the SpaceOAR and the separation between the rectum and prostate was not as desired.
Do you offer bladder-sparing approaches as an alternative to cystectomy for surgery-eligible patients with muscle-invasive bladder cancer?
We have a bladder cancer multispecialty clinic at SCCA/UWMC in which we also see patients with localized MIBC and we balance carefully risks vs benefits, rationale, data, details & logistics of options. Overall, cisplatin-based chemotherapy (for fit patients) ->radical cystectomy with PLND, OR maxim...
Is there a role for a salvage lymph node dissection in patients who present with a biochemical failure after prostatectomy?
It's an important question without randomized data to support an answer. Even this question will evolve as we bring on-board more advanced imaging such as Fluciclovine PET/CT, PSMA PET, etc. These scans are continuuing to introduce new challenges as we start to resolve the location of lesions and so...