Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
In patients with good performance status, metastatic clear cell kidney cancer, and minimal metastatic disease, would you consider nephrectomy or partial nephrectomy if there are mets to brain?
Debulking nephrectomy has a clear role in the management of metastatic RCC, based on prospective trials showing an OS benefit. Patient selection, however, is critical for optimal benefit and minimizing risk. Brain metastases often portend a more aggressive systemic disease, and such patients often d...
How do you approach a solitary pelvic nodal recurrence following definitive radiation therapy to the prostate/SV?
Briefly, I agree with @Dr. First Last and I occassionally offer treatment to solitary nodal disease, most commonly seen in the postprostatectomy, post-salvage RT setting. I'm generally not offering SBRT to nodal disease, since I think of the nodal basin needing RT (like 45 Gy with SIB to nodal disea...
How do you interpret and utilize PSA values in patients on dialysis?
There appears to be no clinically relevant impact on total serum PSA, whereas free PSA and % of total can be impacted in a membrane type-dependent manner to where % free PSA is of less utility for screening. Thus, total serum PSA seems reasonable to continue as marker of biochemical control post-tre...
How do you incorporate NaF bone scan in the initial workup of prostate cancer?
At this point, I think the field is still learning how to make use of these tests and trying to determine which patients are the best candidates. We clearly need better imaging to detect early metastatic disease and lymph node involvement, as these findings would change how we would approach the pat...
What do you use for post-treatment follow up for prostate cancer patients whose cancers make little to no PSA, such as very high Gleason grade/neuroendocrine tumors?
We can probably separate the question into two categories: the rare prostate cancers that make absolutely no PSA and those that make relatively little PSA. For those that make zero PSA, then I've generally followed them with imaging similar to how one might follow a small cell cancer of any primary ...
What combination of clinical and pathologic features would lead you to be comfortable recommending active surveillance in a Gleason 7 prostate cancer patient?
Active surveillance (AS) is an important option for prostate cancer patients, especially for low risk prostate cancer. For intermediate risk prostate cancer, the risk of AS increases somewhat but the benefits of AS remain. To keep the risk of AS acceptable, one should select intermediate risk patien...
How would your management change for high-risk prostate cancer in a patient who is not a surgical candidate (due to age or medical comorbidities) and had prior pelvic irradiation?
Thank you for your question. Indeed, much of the data on re-irradiation in the pelvis corresponds to recurrent disease in GI or GYN malignancies. Historically, many physicians would recommend androgen deprivation alone as management in the setting of high risk prostate cancer with prior pelvic RT. H...
How would you manage a patient with low risk prostate cancer on active surveillance who develops high risk features but absolutely refuses a repeat biopsy?
In the setting of a suspicious mpMRI lesion, we start by acknowledging the patient's likely negative experience with their transrectal biopsy. We ask if they are referring to the one where they were rolled on their side, had a probe inserted in their rectum, and heard a bunch of loud CLICKs. We empa...
How would you manage a cN0 penile cancer with a moderate risk of nodal metastasis?
Pathologic nodal stage is such a strong prognostic factor that patients with moderate or high risk of nodal involvement, even if cN0, should have surgical nodal staging. This includes those patients with MD and PD tumours, and T1b or higher. PET-CT cannot show microscopic involvement. If the patien...
What alternative therapies would you consider for a patient with metastatic castration-sensitive prostate cancer who declines GnRH analogues?
This situation is fairly uncommon, particularly in the metastatic setting, where these therapies are nearly universally effective and toxicities generally manageable. The alternatives of bicalutamide at high dose (150 mg/d) and enzalutamide also have toxicities and much less evidence to support thei...