Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you offer prostate specific PET imaging (e.g. Axumin or PSMA PET) in a post-RT prostate cancer patient that has a rising PSA that has not yet met failure criteria?
Maitre et al., PMID 35189154 This study shows a high pick up rate with PSA not meeting failure criteria and many of them had focal relapses which are potentially salvageable.
When do you offer salvage prostate bed RT to patients who have a biochemical recurrence >5 years after RP?
While retrospective data consistently suggest that biochemical outcomes (and possibly also distant metastases and prostate cancer specific mortality) are better when salvage radiation is delivered at lower PSA values, there is no absolute cut-point to trigger treatment. Many factors must be taken in...
Is antiandrogen monotherapy a reasonable option for a patient with high-risk disease getting IMRT (+/- BT boost) who refuses GNRH modulators?
I do use anti-androgen monotherapy as a compromise for patients who refuse LHRH agonists. Many patients walk out the door when LHRH agonists are mentioned. The PSA nadir is not as low with biclutamide as with LHRH agonists. There is experience with biclutamide at 150 mg both in non randomized report...
For patients with muscle-invasive bladder cancer and borderline renal function, would you consider use of a split-dose cisplatin/gemcitabine regimen for neoadjuvant treatment?
Yes, in patients with borderline creatinine clearance, e.g. 50-59cc/min, we tend to split cisplatin dose, e.g. 35 mg/m2 on days 1 and 8, if gemcitabine/cisplatin is used, or on days 1 and 2, if dd-MVAC is used. Also, we consider 24-hour urine testing to assess more accurately creatinine clearance in...
How does a prominent component of intraductal spread affect your management in a patient with otherwise intermediate-risk prostate cancer?
There are no outcome studies that I am aware of that indicates that an intraductal prostate cancer alters prognosis in men receiving radiation therapy. However, there are numerous reports that this is an "adverse feature" when looking at initial staging (men with this finding seem to be more likely ...
Is there a substitution for etoposide you would recommend for testicular cancer patients who need multiple cycles of BEP?
If it is good risk disease can use our old regimen of cisplatin + vinblastine + bleomycin (PVB) as it was equivalent to BEP therapeutically in the good risk patient population. For intermediate or advanced disease, VeIP or TIP.
If a man has been on a 5-alpha reductase inhibitor for urinary symptoms prior to prostate radiation therapy, is there value in continuing it after radiation therapy?
5-alpha reductase inhibitors, e.g. dutasteride, are indicated for the treatment of symptoms related to BPH and an enlarged prostate and have some efficacy for this indication, especially when combined with alpha blockers. 5-alpha reductase reduces a double bond in testosterone to create a more poten...
For what patient groups (if any) do you routinely recommend screening colonoscopy prior to radiation for prostate cancer?
As a cancer care provider treating both GI and GU malignancies, I see this as a commonly. In many healthy men, an elevated PSA may be what allows them to "plug in" to the American health care system, often the first time in many years. Considering most prostate cancer is detected by an elevated PSA,...
How do you approach treatment for high-risk prostate cancer in patients who need clearance for organ transplant listing?
Our initial approach for these patients is to engage their transplant physician to understand the barrier for organ transplant listing. For some patients, the presence of a detectable PSA is the rate limiting factor, while for others having untreated disease is the main issue. The difference between...
Would you use apalutamide in high risk non-metastatic castrate resistant prostate cancer?
I would consider using apalutamide for the appropriate patient, which I would define as meeting the entry criteria for the study i.e. PSA DT 10 months or less. The label for the drug is broad i.e. any castration resistant PSA only patient, which I beleive is too far to inclusive, many of these folks...