Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you approach locally advanced bladder cancer in a patient on hemodialysis?
It depends on "locally advanced" setting; resectable or unresectable tumor?If resectable and not metastatic may consider radical cystectomy and LN dissection in good surgical candidates; however bladder preservation approach can be considered in well selected patients, e.g. small unifocal tumors wit...
In a medically inoperable, elderly, frail patient with muscle invasive, node negative bladder cancer, would you consider combining immunotherapy with radiotherapy instead of chemotherapy?
Maybe but what about using low dose Gemcitabine ( 27mg/M2 twice weekly) with daily XRT as in NEG 0712? This seems much better to me! WS
For a patient with metastatic castration-resistant prostate cancer to the bones with rising PSA but no evidence of radiographic or symptomatic progression, would you continue with the same treatment or change therapy based on biochemical progression?
This question emphasizes the importance of radiographic monitoring while on treatment for mCRPC. In a recent study from the PREVAIL trial of enzalutamide in chemo naive men with mCRPC, we found that radiographic progression occurred in about 1 out of 4 men (25%) without evidence of formal PSA progre...
How do you manage adjuvant hormonal therapy in a patient with high risk prostate cancer who already received prolonged neoadjuvant ADT prior to being referred for radiation?
For the purpose of answering this question, I will assume that the patient has a stable or declining PSA and has not shown signs of castrate resistance. In general, I am more concerned with the response to ADT prior to beginning radiation, rather than the duration of ADT before RT. Retrospective dat...
How do you approach local control in intermediate risk bladder rhabdomyosarcoma in very young (<24 months) children ?
These two approaches are probably equivalent in qualified hands (cystectomy / prostatectomy or definitive RT) in terms of local control. This issue is balancing morbidity. The surgical approach in many cases will require a full cystectomy, necessitating the creation of a neobladder or some other re...
Would you use AR-V7 testing to decide second-line androgen receptor-axis-targeted therapy vs chemotherapy for patients who with metastatic castration-resistant prostate cancer?
In our PROPHECY multicenter AR-V7 validation trial, we compared the JHU AR-V7 CTC RNA test against the Epic/Genomic Sciences nuclear protein CTC AR-V7 test. Both tests, when positive, were strongly associated with lack of PSA response, short PFS, and short OS in men with mCRPC receiving abiraterone ...
What approach would you take for patients with metastatic castration-resistant prostate cancer with marked PSA response (undetectable) on docetaxel, but radiographic progression in bone metastases?
As a first step I would confirm that the patient has truly had radiographic progression of his bone metastases. Prostate cancer can often demonstrate what has been termed a "healing flare" following response to systemic therapy, and radiographic progression in bone requires a follow up bone scan (us...
How do I convince urologists to send patients for a discussion of adjuvant radiation after prostatectomy?
Howard's advice is spot on as usual.For the residents and even faculty reading this, I think there has been an unnecessary rivalry between radonc and uro-onc that predominately only negatively impacts patients. We are a team and I think if we approach the care of our patients as a team we will provi...
In light of the recently published CARMENA trial, is there still a role for cytoreductive nephrectomy in metastatic RCC patients?
Several features of CARMENA make the data not applicable to all mRCC patients with primary in place. These include a large percentage of poor risk/poor PS patients, lack of receiving intended protocol therapy, including delayed nephrectomy in almost 1 of every 5 patients, and a primary tumor burden ...
If a patient develops intermittent painless hematuria during standard prostate RT do you attribute this to cystitis or would you work it up further?
While acute mucosal deepithelialization may be to blame, painless hematuria may unfortunately mark the beginning of a conundrum. It's good medicine to always develop a broad DDx and remember that radiation injuries are waste basket diagnoses. It's also wise to start with a UA/UCx, and if negative do...