Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach a patient with a non-castrate testosterone level and rising PSA despite receiving LHRH agonist therapy?
This is a good question. It is always good to check on the testosterone value in men on LHRH agonist therapy in order to ensure the level truly is within castrate range. I assume this patient has been on therapy for a number of months (i.e. the testosterone has had time for full suppression). If so,...
What is your preferred first-line therapy for patients with newly diagnosed intermediate- or poor-risk metastatic clear cell RCC?
For intermediate and poor risk advanced clear cell renal cell carcinoma, combination therapy is the standard of care with 4 different regimens showing an improvement in overall survival vs sunitinib: nivolumab/ipilimumab, pembrolizumab/axitinib, cabozantinib/nivolumab, and pembrolizumab/lenvatinib. ...
Can bicalutamide be used instead of LHRH agonist in intermediate to high risk prostate patients receiving EBRT who want to preserve erectile function?
The short answer is yes, BUT with some serious reservations: 1. This is not considered standard of care in this patient population, so patients should be made aware of that fact and that conversation should be documented in the medical record; 2. There are data to indicate that bicalutamide plus EBR...
How do you manage a patient with metastatic prostate cancer who does not acheive a PSA response to upfront ADT?
First and foremost, of course, confirmation that androgen deprivation (ie testosterone <50 ng/dl) has been achieved should be obtained. While uncommon, primary resistance to a particular hormonal agent can occur. In this case, an alternate agent can be tried (eg switching from an LHRH-R agonist to a...
How do you manage patients with bilateral renal cell carcinomas?
Bilateral RCC without distant mets should be managed surgically if at all possible (e.g. bilateral partial nephrectomies), assuming adequate residual renal function. Pre-operative TKI to enable partial nephrectomy has been reported in multiple phase 2 trials with some success. If metastatic, then I ...
How do you manage anejaculation following definitive radiation for prostate cancer?
This is a very common side effect of prostate radiotherapy, either with brachy or external beam. Unfortunately there is no "fix" of which I am aware, as the glandular function of the prostate is reduced after radiation (think of the salivary glands and what we know happens to them!). The best option...
In a patient with localized prostate cancer with rising PSA would you consider EBRT if the patient is also undergoing chemotherapy for active recurrent colon cancer?
Hi. I, generally, agree with @Dr. First Last's response, but I would consider a few other things as well.For example:1. Disease extent or tumor burden of the recurrent colon cancer. Is the patient dying soon because of a heavy tumor burden, or does the tumor involve 5 or less metastatic sites, w/o c...
What is the utility of a biopsy in the setting of an elevated post-prostatectomy PSA and imaging noting a local prostate bed recurrence?
It would generally be reasonable to treat an imaging detected prostate bed mass without a confirmatory biopsy if one was going to treat the patient whether the biopsy was positive or negative. Some radiation oncologists are escalating doses to higher that standard levels in the postoperative setting...
How would you approach risk-stratification/staging of a extra-gonadal germ cell tumor with both mediastinal and retroperitoneal lymphadenopathy?
Actually there is zero chance a primary mediastinal germ cell tumor would ever have retrograde adenopathy to the RPLN's. Thus this is a primary retroperitoneal germ cell tumor. Assuming no non-pulm visceral mets and markers at good risk level, would treat with BEP x 3. You did not mention pathology,...
How does the finding of synchronous bladder cancer affect your treatment recommendations for high risk prostate cancer?
We have quite a few pts with synchronous early bladder ca with prostate ca treated with brachy. I have not seen any significant additional morbidity with IV therapy but have not evaluated objectively