Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your approach to metastatic non-clear cell RCC?
A majority of the clinical trials conducted in renal cell carcinoma are conducted exclusively in clear cell carcinoma. We know from retrospective analyses (De Velasco et al Clin GU Cancer 2017) that these patients have a worse prognosis with traditional therapy. Small randomized trials dedicated exc...
Is it acceptable defer or forgo biopsy and to start androgen deprivation therapy in an elderly, fragile patient with PSA in the 900s and evidence of bone metastases?
These questions come up regularly in practice. There seem to be two questions here.One is the acceptability of starting therapy for prostate cancer without biopsy confirmation. There is a small single institution retrospective evaluation and positive predictive value of PSA in diagnosing PCa. With a...
Are the cardiac risks of LHRH agonists also seen in patients undergoing bilateral orchiectomy for ADT in hormone-sensitive prostate cancer?
Although the true implications of testosterone suppression on cardiac risk/disease remains somewhat undefined, it is the low testosterone levels, not the mechanism of how these levels were obtained i.e. either surgical or medical castration that is the issue.
Should patients who received pelvic radiation get colonoscopy screenings more often than what is recommended for the general population?
The excess risk of secondary cancer after radiation has been estimated at 0.5% in a 15 year follow-up period. This relatively low incidence would not justify a higher interval of screening colonoscopy after pelvic radiation. As a component of our patient-reported quality of life survey, we do screen...
How would you treat patients with muscle-invasive urothelial carcinoma of the bladder with small cell and sarcomatoid differentiation?
Muscle-invasive urothelial carcinoma "with small cell and sarcomatoid differentiation" could represent an inexperienced pathologist failing to recognize a variant of pure urothelial cancer or it might be a stem-cell tumor with variable differentiation. I would start by having the pathology reviewed ...
In a patient who requires prostate cytoreduction prior to EBRT or brachytherapy, do you include a 5-alpha reductase inhibitor in your ADT regimen?
This is a great question. Although 5-aplha reductase inhibitors do shrink the prostate, there is little data reporting on its use prior to RT. Jethwa et al (J of Contem Brachytherapy 2016 Oct; 8(5): 371–378.) evaluated factors that impacted decrease in prostate volume and the initial prostate volu...
Is treating high-risk prostate cancer with trimodality therapy safe for a patient who remains on anti-PD1 therapy for metastatic melanoma?
More important question is do we need to treat patient with triple modality for high risk disease if they have metastatic melanoma as outcome would be dictated by metastatic disease
What morphologic criteria do you use to call prostate cancer N1 on imaging?
Good question. By old CT standards from the 90s that include not only prostate but NSCLC as well, the criteria for positive LNs was a short axis LN diameter of 1cm or greater. Some have used CT with MRI imaging and lowered to as low as 5-7 mm, too.Source: The diagnostic accuracy of CT and MRI in the...
How do you decide between abiraterone or docetaxel for first line treatment of newly diagnosed metastatic prostate cancer?
Abiraterone (LATITUDE and STAMPEDE trials) and docetaxel (CHAARTED and STAMPEDE trials) both have level 1 evidence supporting their use in men with metastatic hormone-sensitive prostate cancer. However, a pre-planned subset analysis from the CHAARTED study demonstrated that docetaxel only appeared t...
Would you recommend starting treatment for a renal cell carcinoma patient with new low-burden, asymptomatic sub-centimeter bilateral pulmonary nodules that arise after a short disease-free interval (<6 months) after nephrectomy for stage I disease?
This patient generally fits the phenotype of someone I would consider for initial observation. Usually if you look closely at prior scans, such nodules were present but unappreciated. There are prospective data supporting such an approach. Having said that, it also depends on the age and performance...