Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
When treating a patient definitively for high risk prostate cancer, how would you interpret the interval development of sclerotic bone lesions that appeared during neoadjuvant ADT?
It most likely reflects treated metastatic disease but can be very difficult to prove, as bx yield is low since it has been treated. Would not change management and complete planned treatment. Stampede also showed benefit of local RT for limited bone mets
Which patients with metastatic hormone sensitive prostate cancer would you treat with enzalutamide or apalutamide (instead of abiraterone or docetaxel)?
Current studies in mHSPC combining docetaxel or abiraterone or enzalutamide or apalutamide suggest that the standard of care for patients who present with de novo high volume metastatic disease has now changed from single ADT (gonadal androgen suppression) to one of the combinations. At this point i...
What duration of ADT do you recommend for patients with high risk or very high risk prostate cancer who undergo radical prostatectomy, adjuvant RT, and adjuvant docetaxel?
Locally advanced prostate cancer remains a significant clinical challenge. The role of "adjuvant" docetaxel to follow patients receiving primary radiotherapy plus ADT has been tested in at least 5 randomized studies, with RTOG 0521 the only one to my knowledge showing survival benefit (albeit a smal...
How long after biopsy is it safe to place rectal spacer when treating a patient definitively for prostate cancer?
Depends on the method of biopsy. Transperineal, think it would be safe to do this immediately. Transrectal biopsy I would be more concerned about infection and would wait 3 days.
How do you treat a patient who develops metastatic prostate CA while on enzalutamide or apalutamide for originally M0 CRPC?
Most patients in this setting actually have mCRPC but very low volume disease. Occasionally this can be local/regional only but most PET imaging studies suggest that M0 CRPC is comprised of metastatic disease below the limits of detection of conventional CT and bone scan imaging. Thus I manage these...
Would you consider cystectomy in a patient who acheived radiologic and cystoscopic CR from chemo-radiation for oligometastatic urothelial carcinoma originating in the bladder if remains disease free > 6 months?
For this patient, I would currently recommend 4-6 cycles of cisplatin based chemotherapy followed by avelumab switch maintenance therapy. I would strongly consider radiation or chemoradiation after the combination chemo directed at the bladder and lymph node, followed soon after by avelumab. I think...
In a patient with newly diagnosed high risk prostate cancer, how do you work up a bone scan showing suspicious areas of radiotracer uptake?
This a great question. In the setting of abnormalities on the bone scan, I would take 2 actions. First, I would certainly get local imaging of the abnormal site, with a CT, MRI or X-ray, depending on the location. I would also use the patient's clinical scenario and treatment response to help in the...
Is the presence of STUMP (Stromal tumor of Uncertain Malignant Potential) after prostatectomy an indication for adjuvant radiation?
Based on limited data there is no role of adjuvant RT for STOMP
How much emphasis do you place on anti-AR therapy in a patient with metastatic castration resistant prostate adenocarcinoma with progressive neuroendocrine differentiation?
While most prostate cancers are adenocarcinomas, there is a histologic spectrum that includes neuroendocrine and small cell tumors -- with the later typically arising in response to chronic androgen deprivation therapy. Often times we are faced with mixed histologies, which can be challenging to man...
Is there any role for neoadjuvant therapy in urothelial Tis refractory to BCG therapy?
No clear role of systemic chemotherapy prior to radical cystectomy. The latter alone is the SOC in this setting; clinical trials should be certainly considered especially in patients who either refuse or can’t tolerate radical cystectomy for BCG unresponsive high risk NMIBC.