Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you prefer FGFR inhibitor or second line immunotherapy in a patient with metastatic urothelial cancer of the bladder with FGFR mutation?
I would clearly prefer immunotherapy specifically with the use of pembrolizumab. I would measure the PDL1 CPS expression, where the impact is much greater. Phase 3 data clearly shows significantly improved survival compared to chemotherapy or BSC. This is the first positive trial in the second-line ...
Do you offer adjuvant chemotherapy or abiraterone for patients with high and very high risk prostate cancer with still detectable PSA after radical prostatectomy and lymph node dissection?
I will recommend reimaging outside conventional CT and bone scans. The goal of imaging is to rule out metastatic disease and (hopefully) identify localized residual disease in prostatectomy bed or pelvic LN and consider early salvage RT. Fluciclovine PET is now commercially available and also PSMA P...
How do you manage androgen deprivation in a patient with oligometastatic prostate cancer in which the primary and all known metastatic sites have been treated with curative intent radiation and PSA remains undetectable?
A great question and one that we don't have data for yet! In the absence of data, we can fall back on what we know about prostate cancer and its response to radiation and hormonal therapy, and remember the goals of treatment. Studies in the localized setting combine ADT with RT for 3-26 mo, with len...
Is there any role for regional lymph node dissection with radical nephrectomy for patients with early stage RCC?
Patients with early stage RCC without unfavorable clinical pathologic features and clinically positive nodes have a low incidence of nodal metastasis. LND is unnecessary in these patients. Furthermore, renal lymphatic drainage is unpredictable.
Is there a lung metastasis size cut-off do you suggest for selecting between BEP and VIP as initial chemotherapy in advanced testicular cancer?
I do not use a size cut off to select initial chemotherapy regimen for advanced testicular cancer. I rather use the International Germ Cell Cancer Collaborative Group (IGCCCG) model for initial risk stratification. Irrespective of risks, BEP is considered standard initial regimen. Nevertheless, for ...
In patients with metastatic RCC who have had a complete response to pembrolizumab and axitinib and undergone a nephrectomy, how long would you continue therapy post-operatively?
This is a great question and increasingly relevant. The larger question is about duration of IO-based therapy in general, especially when patients are at maximal response (CR or deep and stable PRs). The honest answer is that nobody knows. My sense is that the decision is based on pt preference and ...
How does the presence of active rheumatoid arthritis on rituxan impact your decision to proceed with prostate radiation?
I am always concerned about irradiating a patient with an active chronic inflammatory condition, as these people may be more prone to toxicity, both acute and late. In the case of a patient with both prostate cancer and rheumatoid arthritis, the latter being treated with rituximab, the fact that he ...
Would you offer a patient with pT4 renal urothelial cancer adjuvant RT for a positive margin if re-excision is not possible?
Adjuvant radiation therapy for upper tract urothelial cell carcinoma (UTUC) has historically been performed, but is currently not recommended by most cooperative guideline groups (NCCN, European Association of Urology,...). Due to the relative scarcity of this disease, there is no randomized data. L...
In practice, do you discuss the role of Oncotype Dx before ordering the test?
We do discuss the role and implication of Oncotype Dx or any other genomic assay with patients, before ordering it. I make patient aware, how the results will guide us help decide between chemotherapy Vs. No chemotherapy. As a group, we have created an agreed upon criteria for ordering Oncotype Dx, ...
Should systemic therapies be added to ADT and salvage RT in patients with PSAs >2 ng/mL after RP?
The question is asking for patients who underwent RP, and the PSA either was persistently elevated to ~2.0 ng/mL, or was observed until it was 2.0 ng/mL, what is the standard of care. The only salvage RT trial that really enrolled men at a PSA of 2 or higher was RTOG 9601 (GETUG-16 allowed up to 2.0...