Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is the optimal duration of ADT for cN1 disease with EBRT?
Unfortunately there are no prospective data to guide management for cN1 prostate cancer treated with EBRT. The NCCN guidelines do not comment on the optimal duration of ADT in this setting. While 18 months may be considered for some patients with high risk cN0 prostate cancer as per the PCS IV trial...
What is your preferred neoadjuvant chemotherapy regimen for muscle invasive bladder cancer, adequate performance status and preserved kidney function?
I agree, to date there is a lack of published randomized phase 3 data to date (though this is ongoing with NCT01812369) Several retrospective analyses such as one by Peyton et al JAMA Oncol 2019 found that neoadjuvant dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) produced...
For prostate cancer, when do you pursue a biopsy for metastatic disease to the bone found on imaging study?
Presuming the patient has undergone curative care for his prostate cancer, and had become undetectable via PSA, who now presents with bone metastases, when would I consider a bone biopsy? So, if he was treated for cure, and had an undetectable PSA on his most recent follow up visit, my question beco...
How would you treat a patient with newly diagnosed advanced urothelial cancer?
The current standard of front line systemic therapy for advanced urothelial cancer is cisplatin based combination chemotherapy: cisplatin/gemcitabine or ddMVAC, for cisplatin eligible patients. For cisplatin ineligible patients, pembrolizumab (Keynote 052), atezolizumab (IMvigor 210) or carboplatin/...
Do you offer adjuvant chemotherapy to patients with urachal adenocarcinoma and at least one high risk feature?
In the absence of data in this space, I would offer adjuvant chemotherapy applying similar principles from colon adenocarcinoma for patients with T4 or node positive disease. FOLFOX/CAPOX for 3 to 6 months is reasonable in this situation. This regimen has the most reliable and reproducible data in t...
When would you consider active surveillance for a patient with metastatic RCC?
How do you evaluate PSA decline after EBRT for low-and intermediate risk prostate cancer not treated with ADT?
This is not an answer that comes with any hard data, although both NCCN and AUA offer guidelines on PSA monitoring after therapy. First, I check a PSA at treatment completion. This is not so important when ADT is used, as PSA pretty much universally will decline (at least initially) on ADT. However,...
If a patient with low metastatic burden has bulky retroperitoneal adenopathy without osseous metastasis, would you recommend prostatic radiation?
We could debate whether "bulky" retroperitoneal adenopathy is a truly low volume metastatic disease, but technically it would fit the definition used in the STAMPEDE Trial. In addition, patients presenting with nodal metastatic disease may have a more indolent course than those presenting de novo wi...
In a patient with pN1 penile squamous cell carcinoma s/p inguinal lymph node dissection, would you offer adjuvant TIP vs adjuvant chemoRT vs surveillance?
With no high risk features (i.e. pN1 disease is <= 2 unilateral inguinal lymph nodes involved with no extracapsular extension), the best evidence for any treatment would be for adjuvant chemoradiotherapy which would come from an extrapolation of a GOG study on vulvar cancer. As reference, NCCN Guide...
Do you consider adjuvant chemotherapy in a patient who has received ddMVAC preoperatively and had pT3pN2 disease at time of surgery?
No. There is no high level evidence of doing that. I would strongly favor clinical trial, e.g. AMBASSADOR is accruing (or active surveillance if no trial available).