Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
In a patient with M0CRPC with PSA doubling time < 6 months, will you wait until the absolute PSA value is >2, or is PSADT alone sufficient to start an AR targeted agent?
The SPARTAN trial required patients to have evidence of PSA progression per Prostate Cancer Working Group 2 (PCWG2) criteria at the time of enrollment. Per PCWG2 criteria, the PSA must be ≥25% and ≥2 ng/ml above the nadir, and it must be confirmed to be rising ≥3 weeks later. Similar eligibility cri...
What is the protocol for stopping TKI used in RCC prior to a surgery?
It depends on the half life of the TKI, but generally I stop 4-5 half lives prior to any invasive procedure from dental work to a major surgery. The bigger issue is when to restart afterwards, and I usually wait until surgical wounds are 90% or more healed. This might depend on the disease status of...
For post-prostatectomy radiation, are there any special considerations if there is a bladder sling or artificial urinary sphincter?
Great question. I have treated patients with artificial sphincters and penile prosthesis, and the thing I noted was one of the most important thing to do: document the urinary status of his function. I can say that for the most part I typically saw my patients after they have developed PSA progressi...
How would you manage a patient with intact prostate cancer with metastases to a para-aortic node and single bone?
I would consider treating the primary site per STAMPEDE as well as possible SABR the other lesions, so long as he understands this is an evolving area and the benefit has not been conclusively demonstrated. Would recommend confirming the bone lesion by biopsy as well.
How do you treat metastatic testicular cancer with the primary orchiectomy pathology showing non-seminoma with components of teratoma and primitive neuroectodermal tumor?
If such a patient had evidence of widespread metastases with normal tumor markers, I would have the pathology on the orch specimen reviewed at an experienced center. Assuming that review confirms PNET component, I would consider systemic chemotherapy with alternating VIP/CAV. It is very unlikely to ...
What would be the best treatment approach for bladder cancer patients s/p neoadjuvant therapy and surgical resection who develop oligometastatic recurrence within 1 year that is amenable to resection?
I agree with @Dr. First Last that this is a systemic disease and a "harbinger" for other micrometastasis. Data on metastasectomy is retrospective and of low level of evidence due to selection and confounding factors. I personally would not recommend local therapy with surgery or radiation, but rathe...
Would you treat a patient with testicular cancer stage I, pure seminoma on orchiectomy, but with high bHCG (in 1000s) as seminoma or as non-seminoma?
It would depend on what happens with the HCG of 1000 after orchiectomy. If it normalizes, I would proceed with active surveillance. If it persists or plateaus at a high level post orchiectomy, I would treat them the same way I would with a CSIS non seminoma typically BEP X 3. I would also review the...
How do you sequence ADT relative to radiation for a low volume M1 prostate cancer?
Start with radiotherapy, carry on hormone therapy for up to two years.
Would you treat unfavorable intermediate risk prostate cancer in the setting of recently resected NSCLC?
This greatly depends on the stage of the lung cancer. If stage IIIA resected NSCLC, I would not treat the prostate cancer immediately, and effectively enter them into active surveillance until the patient is 2 years free of NSCLC on follow-up imaging. If they recur from NSCLC within 2 years, they ha...
Would you offer neoadjuvant chemotherapy for a patient with low-grade upper tract/renal pelvis urothelial carcinoma with concurrent bladder drop-metastasis?
This question has several aspects. How commonly does a low-grade urothelial tumor metastasize? Is the described lesion in bladder truly a drop metastasis from upper tract? How can concurrent lesions in upper urinary tract and bladder be approached?Underestimation of staging and grading is a problem ...