Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is orchiectomy necessary for a patient with primary retroperitoneal seminoma and calcifications seen on testicular ultrasound (but no primary testicular mass)?
No!
Do you modify your neoadjuvant considerations for patients with micropapillary histology and pT2 urothelial carcinoma and no distant neoplastic disease?
No. The prognostic significance of this histology is uncertain (EAU Systematic Review, Veskimae et al., Eur Urol Onc 2019). Prospective well powered studies with overall survival as the primary outcome and which incorporate disease classifiers that are more accurate than histology (e.g. a molecular ...
How do you think through the various treatment options for patients with unfavorable intermediate risk prostate cancer?
The first thing I do is make sure that I have plenty of time blocked off for this consultation, because these tend to be long encounters, and may require follow-up visits and/or phone calls to address all of the patient's questions. I think these are the most complex of all GU consults. The next thi...
Do you recommend MRI pelvis/prostate in a patient with biochemical recurrence after XRT and negative axumin PET scan?
This is a difficult question to answer as the context is very important. If this is a younger patient with fast doubling time that warrants aggressive treatment, the answer will be different than in an older patient with a slow doubling time. The patient's particulars (co-morbid conditions, prior tr...
How do you think about management options in a patient with a minute focus of Gleason grade 4 (4+4) on 1 core from needle biopsy along with only Gleason 3+3 disease in other biopsy cores and PSA<10?
This patient has "Favorable High Risk Prostate Cancer", and has outcomes similar to an intermediate unfavorable risk patient, rather than a true high risk patient. See here.I would offer this patient at least 6 months of ADT with IMRT. It would not be wrong to offer a longer course of ADT (24 mo), b...
What length of ADT do you recommend in a patient with a very low risk prostate cancer who otherwise has a PSA >20?
I would start by confirming that I feel comfortable with their biopsy results:1) ensuring that there appears to be adequate sampling of the prostate on biopsy,2) obtaining an MRI to make sure there is not a concerning appearing lesion that was not sampled (for instance, anterior disease),3) would al...
How do you manage TKI induced secondary polycythemia in a patient with RCC?
Fortunately this is fairly rare, although this has been described especially with axitinib. Polycythemia can also be RCC-related. I usually will engage my benign Heme colleagues who can help with the work up to ensure there are no other causes, and also direct phlebotomy as needed. I'm not aware thi...
What duration of ADT do you recommend for a patient with otherwise favorable intermediate risk features but a mpMRI showing gross extracapsular extension?
All of the responses so far are reasonable to me. I am assuming the patient is Gleason 3+4 with PSA <10 ng/mL. I am wary of applying a new technology to categorize patients to older trials (i.e., T3 on mpMRI and assuming that is the same as clinical T3 prior to MRI). That said, I can't call a patien...
Do you alter your management of ADT in a patient with high-risk prostate cancer who is a transwoman receiving estradiol hormone therapy?
We published a case report several years regarding a transwoman who developed prostate cancer who had been on estradiol therapy in JAMA. She presented with a PSA of over 100. She continued on her estradiol therapy. We did not use LHRH since she had a bilateral orchiectomy for her transition. She was...
Would you give abiraterone in the post-prostatectomy setting to patients with positive nodes detected at surgery?
This clinical scenario of N1 but resected disease post-RP represents an area where there is not sufficient evidence to recommend abiraterone or any potent AR inhibitor. While there is evidence to support ADT in this adjuvant setting for N1 resected patients based on the older Messing ECOG trial, sim...