Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Are TKIs safe for a patient with metastatic renal cell carcinoma and a transplanted kidney?
No contraindications from my experience, and does not look like there are any known interactions or interactions with metabolism. It is helpful to make sure the treating nephrologist is aware of the diagnosis and therapy in order to monitor immunosuppression levels. Often we will change the immunosu...
Would you treat a patient with refractory, metastatic castrate resistant prostate cancer who has somatic ATM mutation with a PARP inhibitor?
Yes, I would consider Olaparib (not Rucaparib), but only after they have received at least two AR-targeting drugs and at least one taxane drug, and only if an ATR inhibitor trial was not available. And I would set the expectations really low: PSA response rate of 5-10%, PFS of 4-6 months.
How would you approach multiply recurrent prostate cancer in a patient who has had both LDR and salvage HDR?
Very carefully! The risk of GU and GI toxicity from any salvage therapy after both LDR and salvage HDR is very high. If there is a focal lesion identified on MR/PSMA that is distant from the bladder, urethra, and rectum, then maybe you can try a focal treatment. I'd be very careful because the risk ...
Would you offer neoadjuvant chemotherapy to a patient with high risk non-muscle invasive urothelial carcinoma for whom cystectomy is planned?
Short answer is no in NMIBC. If there is pT3/4 and/or pN+ path Stage at radical cystectomy, would consider adjuvant therapy options, e.g. cisplatin-based chemo or clinical trial.
How does presence of MMR deficiency/Lynch syndrome affect your recommendation on peri-operative chemotherapy for high-grade upper tract urothelial cancer?
The presence of MMR deficiency does not really alter my recommendation regarding peri-op chemo for high-grade upper tract UC. Firstly, I don't personally think the MMR deficiency data are ready for prime-time use in chemo-prescribing; I do think this connotes for a higher likelihood of resistance, b...
How do you treat locally advanced choriocarcinoma of the urinary bladder?
This is a very rare site and a rare subset of germ cell tumor. I assume the pathology has been reviewed and full scans including ultrasound of testes if a male and HCG/AFP have been performed. Is the patient in the typical age range for germ cell tumors? If this is confirmed and the patient has a ty...
How do you approach a patient with metastatic urothelial carcinoma who has progressed on maintenance avelumab?
This patient would be in the 3rd line so options include Enfortumab vedotin (based on EV-201, cohort 1, published data, and EV-301 press release) or Erdafitinib (if FGFR2 or FGFR3 activating mutation or fusion based on BLC2001 trial published data) or clinical trial. Outside the US, without access t...
What is your preferred choice and timing of systemic therapy in a patient with high risk oligometastatic prostate cancer undergoing metastasis directed therapy to all sites of disease, including the prostate?
Metastasis-directed therapy (MDT) is an option for patients with oligometastatic prostate cancer who wish to delay initiation of ADT, based on STOMP (Decaestecker et al., PMID: 25223986) and ORIOLE (Phillips et al., PMID: 32215577) trials. In the STOMP study, 61% of patients (3 or fewer metastases) ...
How would you manage a patient with localized prostate cancer treated with radical prostatectomy and found to have a single involved pelvic lymph node on final pathology and a detectable postoperative PSA?
This patient is now in the salvage setting with PSA recurrence after RP and with PSA persistence and node-positive disease. This is a grey area of medicine without level 1 evidence from RCTs but there are some sources of data to help guide optimal outcomes. This patient is at high risk for further m...
How would you treat a patient with recurrent malignant perivascular epithelioid cell neoplasm (PEComa) arising from the kidney and metastatic to lungs?
At our institution, first-line systemic therapy would be with mTOR inhibition.