Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
For persistent PSA elevation after prostatectomy, would you recommend salvage radiation if pathologically negative nodes, but regional and non-regional lymphadenopathy on PSMA PET?
While based on classical staging methods, it appears that he would fulfill the criteria for salvage RT with a persistent PSA, it sounds like this patient has M1a disease by advanced imaging (possibly at presentation). I think that it is very unlikely that he would gain any meaningful benefit from ad...
How would you treat oligometastatic kidney cancer in a young, fit patient with recurrence <6 months after nephrectomy?
This is a good question. Short time to recurrence of mets would generally indicate more aggressive biology i.e., the mets aren't really oligo and other mets are lurking. Having said that, careful review of prior scans may reveal that the metastatic sites were present prior to being fully recognized ...
Do you recommend prophylactic ureteral stenting in patients who have recently completed SBRT to a region in close proximity to the ureter prior to the potential development of fibrosis?
No, just F/U MRI.
After completing 6 cycles of docetaxel plus ADT for metastatic hormone-sensitive prostate cancer per CHAARTED, are there clinical scenarios in which you would add an additional AR targeted agent (ex: enzalutamide, abiraterone, or apalutamide) to ADT?
This is an important question and has in part been asked as part of subgroup analyses of the phase 3 ENZAMET, ARCHES, and TITAN mHSPC trials. In these trials, there was clinical benefit observed with combined chemohormonal therapy AND potent AR inhibition, sequentially in ARCHES/TITAN, and in combin...
What is the importance of finding a positive titer for FGFR3 and what treatment would be advised for these patients?
The significance of positive FGFR3 antibodies in patients with neuropathy, and the optimal treatment regimen for those patients remain to be determined. Based on the largest case series of FGFR3-IgG + patients to date, the antibodies seem to be associated predominantly, if not exclusively, with non-...
How would you sequence therapies for a patient with chemotherapy-naive metastatic castration-resistant prostate cancer who is MSI-H on tissue-based NGS?
Yes, I absolutely would use Pembrolizumab (200 mg IV q3wk, or 400 mg IV q6wk) in a MSI-high patient with mCRPC who has not yet received chemotherapy. However, I would probably postpone this until after the patient has progressed on one novel AR-directed therapy. I think that the "sweet spot" for usi...
When would you recommend adjuvant therapy for a patient with urethral adenocarcinoma after partial urethrectomy?
My first approach in this setting is to have the pathology reviewed by an expert tumor pathologist, and to be sure of the T stage, margins, N/M stage, and whether any tumor markers are heavily expressed. If there is a strongly expressed tumor marker, such as CEA, I will obtain baseline, and interval...
How would you treat a patient with widely metastatic penile squamous cell carcinoma with mixed response to 4 cycles of TIP chemotherapy?
Penile squamous cell carcinoma (PSCC) is a challenging and rare malignancy. In those with metastatic disease following therapy with cisplatin-based combination chemotherapy, there are no optimal or approved options. Clinical outcomes are dismal with currently used salvage therapy agents. Cetuximab o...
Would you recommend surgery or radiation for newly diagnosed localized prostate cancer diagnosed on a urethral lesion biopsy?
I think the underlying question here is whether its urethral location changes the recommendations we would otherwise make, and really it doesn't. Let's talk it through: I don't feel that the urethral location affects my ability to treat this with EBRT as the urethra gets the same (curative) dose as ...
How do you manage testosterone replacement therapy-induced erythrocytosis?
Testosterone is a known risk for thromboembolism. What is not known is whether it is the hematocrit or the testosterone itself that is the trigger for thrombosis. Note also that epidemiologically, the age group that generally is prescribed testosterone also has a high prevalence of thrombosis. My ap...