Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
At what PSA value do you obtain molecular imaging in a post RP patient with previous salvage prostate bed radiotherapy?
The answer to this question will strongly depend on what you intend to do with this information. If you have a patient with a very slowly rising PSA, say a doubling time of years, this patient may not benefit from any treatment so you may want to continue to observe them without any further testing....
How would you treat a seminoma if orchiectomy showed a burned out primary with positive pelvic and paraaortic lymph nodes?
If volume of disease is small, would treat with RT and if large, meaning bulky nodes >3 cm or entire chain which seems like the case here, then with chemotherapy CP regimen.
When using IO therapy for front line treatment of metastatic RCC, is there a role for cytoreductive nephrectomy?
The role and timing of debulking nephrectomy in mRCC has been evolving over the last several years. This is in part due to CARMENA, which in my opinion reinforced that patient selection is critical, and in part due to increased activity of systemic therapy. I think patients with limited IMDC risk fa...
Would you consider radical prostatectomy for a young male with unfavorable intermediate risk cT3a prostate cancer and PSMA PET concerning for regional lymph nodes involvement but negative conventional imaging?
I would approach this scenario by considering two main issues. The first issue is what the probability of the patient truly having pN+ disease based on cN+ findings on advanced imaging. There have recently been two trials published from the Netherlands, PEPPER (using 68¸Ga-PSMA-11) and SALT (using 1...
Can adjuvant nivolumab for bladder CA as per Checkmate 274 be extrapolated for the concurrent chemoRT bladder preservation setting?
Great question. Short answer is no. Different scenario and very hard to extrapolate from the adjuvant post radical cystectomy setting. We need dedicated bladder preservation trials, e.g. S1806 and Keynote992. Recommend to accrue in those 2 large phase III trials for patients who opt for bladder pres...
Would you treat the pelvis in a high risk prostate cancer patient who is anticipating pelvic kidney transplantation?
My decision to treat pelvic nodes depends on the specific risk criteria present, but let's assume that this patient meets those criteria. In this situation, it is important to discuss the options for locating the vascular anastomoses with the transplant surgeon. Typically, these would involve either...
Would you give adjuvant immunotherapy after nephrectomy?
The KN-564 will certainly change the landscape of adjuvant RCC. Prior studies had either been negative, or have been positive (sunitinib in S-TRAC) but with toxicity that has precluded widespread use. The OS data from KN-564 is too immature to interpret, in my opinion, so the debate of whether to tr...
Do you use the highest or most recent PSA for risk stratification for newly diagnosed prostate cancer?
This happens on occasion and can be a dilemma. First, I would repeat the PSA and see if it is <20 or >20, and take that into account. I would also take into account the genomic score. This may help further clarify the patient's risk category. If the patient had a reason for the first elevated PSA li...
Will you offer adjuvant BEP after orchiectomy to a patient with embryonal carcinoma, solely based on the size at presentation, such as a 6 cm testicular mass?
I would not consider adjuvant BEP in this setting. While the risk of relapse is likely higher than smaller non ECC predominant tumor, it likely does not exceed a 50% chance of recurrence. Our general stance is active surveillance for all CS 1 seminoma and non seminoma patients. Adjuvant anything imm...
How would you approach a pT2 nonseminomatous testicular cancer, embryonal caricnoma with +LVI with persistent b-hcg < 20 post-operatively?
If a patient has had an inguinal orchiectomy and has a persisting b-HCG in a reliable lab (remember that alpha-HCG can cross-react with the alpha chain of LH, so a "good" beta-HCG assay is important, especially as hypogonadal males often have an elevated LH), it suggests clearly that there is residu...