Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What treatment would you offer for a patient with prior primary prostate radiation, with a biochemical progression to PSA >1.0 and negative PSMA scan?
I’m assuming the patient has already received a prostatectomy and received prostate bed radiation, with a rising PSA. First, in terms of imaging, you may want to consider a contrasted pelvic MRI, which may reveal a small lesion in the prostate bed which may have been obscured by PET activity from t...
How do you approach a local failure with a rising PSA following prostate SBRT?
I would obtain an MRI if not already done to help delineate local disease extent. A variety of salvage options are available (RP; HIFU; cryotherapy; and re-irradiation with brachytherapy or focal SBRT). A recent systematic review and meta-analysis of local salvage therapies was published by a group ...
When do you consider the insertion of nephrostomy tubes for gynecologic malignancies without fistulas?
I agree with Professor @Dr. First Last, in addition, bilateral hydronephrosis, cortical thickness intermediate for imminent renal function decline, and treatment (chemoradiation) is planned, nephrostomy tubes can be considered. In some cases, inflammation from radiotherapy (obstructive uropathy) and...
How does a diffusely positive PSMA in the prostate affect treatment planning in a patient with MRI and biopsy showing only one area of disease?
There are three parts to my answer: First, mild to moderate PSMA uptake can be seen in benign conditions, including BPH and prostatitis (e.g., reviewed by Satapathy et al., PMID 32755196). Second, I don't see how the discrepancy between PSMA PET and MRI/biopsy would affect radiation treatment planni...
How would you approach second line treatment for prostate adenocarcinoma with diffuse neuroendocrine features?
Men with NEPC (histologic evidence of small cell carcinoma) face a poor prognosis and are typically refractory to all hormonal interventions, and in fact transformed NEPC much more typically evolves after potent AR inhibition than present de novo at diagnosis. Autopsy series and biopsy series sugges...
How do you manage a Ta pure squamous cell carcinoma of the urinary bladder?
The ideal management of non-muscle invasive bladder cancer (NMIBC) with histologic variants remains controversial. The American Urological Association and the National Comprehensive Cancer Network guidelines recommend radical cystectomy for T1 patients with variant histology based on expert opinion ...
How would you manage an older, frail ECOG 2 patient with stage II muscle-invasive bladder cancer with other competing risk of death?
Conceivably, treatment options are extremely limited for older, frail patients with localized muscle-invasive bladder cancer, who are not candidates for cystectomy or radiation. TURBT is a common practice in this patient population (Trulson et al., PMID 23817891), but without any improvement in outc...
For a patient with localized high risk prostate cancer with high risk Decipher score receiving ADT and abiraterone, is there any value of continuing ADT and abiraterone beyond two years?
Since the trial (STAMPEDE) stopped abi at 2 years, that is the longest duration that I use.In the mHSPC setting, we are seeing many patients stay on their first-line treatment for many years (often longer than 2 years). This has made me more cognizant of the long-term effects of abi/prednisone (acce...
In a patient with otherwise low-risk prostate cancer, does presence of a small component of Grade Group 3 disease up-stage to unfavorable intermediate?
I agree with Dr. @Dr. First Last's response and will just add a couple of additional thoughts. There are many things that go into making a decision about whether treatment is necessary, and what type of treatment is performed. In this case, it's important to consider patient factors (i.e. age, co-mo...
What is the best treatment for pT2 cN1 seminoma with mild elevation of B-HCG (~100)?
I would recommend making sure that the pathology is seminoma (with either review of the orchiectomy specimen and making sure there are trophoblastic elements or a biopsy of the retroperitoneal lymph node) as the beta hCG level is getting close to the upper end of what I would expect from a seminoma....