Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
After definitive prostate RT, when do you prescribe ADT for local salvage (EBRT, HDR, LDR)?
For patients with localized recurrence after definitive radiotherapy, re-irradiation without ADT is a reasonable course of action and the one I usually favor. There are no current clinical trials that have been reported to demonstrate the benefit of ADT in this setting, but this practice is consiste...
Do you routinely obtain next generation sequencing for patients with metastatic renal cell carcinoma and if so, what is your approach to incorporating these results into treatment decision making?
Currently, I do not routinely send NGS for patients with metastatic clear cell RCC as we do not have level 1 evidence that these results should guide treatment decisions. We do not have "actionable mutations" that would change or guide our treatment of choice. IMDC still remains our best risk strati...
What clinical and pathological features do you consider when deciding which androgen receptor targeted agent to combine with ADT for a patient with newly diagnosed castrate sensitive metastatic prostate cancer?
Regarding which novel hormonal agent I use with ADT, there are no specific pathologic features which suggest that any one agent is better than any others as far as I know, so I do not consider that in the decision. The primary reasons why I choose an agent are based on adverse events and side effect...
Does recent COVID-19 infection result in elevated PSA?
A study from Turkey showed that PSA can increase sometimes dramatically in men with BPH (not necessarily with prostate cancer) during active COVID infection, from an average of 1.5 pre-COVID to 4.3 during active infection. (Cinislioglu et al., PMID 34626600). One can imagine a similar phenomenon may...
What is the recommended length for ADT in the setting of N1 disease receiving definitive radiation?
In such cases, I typically recommend two years of ADT + abiraterone based on the results of the STAMPEDE high risk localized/N+ subgroup (Attard et al., PMID 34953525). At 6 years, the addition of abiraterone led to an absolute benefit of 13% in metastasis-free survival (82% vs. 69%; HR 0.53), and a...
What is your approach to BK hemorrhagic cystitis not responding to cidofovir?
BK hemorrhagic cystitis can range from completely asymptomatic infection (with positive BK viremia and viruria by PCR) or grade 0 to massive macroscopic hematuria requiring instrumentation for clot evacuation and urinary obstruction requiring bilateral nephrostomy tubes for urine diversion (grade 4)...
How would you treat a patient with active lupus nephritis (class 3/4) who requires PD-1 immunotherapy for refractory metastatic renal cell carcinoma?
This is a complex question and there is a paucity of data to address it. The critical issues are of timing (new onset or existing nephritis, disease activity) and treatment regimen. Given that oncologists will not use checkpoint inhibitors on patients requiring more than 10 mg of prednisone at base...
How do you define bone disease progression in mCRPC while on docetaxel?
Defining bone scan progression on docetaxel is no different than in other treatment contexts and generally, I use PCWG2-3 criteria. I generally do not stop docetaxel in the first 4 cycles based on PSA changes alone since transient PSA rises followed by falls can occur during these first 3 months. Ho...
How frequently do you obtain 24 hour urine stone risk profiles in your patients with kidney stone disease who pass less than one stone per year?
When I do 24h urine collections in patients, I repeat the collection in order to see if the goal of therapy was achieved. Whether that was fluids, dietary changes, or medications, I usually want to see if we were successful. After that, I'm less interested in repeating the study especially if the st...
In which patients do you obtain genetic testing for further evaluation of kidney stone disease?
First stone as a pre-adolescent, stone complicated by kidney failure, history of growth retardation, family history of stones or nephrocalcinosis or unexplained kidney failure, hearing impairment, ocular crystals High stone burden on imaging or nephrocalcinosis Concomitant low molecular weight prot...