Michael S. Cookson, MD, MMHC, presented “Muscle Invasive Bladder Cancer: 2018 Guidelines” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Cookson, Michael S. “Muscle Invasive Bladder Cancer: 2018 Guidelines” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/muscle-invasive-bladder-cancer-2018-guidelines/

Muscle Invasive Bladder Cancer: 2018 Guidelines – Summary:

Michael S. Cookson, MD, MMHC, outlines the purpose, methodology, and background for recently released guidelines for treating muscle invasive bladder cancer, including cisplatin-based chemotherapy. He highlights recommendation statements regarding patient counseling, neoadjuvant/adjuvant chemotherapy, radical cystectomy, pelvic lymphadenectomies, and more.

Abstract:

In 2018, the American Urology Association, along with a panel of organizations, created thirty-five guidelines for the treatment of muscle invasive bladder cancer (MIBC), based on randomized controlled trials (RCTs), high-level evidence, clinical principles, and expert opinions.

To note a few of the most important guidelines, the panel recommends offering cisplatin-based, and not carboplatin-based, chemotherapy prior to radical cystectomy (RC). Clinicians should complete the RC as soon as possible (6-8 weeks after chemotherapy). In most cases, this should not be a partial cystectomy. The guidelines also cover decision-making for bladder and organ preservation. Regarding perioperative management, the guidelines highlight Enhanced Recovery After Surgery (ERAS) principles, thromboembolic prophylaxis, opioid antagonist therapy, and counseling patients on urinary diversion care.

Also, the panel strongly recommends performing pelvic lymphadenectomies to help with curative intent, removing at least the external and internal iliac and obturator lymph nodes. For patients that choose a multi-modal bladder preserving therapy, they should undergo a maximal transurethral resection (TUR) of bladder tumor. Furthermore, patients with MIBC should not have radiation therapy as stand-alone treatment.

Additionally, the panel recommends counseling patients on how treatment will affect their quality of life. While clinicians may want to downplay this, it is critical to be upfront about life-altering side effects. Also, physicians should counsel patients about proper nutrition, smoking cessation, and other healthy lifestyle choices in the perioperative setting. Finally, follow-up should include chest imaging, cross sectional CT or MRI imaging of the abdomen and pelvis at 6-12 month intervals for the first 2-3 years, and then annually since most recurrences appear in the first two years.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Cookson presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Phillip J. Koo, MD, presented “Timing and Optimization of Radium 223 in CRPC” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Koo, Phillip J. “Timing and Optimization of Radium 223 in CRPC” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/timing-and-optimization-of-radium-223-in-crpc-2/

Timing and Optimization of Radium 223 in CRPC – Summary:

Phillip J. Koo, MD, briefly reviews several clinical trials examining the use of radium 223, focusing on its use in combination with second generation AR inhibitors. He also reviews the data from the ERA 223 trial that was recently reported at ESMO 2018 and discuss lessons learned, including the optimal use of radium 223 in patients with endocrine resistant prostate cancer.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Phillip J. Koo presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Steven E. Finklestein, MD, presented “Emerging Indications for a Novel Absorbable Hydrogel Spacer: A 2018 Review” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Finklestein, Steven E. “Emerging Indications for a Novel Absorbable Hydrogel Spacer: A 2018 Review” November 9, 2018. Accessed [date today]. https://grandroundsinurology.com/emerging-indications-for-a-novel-absorbable-hydrogel-spacer-a-2018-review/

Emerging Indications for a Novel Absorbable Hydrogel Spacer: A 2018 Review – Summary:

Steven E. Finkelstein, MD, FACRO, describes how hydrogel spacing is becoming standard of care for prostate cancer radiotherapy. He reviews the clinical investigations of adjacent prostate indications, as well as indications in other organs throughout the body, for this technology.

Abstract:

Hypofractionated radiation therapy is standard of care for treating prostate cancer. However, at high doses, it results in gastrointestinal tract side effects. Due to proximity to the prostate, delivering a radiation dose to the rectum or the organ at risk (OAR) is inevitable unless prevented. A possible solution to this problem is the use of pegylated (PEG) SpaceOAR Hydrogel to create space between organs.

This not only significantly protects the rectum from radiation, but allows for administration of higher doses and the acceleration of treatment. Additionally, it provides an advantage by operating as a transperineal, not transrectal, injection.  

A pivotal definitive external beam radiation therapy (EBRT) study demonstrated that using SpaceOAR resulted in 74% less rectal radiation, 75% less late rectal toxicity, a creation of a 1.3 cm space, as well as long-term quality of life (QOL) benefits. No other randomized trial has identified such an improvement in erectile dysfunction and sexual QOL. Over 500 centers have utilized space OAR in over 27,000 procedures. Furthermore, it has emerging uses in all forms of prostate radiation. Current clinical trials, such as the NRG GU 005 and COMPPARE trials, allow the use of SpaceOAR in the same way as a rectal balloon.

Most exciting are the potential implications of this technology. The ongoing POTEN-C study investigates the sexual QOL of patients undergoing ultra-hypofractionation therapies. Currently, three studies are researching the effect of SpaceOAR with salvage post-prostatectomy. Also, a study from the Medical University of South Carolina described how SpaceOAR can aid prostatic cryoablation.

Hydrogel technology is rapidly becoming standard of care for prostate cancer radiotherapy and may have potential new indications to other organs throughout the body.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Finkelstein presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Erik P. Castle, MD, presented “Recent Advances for Renal Cell Carcinoma: A 2018 Review” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Castle, Erik P. “Recent Advances for Renal Cell Carcinoma: A 2018 Review” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/recent-advances-for-renal-cell-carcinoma-a-2018-review/

Recent Advances for Renal Cell Carcinoma: A 2018 Review – Summary: 

Erik P. Castle, MD, highlights recent advances in surgery, individualized medicines, and immunotherapies for patients with renal cell carcinoma (RCC). He reviews updates in genetic sequencing and CAR-T cell therapy, as well as developing role of cancer-associated macrophage-like cells (CAMLs), in these patients.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Castle presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Michael S. Cookson, MD, MMHC, presented “BCG Maintenance Should Be Less Intense” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Cookson, Michael S. “BCG Maintenance Should Be Less Intense” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/bcg-maintenance-should-be-less-intense-2/

BCG Maintenance Should Be Less Intense – Summary:

Michael S. Cookson, MD, MMHC, suggests that the primary evidence does not provide convincing evidence in favor of 3 years of bacillus Calmette-Guérin (BCG) maintenance for non-muscle-invasive bladder cancer (NMIBC). He also notes that long-term BCG often leads to toxicities, contributing to low patient compliance.

Abstract:

BCG has been the standard of care for high-risk NMIBC since 1976. Currently, most guidelines recommend BCG maintenance for 1-3 years. However, there are limitations to the evidence behind these guidelines, necessitating need for a reassessment of the use of maintenance.

Indirect comparisons from meta-analyses provide the basis for most recommendations for BCG maintenance. Furthermore, many randomized controlled trials (RCTs) found no direct evidence of benefit at all. These RCTs that looked at BCG maintenance also had serious limitations. They were mostly underpowered, lacked quality individual patient data with long-term follow-up, did not use enhanced imaging with blue-light cytoscopy or narrow-band imaging, and included patients who had experienced wide variations in the quality of transurethral resection. Similarly, these trials did not record important data, such as which patients received BCG retreatment for relapse after induction.

Of the 7 RCTs which compared induction BCG plus maintenance to induction alone, only 2 studies found significant differences in favor of maintenance. The SWOG (originally known as Southwest Oncology Group) maintenance study showed a reduction in disease progression with maintenance. However, the study defined progression as worsening-free survival, a broad, composite endpoint. 

Though not underpowered, this study featured many of the same issues as other BCG maintenance RCTs, and its methodology was not statistically sound.     

Long-term BCG maintenance leads to risk of toxicity and non-compliance. Around 50% of patients treated with BCG complain of side effects and. This toxicity then contributes to low compliance, as few patients complete the full recommended three years of maintenance. The optimal length of BCG maintenance remains unknown, but arguably, guidelines should recommend less intense treatment.        

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Cookson presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

E. David Crawford, MD, and Phillip J. Koo, MD, presented “Summarizing the RADAR Guidelines” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Crawford, E. David and Koo, Phillip J. “Summarizing the RADAR Guidelines” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/summarizing-the-radar-guidelines/

Summarizing the RADAR Guidelines:

E. David Crawford, MD, reviews the findings and recommendations of the Radiographic Assessments for Detection of Advanced Recurrence (RADAR) I and II working groups. Phillip J. Koo, MD, then discusses the rationale for RADAR III and the expansion in recommendations from the first two iterations, focusing on updates regarding next generation imaging.

Abstract:

RADAR I, published in 2014, addressed a lack of consensus among imaging guidelines for metastatic disease in prostate cancer. As a result of these inconsistencies, there was significant underdiagnosis of metastatic disease. The group of experts reviewed the guidelines available at the time and presented their own recommendations defining optimal strategies for early identification of metastases in patients with prostate cancer.

The RADAR II group coined the term “therapeutic layering” in their review, published in 2017. Their goal was to provide consensus and guidance on the sequencing and combination of approved treatments for metastatic castration resistant prostate cancer (CRPC).

Building from the first two iterations of the RADAR working group, RADAR III aimed to understand the potential use of next generation imaging (NGI) modalities in the initial staging of prostate cancer, as well as in biochemically recurrent, nonmetastatic or metastatic prostate cancer, and CRPC patients. This presentation summarizes the expansions from RADAR I and II recommendations included in RADAR III.

Additional objectives of RADAR III involved the integration of results obtained into clinical decision-making algorithms, gauging the rapidity and ease of uptake of these modalities in different clinical practice settings across the country, as well as redefining existing terminology to better represent the changing landscape in these disease settings.

RADAR III discussed major radiopharmaceuticals such as fluciclovine, C-11 choline, and gallium 68 PSMA. The most mature and robust data evaluating these NGI tools has been in biochemical recurrent patients. Overall, the data favors these NGI agents as compared to conventional imaging methods. Therefore, the group’s strongest recommendation for use of NGI is in patients with biochemical recurrent prostate cancer.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Drs. Crawford and Koo presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

E. David Crawford, MD, presented “Navigating the M0 Space” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Crawford, E. David. “Navigating the M0 Space” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/navigating-the-m0-space/

Navigating the M0 Space Summary:

E. David Crawford, MD, reviews the historical developments in androgen deprivation therapy (ADT) for prostate cancer and the emergence of the non-metastatic castration-resistant, or M0, prostate cancer. He then describes future directions for treatment options for these patients with a focus on androgen pathway inhibitors.

Abstract:

The concept of androgen deprivation therapy (ADT) to control prostate cancer goes back to the 1780s. At that time, the surgeon John Hunter established the relationship between castration and the size of the prostate gland. Since then, there have been historical developments in ADT. Major developments include the advent of luteinizing hormone-releasing hormone (LHRH) agonists in the 1970s, antiandrogens in 1995, and finally third-generation antiandrogens in recent years.

However, there are significant quality of life and medical issues, notably cardiovascular adverse events, associated with ADT. In addition to these issues, ADT had played a role in the development of a new challenge facing physicians.

Perhaps due to the use of ADT in cases of biochemical failure, an iatrogenic space called non-metastatic castration-resistant prostate cancer (nmCRPC), or M0 disease, has emerged. The definition of M0 disease is the presence of biochemical progression with no radiographic progression despite castrate levels of testosterone.

Treating these patients, with the goals of prolonging life, preventing pain and complications, as well as preserving quality of life and performance status, can be a challenge for physicians to navigate. The American Urological Association (AUA) has published guidelines for clinical decision-making in CRPC. Also, research shows prostate-specific antigen doubling time (PSDAT) can help physicians risk-stratify patients with nmCRPC, as well as predict bone metastasis and death. However, there are still many unanswered questions in this space.

In the future, androgen pathway inhibitors could address this unmet need. This presentation reviews the mechanisms, major trials evaluating, and reported adverse events of abiraterone acetate, enzalutamide, and apalutamide in patients with M0 disease. Antiandrogen monotherapy without ADT might be an optimal treatment method. However, there is much research still needed on ADT and M0 space.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Crawford presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Michael S. Cookson, MD, MMHC, presented “Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Con Argument” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Cookson, Michael S. “Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Con Argument” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/mri-in-the-enhanced-detection-of-prostate-cancer-what-urologists-need-to-know/

Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Con Argument – Summary:

Michael S. Cookson, MD, MMHC, argues that neoadjuvant chemotherapy (NAC) is not appropriate or necessary for all patients with muscle invasive bladder cancer (MIBC) prior to cystectomy. Instead, physicians should use a selective approach to NAC to avoid unnecessary harms, toxicities, and delays in local therapy.

This presentation is the “con” or negative installment of a debate over the use of neoadjuvant chemotherapy prior to cystectomy for MIBC. The rebuttal to this argument is  “Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Pro Argument” by Daniel P. Petrylak, MD.

Abstract:

Level 1 evidence from the SWOG 87-10 trial does demonstrate improved survival with NAC in patients with MIBC undergoing cystectomy. The most dramatic improvement in this study was in patients with locally advanced disease.

However, there is no proven benefit to non-cisplatin based NAC in bladder cancer. This means patients who are ineligible, for reasons such as poor performance status, impaired renal function, or comorbidities, or may not tolerate cisplatin must proceed to cystectomy or seek a clinical trial. Physicians must carefully screen patients for cisplatin eligibility based on consensus factors such as glomerular filtration rate (GFR) and Eastern Cooperative Oncology Group (ECOG) Performance Status.

Currently, European Association of Urology (EAU) guidelines recommend platinum-based NAC for invasive tumors. However, they recommend against NAC when there is a contraindication, and to discontinue NAC in cases of progression.

Another drawback of NAC is that not all tumors will respond, as certain molecular subtypes resist platinum altogether, and patients with “secondary,” as opposed to “primary,” MIBC have lower response rates. Furthermore, up to a third of patients undergoing NAC will have Grade 3 and 4 toxicity.

For these reasons, a selective approach to identify patients who will do well with radical cystectomy alone and those who will benefit from NAC is essential. A group from MD Anderson Cancer Center has reported on refining this patient selection process based on clinical risk-factors.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Cookson presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Daniel P. Petrylak, MD, presented “Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Pro Argument” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Petrylak, Daniel P. “Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Pro Argument” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/debate-neoadjuvant-chemotherapy-prior-to-cystectomy-pro-argument/

Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Pro Argument – Summary:

Daniel P. Petrylak, MD, argues the advantages of using neoadjuvant chemotherapy prior to cystectomy to treat patients with muscle invasive bladder cancer (MIBC). He reviews evidence including  the SWOG 87-10 trial and a meta-analysis to support this stance.

This presentation is the “pro” or positive installment of a debate over the use of neoadjuvant chemotherapy prior to cystectomy for MIBC. The rebuttal to this argument is  “Debate: Neoadjuvant Chemotherapy Prior to Cystectomy | Con Argument” by Michael S. Cookson, MD, MMHC.

Evidence of Pro Stance: SWOG 87-10

Data from the SWOG 87-10 trial provides some evidence supporting the use of neoadjuvant chemotherapy prior to cystectomy in MIBC. The SWOG 87-10 trial is the first in this context to demonstrate a survival advantage in favor of chemotherapy. However, the regimen given in the SWOG 87-10 trial was relatively toxic. The rate of cytopenia was fairly high, but there were no reported toxic deaths related to chemotherapy. Also, regarding patients with more advanced disease, administering chemotherapy later on becomes difficult. Comparing post-cystectomy complications between the cystectomy alone arm and chemotherapy prior to cystectomy arm, there were no differences in hemorrhage, embolisms, edema, infection, and genitourinary events. These results support the safety of neoadjuvant chemotherapy.  

The trial showed a 74-month median survival for patients receiving chemotherapy compared to the control arm, which  had a 43.2-month median survival. Notably, neoadjuvant chemotherapy showed a survival benefit across all grades and stages, with the greatest observed benefit being in T3 disease.

Clinical Evidence to the Benefits of Neoadjuvant Chemotherapy

Corroborating these results, a meta-analysis of trials comparing neoadjuvant chemotherapy plus local treatment against the same local treatment alone showed results all generally favored neoadjuvant treatment.

New regimens of neoadjuvant chemotherapy are under investigation. For instance, data on a new dose-dense methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) neoadjuvant chemotherapy regimen is promising. The National Comprehensive Cancer Network (NCCN) has accepted this regimen as a frontline therapy. Additionally, a study comparing MVAC, the mainstay of treatment in this setting, with gemcitabine and cisplatin (GC), showed no difference in overall outcomes between the two arms. As a result, the NCCN now accepts GC as an alternative regimen.

Neoadjuvant chemotherapy has a potential bladder-sparing benefit, however, there is controversy surrounding this possibility. Studies by Herr and Sternberg show about three-quarters of patients survive following bladder-sparing surgery,about half with their bladder intact, and that salvage chemotherapy is an option for these patients.

Arguably, neoadjuvant chemotherapy remains a superior option to adjuvant chemotherapy, as there is no study to date showing a proven survival benefit with adjuvant chemotherapy. While adjuvant chemotherapy allows for the selection of high-risk patients and avoidance of overtreatment, it does not allow for the option of bladder preservation, and may come with a burden of increased toxicity.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Petrylak presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Daniel P. Petrylak, MD, presented “Checkpoint Inhibitors for NMIBC” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Petrylak, Daniel P. “Checkpoint Inhibitors for NMIBC” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/checkpoint-inhibitors-for-nmibc/

Checkpoint Inhibitors for NMIBC – Summary:

Daniel P. Petrylak, MD, provides an overview of immunotherapy treatment options for non-muscle invasive bladder cancer (NMIBC) including BCG, intravesical therapies, and checkpoint inhibitors. He also discusses clinical trials investigating alternative immunotherapy options for NMIBC other than BCG.

Overview of NMIBC Treatment

Non-muscle invasive bladder cancer (NMIBC) encompasses about 75-85% of bladder cases. Unfortunately, it is an expensive disease to treat due to the long term management needed. However, a main goal for physicians treating NMIBC is to avoid cystectomy. Avoiding cystectomy improves patient quality of life and averts large healthcare costs. Unfortunately, radical cystectomy is the standard of care treatment for BCG refractory, high-grade NMIBC.

Nevertheless, there are other agents, including new immunology-based therapies, in development and undergoing clinical trials for NMIBC. Other options in this setting include Intravesical therapies, such as chemotherapies, vaccines, and viruses. Additionally, the Southwest Urology Group (SWOG) is investigating a different form of BCG: Tokyo-172 strain BCG. The shortage of BCG largely influenced this investigation. SWOG is also evaluating T-cell priming in BCG-naive, high-grade NMIBC (SWOG 1602).

Checkpoint Inhibitors for NMIBC

Checkpoint inhibitors have activity in a variety of different cancers, such as lung and bladder cancer. Generally, cancer types with high mutational rates respond well to checkpoint inhibition. Pembrolizumab and atezolizumab are checkpoint inhibitors with FDA-approval for first-line therapy in cisplatin-ineligible metastatic urothelial carcinoma (mUC).

For NMIBC, patients who are BCG-resistant may have upregulation of PD-1. In the KEYNOTE-057 study, NMIBC patients who failed BCG received pembrolizumab every 3 weeks. The results of the study showed that almost 40% of patients with pembrolizumab had a complete tumor response. Also, no patients progressed from T2 disease in the group treated with pembrolizumab, and only 8.7% of patients had stage progression.

Other trials, as seen in the table to the left, are investigating checkpoint inhibitors in BCG-resistant, as well as BCG-naive, patients. The BCG-naive studies are focusing on combining checkpoint inhibitors with BCG.

Overall, high mutational load makes NMIBC an ideal target for immunotherapy. BCG immunotherapy is the standard of care for NMIBC. There is limited utility of chemotherapy for NMIBC, but there are clinical trials assessing the role of checkpoint inhibitors in NMIBC.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Petrylak presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Raoul S. Concepcion, MD, FACS, presented “Upper Tract Urothelial Cancer: What You Need to Know” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Concepcion, Raoul S. “Upper Tract Urothelial Cancer: What You Need to Know” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/upper-tract-urothelial-cancer-what-you-need-to-know/

Upper Tract Urothelial Cancer: What You Need to Know –
Summary:

Raoul S. Concepcion, MD, FACS, provides an overview of the epidemiology of upper tract urothelial carcinoma (UTUC). He discusses the most recent efforts in improving management for the disease, particularly focusing on neoadjuvant chemotherapy when treating high-grade tumors and nonsurgical ways to combat low-grade UTUC.   

Abstract:

UTUC is an orphan disease with morphologic similarities to the far more common urothelial cancer of the bladder (UCB). However, UTUC is phenotypically and genotypically quite different. It is more likely for UTUC to exhibit microsatellite instability and hypermethylation and present as a high-grade tumor than UCB. Also, there can be diagnostic difficulties with UTUC. Even with the advent of flexible ureteroscopy, imaging UTUC presents challenges. Since recent research suggests as many as 21% of UTUCs may be associated with Lynch syndrome, it is important to consider family histories in patients suspected of having UTUC.

The primary treatment for high-grade UTUC with nephroureterectomy with a cuff of bladder. Without removing the entire orifice, the chance of recurrence rate in the ureteral stump is between 20% and 30%. However, there is mounting evidence supporting the use of neoadjuvant chemotherapy in UTUC patients. For instance, a recent, small study showed a five-year overall survival benefit with neoadjuvant chemotherapy. Contrarily, a larger study suggests that, while neoadjuvant chemotherapy may result in greater downstaging and less lymphovascular invasion, it has no notable impact on overall survival.

There have also been recent efforts to find nonsurgical methods to treat low-grade UTUC. While endoscopic resection/ablation is an acceptable method for managing low-grade UTUC, this can lead to technical difficulties and high recurrence rates require repetitive intervention. Nephroureterectomy may be overtreatment in this setting.

The phase III OLYMPUS trial is investigating chemically ablating UTUC with UGN-101, a gel that solubilizes in the urinary tract, resulting in a release of mitomycin. Because so few people have low-grade UTUC, finding enough participants for the trial has been difficult, but so far the data is promising.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Concepcion presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Alan H. Bryce MD, presented “Adjuvant Therapy in High Risk Renal Cell Carcinoma” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Bryce, Alan H. “Adjuvant Therapy in High Risk Renal Cell Carcinoma” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/adjuvant-therapy-in-high-risk-renal-cell-carcinoma/

Adjuvant Therapy in High Risk Renal Cell Carcinoma Summary:

Alan H. Bryce, MD, surveys data from three phase III trials on adjuvant therapies for high-risk renal cell carcinoma. He discusses the controversies following the conclusions of the completed trials and emphasizes the need for research in further adjuvant therapies beyond those that target the VEGF pathway.

The Need for Adjuvant Therapies in Renal Cell Carcinoma  

About 15%-20% of renal cell carcinoma (RCC) patients present with high-risk locoregional disease. This carries a poor 5-year overall survival (OS) rate for Stage III disease, at around 50%-60%. Subsequently, there is a motivation to improve treatments for these patients. In the metastatic RCC setting, the FDA has approved a variety of agents since 1992. Also, anti-vascular endothelial growth factor (VEGF) tyrosine-kinase inhibitors (TKIs) have proven to provide OS benefit in metastatic disease. Because of this, there is interest in moving these agents forward to the adjuvant setting.

Completed Trials for Adjuvant Therapies

Of the approved agents for metastatic RCC, phase III trials have reported on sunitinib, sorafenib, and pazopanib.

The ASSURE trial randomized patients to sunitinib, sorafenib, or placebo and showed no difference in progression-free survival (PFS) between the three arms. Contrastly, the S-TRAC trial investigated sunitinib against placebo and showed a clinically-significant PFS benefit to sunitinib. A meta-analysis of this data demonstrated that sunitinib resulted in significant toxicities, and therefore inferior quality of life outcomes for patients.

This meta-analysis also noted four treatment-related deaths. The discrepancies in trial designs between ASSURE And S-TRAC substantiated reasoning that the differing results could be due to the idea that sunitinib could be effective in high-risk patients, but inappropriate for low-risk patients. However, an unplanned subset analysis of ASSURE evaluated sunitinib in high-risk patients and still found no significant benefit.

The PROTECT Trial looked at pazopanib in the adjuvant setting. During this study, the side-effects of treatment led to massive participant attrition. In response, the investigators readjusted the trial from an 800mg dose to a 600mg dose. Ultimately, the trial concluded that the toxicity of pazopanib at full dose was difficult for patients to tolerate in the adjuvant setting, and the 600mg dose showed no disease-free survival (DFS) or OS benefit.

Future Directions

While sunitinib is the only agent with FDA approval for high-risk adjuvant RCC, adoption amongst oncologists is low. When deciding whether or not to recommend sunitinib in this setting, a 12-member Oncologic Drugs Advisory Committee (ODAC) panel split 6-6 on the issue. There are ongoing studies into additional adjuvant therapies, namely everolimus, an MTOR inhibitor, as well as a nivolumab plus ipilimumab combination, pembrolizumab, and atezolizumab. Future research about better adjuvant therapies should continue, especially those which do not target the VEGF pathway, focusing on a goal to cure.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Bryce presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

John C. Chang, MD, PhD, presented “Can MR Imaging Help Triage Bladder Cancer Patients?” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Chang, John C. “Can MR Imaging Help Triage Bladder Cancer Patients?” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/can-mr-imaging-help-triage-bladder-cancer-patients/

Can MR Imaging Help Triage Bladder Cancer Patients? – Summary: 

John C. Chang, MD, PhD, examines the potential of  MRI for staging bladder cancer, emphasizing MRI’s facility in differentiating between muscle invasive and non-muscle invasive bladder cancer (NMIBC). He also acknowledges that MRI scanning can lead to overstaging, and that CT can be effective for detecting higher stages of bladder cancer.   

Abstract:

While CT scanning is the standard technique for staging bladder cancer, MRI scans can help to better triage bladder cancer patients. Muscle-invasive bladder cancer (MIBC) and NMIBC require different treatment approaches. Therefore, physicians must be able to distinguish if cancers have invaded deeper layers of the bladder and become muscle-invasive. Unfortunately, tumors and muscles have a similar density, making it difficult for physicians to differentiate between them on a CT scan. However, MRI scanning generates different forms of contrast from CT scanning. MRI scanning allows for 85% accuracy in differentiating MIBC from NMIBC, and 82% accuracy in differentiating organ-confined from non-organ-confined bladder cancer. Physicians can add a diffusion sequence to detect water movement for even greater accuracy. MRI scanning may also be better than CT at detecting very small lesions.

There are limits to MRI’s facility in staging bladder cancer. Physicians tend to overstage disease when using MRI scanning. Also, from a practical standpoint, MRI scans are very sensitive to movement. If a patient struggles to keep still, it is better for a physician to rely on CT scans.

CT scanning is a good method for detecting bladder cancer, with 85% sensitivity and 94% specificity. However, CT does not provide the contrast needed to easily differentiate between MIBC and NMIBC, and it can be hard to spot small lesions on CT scans. The different kinds of contrast MRI scanning provides can help physicians fill in the gaps that CT leaves, and can therefore be a helpful additional tool.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Chang presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Raoul S. Concepcion, MD, FACS, presented “AR-V7 Predicts Response in CRPC” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Concepcion, Raoul S. “AR-V7 Predicts Response in CRPC” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/adjuvant-therapy-in-high-risk-renal-cell-carcinoma/

AR-V7 Predicts Response in CRPC Summary:

Raoul S. Concepcion, MD, FACS, emphasizes the need for more effective biomarkers when determining adequate treatment for patients with castrate-resistant prostate cancer (CRPC). Concurrently, he compares the findings of studies exploring various options, including the AR-V7 splice variant.

Abstract:

Physicians have developed myriad new drugs to treat prostate cancer during the past few decades. Unfortunately, many patients with CRPC have become resistant to one or more therapies, limiting their treatment options. This presentation reviews the scientific concepts behind this, as well as how using biomarkers to test for DNA mutations could provide new treatment options.

With the increased development of resistance in patients with CRPC, physicians must understand the androgen receptor (AR) and its functions. It is important to understand the development of resistance mechanisms, as some are AR-dependent and some are not.

This presentation reviews current agents with overall survival benefits in metastatic CRPC. The E3805 CHAARTED trial showed that androgen deprivation therapy (ADT) is more effective in combination with medication, although patients with high-volume disease differ from those with low-volume disease. Additionally, the discussion covers potential heterogeneity-induced resistance to treatment. This includes genetic alterations to drug targets, expression of multidrug resistance pumps, and evasion of apoptosis.

Lastly, this presentation discusses recent findings regarding inherited mutations in DNA-repair genes, and their associated risks. A 2016 study found that 12% of prostate cancer deaths coincide with germline alterations in DNA repair genes. A 2014 study of the AR-V7 variant showed that AR inhibitors and AR blockers are ineffective for patients with this mutation. Patients with CRPC demonstrate increased expression of this variant. This means physicians can use circulating tumor cells as a predictive biomarker during testing.

As new drugs for treating CRPC become available, testing for resistance to these drugs and alternative treatment options increase in importance. Ongoing research involving predictive biomarkers will allow physicians to make more informed decisions about how and when to treat patients with CRPC.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Concepcion presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

John C. Chang, MD, PhD, presented “MR Guided Biopsy” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Chang, John C. “MR Guided Biopsy” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/mr-guided-biopsy/

MR Guided Biopsy – Summary:

John C. Chang, MD, PhD, compares advantages and disadvantages of MRI-guided biopsy and transrectal ultrasound-guided (TRUS) biopsy. He emphasizes MRI-guided biopsy’s detection rates and its effectiveness in patients undergoing repeat biopsies, while acknowledging its relative inefficiency and limitations in low grade cancers.   

Abstract:

While transrectal ultrasound guided (TRUS) biopsy is the standard procedure for detecting prostate cancer, MRI-guided biopsy produces superior results. The PROMIS trial shows that MRI-guided biopsy is far more sensitive than TRUS biopsy. The former demonstrating around 88% sensitivity compared with the latter’s 48%. In addition to having greater sensitivity, MRI-guided biopsy better performs in detecting cancers in the anterior prostate.

MRI-guided biopsy particularly increases yield in patients undergoing repeat biopsies. With TRUS, the positive rate tends to be lower than 20%, but with MRI-guided biopsy, the yield increases to 30-40%. Therefore, the American Urological Association (AUA) and the Society of Abdominal Radiology (SAR) recommend that patients who have had prior negative TRUS biopsies undergo high-quality multiparametric-MRI.

However, MRI-guided biopsy is far from perfect. It misses most Gleason Score 6 cancers and some Gleason Score 7 cancers. A recent study shows equivalence between MRI-guided biopsy and systematic TRUS with a sampling of ultrasound-visible lesions. TRUS also has the advantage of being a standard and convenient procedure, whereas MRI-guided biopsy techniques can be time-consuming, labor-intensive, and more painful for patients.

Certain targeted MR/ultrasound fusion systems, such as Invivo’s transrectal MRI biopsy system, may offer a solution to reconciling the pros and cons of each technique.

Overall, MRI-guided biopsy allows doctors to be precise in finding and targeting small lesions that are difficult to discover with TRUS. There may be limitations to MRI-guided biopsy, but the benefits to patients make it worthwhile.       

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Chang presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Michael S. Cookson, MD, MMHC, presented “MRI in the Enhanced Detection of Prostate Cancer: What Urologists Need to Know” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Cookson, Michael S. “MRI in the Enhanced Detection of Prostate Cancer: What Urologists Need to Know” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/mri-in-the-enhanced-detection-of-prostate-cancer-what-urologists-need-to-know/

MRI in the Enhanced Detection of Prostate Cancer: What Urologists Need to Know – Summary:

Michael S. Cookson, MD, discusses prostate MRI as an upfront assessment for targeting lesions in biopsy naive patients and the conclusion from PROMIS and PRECISION regarding this application. He also reviews the potential applications of MRI in patients with prior negative biopsy and in those on active surveillance.

Abstract:

Biopsies ordered initially for patients presenting with an elevated PSA are often negative, and transrectal ultrasound (TRUS) biopsies often miss significant cancers. However, a 2017 American Urological Association (AUA) policy statement clearly acknowledges that MRI-guided biopsy and MRI-targeting reduces these failures. Even so, this statement did not recommend routine MRI for every biopsy naive patient due to insufficient evidence.  

Since then, the PROMIS and PRECISION trials have reported data that is favorable to this application of MRI. In the PROMIS trial, MRI-targeting demonstrated an improved rate of significant cancer detection and a reduction in overdiagnosis of insignificant cancers compared to standard 12-core TRUS biopsy. The PRECISION trial, testing non-inferiority of MRI-targeting to TRUS biopsy, found similar results. Notably, 28% of men in this study avoided biopsy because of negative results on MRI.

Many societies have changed their guidelines in the post-PROMIS and -PRECISION era. For example, the National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer early detection now include consideration of MRI for evaluation before biopsy.

Additionally, there is a rationale for utilizing MRI following prior negative biopsy. As an AUA initiative states, “While blood, urine and tissue based biomarkers may improve patient selection for repeat biopsy, they do not help to improve the diagnostic yield of the biopsy itself. Only imaging has the potential to both improve patient selection and the yield of repeat biopsy.”

MRI could also be a noninvasive monitoring technique for patients on active surveillance. Although there is not yet high-level evidence for this application, it demonstrates favorable detection rates in small cohort studies. The AUA policy statement maintains MRI for active surveillance could be beneficial, but evidence is insufficient for a full endorsement.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Cookson presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Erik P. Castle, MD, presented “It is Not Time to Abandon Transrectal Prostate Biopsy for Perineal Biopsy” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Castle, Erik P. “It is Not Time to Abandon Transrectal Prostate Biopsy for Perineal Biopsy” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/it-is-not-time-to-abandon-transrectal-prostate-biopsy-for-perineal-biopsy/

It is Not Time to Abandon Transrectal Prostate Biopsy for Perineal Biopsy – Summary:

Erik P. Castle, MD, argues that while urologists should consider increasing the application of transperineal biopsy, the abandonment of transrectal biopsy is unlikely due to cost and convenience. He sites risk of infections, type of anesthesia, guided imaging modalities, as well as practical considerations to support this case.

Abstract:

It would be difficult to win a debate arguing that transrectal prostate biopsy is the best available biopsy technique. While cancer detection rates prove to be roughly equal between the transperineal and transrectal approaches, transperineal more effectively identifies anterior tumors. Transperineal biopsy is also clearly superior in minimizing risk of biopsy-related sepsis. However, one can make a compelling argument that the urologic community is not ready to abandon transrectal biopsy altogether.

Cost and convenience, for both the patient and physician, are two major barriers to adopting transperineal biopsy in clinical practice.

Type of anesthesia, number of cores taken, and image-guiding modality factor into the cost of each biopsy. The cost of a transrectal procedure is generally less expensive that transperineal. Most transperineal biopsies require general anesthesia and an operating room, while a patient must only undergo local anesthesia for transrectal. The logistics of performing a transrectal biopsy work better that coordinating the technological and practical aspects of transperineal in the scheme of a patient’s care. Moreover, while transrectal infamously carries the burden of significant infection risk, transperineal does lead to complications, mainly urinary retention.

It is also important to note that the debate is not always whether transrectal or transperineal is the better technique. In some cases, urologists should tailor the choice of technique based on patient’s risk of either infection or retention. Overall, though urologists should consider the increased application of transperineal biopsy, the complete abandonment of transrectal biopsy is not likely.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Castle presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

J. Kellogg Parsons, MD, MHS, FACS, presented “It is Time to Abandon Transrectal Prostate Biopsy for Perineal Biopsy” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Parsons, J. Kellogg. “It is Time to Abandon Transrectal Prostate Biopsy for Perineal Biopsy” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/it-is-time-to-abandon-transrectal-prostate-biopsy-for-perineal-biopsy/

It is Time to Abandon Transrectal Prostate Biopsy for Perineal Biopsy – Summary:

J. Kellogg Parsons, MD, MHS, FACS, discusses rising concerns of sepsis following transrectal ultrasound (TRUS) prostate biopsy. He then reviews the literature proving a reduction of infection-based complications with transperineal biopsy and argues for the transperineal approach superseding TRUS in clinical practice.

Abstract:

As an illustration of overall opinions regarding the TRUS versus transperineal prostate biopsy debate, the Prostate Cancer and Prostatic Diseases journal conducted a Twitter poll. The poll asked an audience of practicing urologists, “What would be your choice if you had to undergo prostate biopsy?” Out of 379 participants, 58% said they would prefer the transperineal technique.

Sepsis following prostate needle biopsy is a growing concern in the urologic community. A population-based study of hospital admission rates for complications following TRUS in Ontario, Canada showed a 4-fold increase in infection-based complications from 1996 to 2005. An analysis from New York State showed a significant increase in infectious complications after prostate needle biopsy from 2011 to 2014.

The press and consumer reports further reflect these concerns. An article in Medscape argued for a shift from TRUS biopsy to a transperineal approach, coining the term “transfecal” biopsy. An Australian publication similarly reported on the dangers of sepsis due to TRUS biopsy.

Because of these growing concerns, it is essential that the urologic community evolve from the unsustainable TRUS technique and consider better options. Out of the methods recommended in the American Urological Association (AUA) white paper on preventing and treating prostate biopsy complications, the transperineal approach proves to be the most suitable option. Moreover, the transperineal approach provides a much better angle for accessing the prostate than TRUS biopsy does.

Resistance to transperineal biopsy stems from the assumption that transperineal biopsy is relatively complex and expensive. There is also an assumption that this approach requires general anesthesia. However, a group led by Michael A. Gorin, MD, has designed a transperineal application that can attach to a TRUS device. Innovations like this, as well as MRI technologies for needle guidance, may mitigate the complexity of transperineal biopsy in the future.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Parsons presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Phillip J. Koo, MD, presented “Fluciclovine 18F PET-CT Impact on Clinical Management of Recurrent Prostate Cancer” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Koo, Phillip J. “Fluciclovine 18F PET-CT Impact on Clinical Management of Recurrent Prostate Cancer” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/fluciclovine-18f0-pet-ct-impact-on-clinical-management-of-recurrent-prostate-cancer/

Fluciclovine 18F PET-CT Impact on Clinical Management of Recurrent Prostate Cancer Summary:

Phillip J. Koo, MD, discusses conventional prostate cancer imaging techniques and the need for advanced imaging techniques in order to better detect recurrent disease. He then argues that fluciclovine (18F) positron emission tomography/computed tomography (PET/CT) could satisfy this unmet need.

Abstract:

Prostate cancer typically recurs in 40%-50% of patients after initial treatment. In order to effectively manage recurrent prostate cancer, it is essential to have accurate, reproducible, validated, accessible, and cost-effective imaging modalities. Imaging helps guide prostate cancer management, since the presence, volume, and distribution of disease have implications for therapeutic choices. Evidence shows that conventional imaging techniques that emerged in the 1970s, including bone scans, CT, and MRI, have limited sensitivity and specificity for detecting recurrence. Therefore, a demand in the urological community for optimized imaging modalities has emerged over the last decade. Fortunately, next generation PET/CT imaging may allow for detection of metastases that conventional imaging cannot detect.

The rationale behind PET/CT imaging is that many positron-emitting isotopes can target certain prostate cancer-specific membranes, proteins, and receptors. This presentation focuses on the molecular imaging agent fluciclovine (18F), an amino acid analog that detects increased cellular metabolism. The FDA approved this agent in 2016 for PET/CT imaging in men with suspected prostate cancer recurrence. 

This has significant ramifications for the management of recurrent prostate cancer, as the 18F isotope has a half life of about two hours, allowing for widespread accessibility.

The discussion will review the two registrational studies for fluciclovine (18F) that led to its FDA approval, the LOCATE trial, as well as the RADAR III expert consensus. It will also comment on commercial coverage issues for this agent.

Following his presentation, Dr. Koo responds to questions from Daniel P. Petrylak, MD, Raoul S. Concepcion, MD, and Steven E. Finkelstein, MD.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Koo presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Steven E. Finkelstein, MD, presented “Next Generation Updates in Radiation Oncology” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Finkelstein, Steven E. “Next Generation Updates in Radiation Oncology” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/next-generation-updates-in-radiation-oncology/

Next Generation Updates in Radiation Oncology Summary:

Steven E. Finkelstein, MD, discusses radiobiologic concepts of different fractionation schedules for prostate cancer. He also reviews a 2018 guideline for hypofractionated external beam radiotherapy (EBRT) to treat localized prostate cancer, and its ramifications for the future of radiation oncology.

Abstract:

Although conventional wisdom dictates that the α/β ratio for prostate cancer is 10 and that optimal delivery should occur over 6 ½ to 9 weeks, there is no evidence to prove this is so. This uncertainty leads to the question: can fewer fractions of a higher dose generate better or equivalent cancer control with fewer complications, greater convenience, better patient acceptance, and a lower cost when compared to conventional fractionation?

To respond to this question, in 2018, the American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), and American Urological Association (AUA) created an evidence-based guideline on hypofractionated EBRT in localized prostate cancer. These recommendations apply to patients who require or prefer treatment instead of surveillance and have opted for EBRT.

This presentation provides commentary on this guideline’s recommendations regarding moderate hypofractionation and ultrahypofractionation, or stereotactic body radiation therapy (SBRT). The discussion will cover patient selection, suggested regimens, randomized trials, and cancer control and toxicity data for both techniques.

Of note, clinician technical expertise and radiation delivery planning are particularly important when performing SBRT. While the conventional method of delivering 45 treatments over 9 weeks allows for a margin of error in regards to hitting the target, a method limited to 5 treatments requires precise delivery. Therefore, the expert panel universally recommends image-guided radiation therapy and avoidance of non-modulated conformal techniques for SBRT.

In regards to the future of radiation oncology for prostate cancer, one should anticipate reactions to these guidelines. There is also a possibility for the emergence of a synergistic combination of radiation and immunotherapy.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Finkelstein presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Timothy C. Brand, MD, FACS, presented “There is a Role for Currently Available Biomarkers: Genomics in the Risk Stratification of Prostate Cancer” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Brand, Timothy C. “There is a Role for Currently Available Biomarkers: Genomics in the Risk Stratification of Prostate Cancer” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/there-is-a-role-for-currently-available-biomarkers-genomics-in-the-risk-stratification-of-prostate-cancer/

There is a Role for Currently Available Biomarkers: Genomics in the Risk Stratification of Prostate Cancer – Summary:

Timothy C. Brand, MD, FACS, argues that biomarkers and genomics have a role in the clinical decision-making process for individual patients with low- and favorable intermediate-risk prostate cancer. He also reviews the literature validating the risk stratification utility of recommended biomarkers.

This presentation is part of a Point-Counterpoint debate. Watch the rebuttal: “Biomarkers in Localized Prostate Cancer: Sure You Can, But Why Would You?” by Alan H. Bryce MD.

Abstract:

Risk stratification is essential when treating prostate cancer, primarily because it equips clinicians to determine if a patient should continue active surveillance or treatment. Additionally, risk stratification helps to guide decisions regarding node dissections, neoadjuvant hormone therapy, and adjuvant radiotherapy.

Without biomarkers or genomics, clinicians have the patient’s PSA level, prostate exam results, Gleason score, percent of cores positive, and a variety of nomograms at their disposal for risk-stratifying patients. However, biomarkers can help reduce clinical indecisiveness in complex cases of low- and favorable intermediate-risk prostate cancer.

For patients in this risk category whose life expectancy is 10 years or longer, the National Comprehensive Cancer Network (NCCN) guidelines recommend considering molecular testing the tumor. The NCCN lists four options for biomarkers in this space, namely Oncotype DX, Prolaris, Decipher, and Promark.

This presentation reviews validation and clinical utility studies for these biomarkers. Overall, the data shows these biomarkers add predictive value to other risk assessment tools and relatively increase active surveillance candidates.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Brand presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Alan H. Bryce MD, presented “Biomarkers in Localized Prostate Cancer: Sure You Can, But Why Would You?” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Bryce, Alan H. “Biomarkers in Localized Prostate Cancer: Sure You Can, But Why Would You?” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/biomarkers-in-localized-prostate-cancer-sure-you-can-but-why-would-you/

Biomarkers in Localized Prostate Cancer: Sure You Can, But Why Would You? Summary:

Alan H. Bryce, MD, discusses the role of biomarkers in clinical decision-making for localized prostate cancer. He argues that while currently available assays have demonstrated predictive ability, prospective data remains insufficient to determine whether or not they improve clinically meaningful endpoints.

This presentation is part of a Point-Counterpoint debate. Watch the rebuttal: “There is a Role for Currently Available Biomarkers: Genomics in the Risk Stratification of Prostate Cancer” by Timothy C. Brand, MD.

Abstract:

Decision-making in the management of localized prostate cancer remains complex. Patients and practitioners struggle with decisions regarding biopsy versus surveillance, surveillance versus treatment, and adjuvant radiation therapy versus ongoing observation. Clinical risk calculators have proven imperfect.

A variety of commercially available genomic testing platforms are currently available to help in the decision-making process. These assays have demonstrated ability to predict the risk of meaningful clinical outcomes, such as biochemical recurrence, time to metastasis, and overall survival.

However, none of these tests have been tested in randomized controlled trials. Therefore, it is unknown whether their use can lead to improvement in clinically meaningful endpoints. Tests of their utility have only proven a decrease in patient anxiety and changes in recommended treatment. Prospective data is necessary before guidelines can recommend these tests for routine clinical use. Combining the evaluation of other tumor-related features and patient characteristics with biomarker analysis is a more ideal decision-making approach. New diagnostic methods, such as advanced imaging, may have better applicability than biomarkers altogether in the modern era.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Bryce presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Sigrid V. Carlsson, MD, PhD, MPH, presented “Prostate Cancer and Early Detection: Should We Follow the NCCN Guidelines?” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Carlsson, Sigrid V. “Prostate Cancer and Early Detection: Should We Follow the NCCN Guidelines?” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/prostate-cancer-and-early-detection-should-we-follow-the-nccn-guidelines/

Prostate Cancer and Early Detection: Should We Follow the NCCN Guidelines? – Summary:

Sigrid V. Carlsson, MD, PhD, MPH, compares the National Comprehensive Cancer Network (NCCN) Prostate Cancer Early Detection v2.2018 guidelines to Memorial Sloan Kettering Cancer Center (MSKCC) recommendations for prostate cancer screening in terms of optimizing oncological benefits and reducing negative effects on quality of life.

This presentation is part of a Point-Counterpoint debate coupled with “Prostate Cancer Screening: The NCCN Perspective” by J. Kellogg Parsons, MD, MHS, FACS.

Shifting the Balance of Prostate Cancer Screening Benefits and Harms

This presentation reviews components of the NCCN Prostate Cancer Early Detection v2.2018 guidelines. These components include baseline evaluation, screening tests, the ages at which to initiate and discontinue screening, frequency of screening, indications for biopsy, and pre-biopsy workup methods that incorporate clinical information, novel biomarkers, and imaging. It will compare the NCCN guidelines with the MSKCC recommendations for prostate cancer screening, which is similarly a risk-based algorithm.

The balance between benefits and harms of prostate-specific antigen (PSA) screening is entirely dependent on how one screens. While screening large populations does improve life years gained, it causes a reduction in quality-adjusted life years (QALYs). Following five straightforward “golden rules” can cause a shift toward a more favorable balance of these benefits and harms.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Carlsson presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

J. Kellogg Parsons, MD, MHS, FACS, presented “Prostate Cancer Screening: The NCCN Perspective” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Parsons, J. Kellogg. “Prostate Cancer Screening: The NCCN Perspective” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/prostate-cancer-screening-the-nccn-perspective/

Prostate Cancer Screening- The NCCN Perspective – Summary:

J. Kellogg Parsons, MD, discusses the role of the National Comprehensive Cancer Network (NCCN) Prostate Cancer Early Detection guidelines in the PSA screening debate. He then provides commentary on the three algorithms included in the guidelines.

This presentation is part of a Point-Counterpoint debate, coupled with “Prostate Cancer and Early Detection: Should We Follow the NCCN Guidelines?” by Sigrid V. Carlsson, MD, PhD, MPH.

The NCCN Prostate Cancer Early Detection Guidelines: A Middle Ground Between the USPSTF and the AUA

This presentation frames the development of the NCCN Prostate Cancer Early Detection guidelines through the context of the PSA screening debate exacerbated by the United States Preventive Services Task Force (USPSTF). In 2012, the USPSTF released their recommendation against PSA screening. In turn, the American Urological Association (AUA) responded to the USPSTF grading by arguing for screening large populations. The NCCN guidelines provide a practical middle ground in the polarized early detection debate.

The NCCN guidelines undergo annual updates and clearly note changes from prior versions for transparency. The society also makes great efforts to keep the guideline panelists free of conflicts-of-interest. It is essential to maintain the integrity of these guidelines, as Medicare and other payers use them to determine fee schedules.

The Prostate Cancer Early Detection guidelines include three practical, evidence-based algorithms designed for easy use in clinical practice. Each of these algorithms informs a different component of early detection and flows from one to the other in step-by-step order, from PSA screening, to indications for biopsy, and then to interpreting biopsy results.

This presentation reviews these three algorithms and provides commentary on relevant controversies, such as age-stratification for PSA screening and the introduction of MRI into the guidelines.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Parsons presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.

Alan H. Bryce MD, presented “Genetic Testing and Next Generation DNA Sequencing” during the 27th Annual Perspectives in Urology: Point Counterpoint on November 9, 2018 in Scottsdale, Arizona.

How to cite: Bryce, Alan H. “Genetic Testing and Next Generation DNA Sequencing” November 9, 2018. Accessed Oct 2026. https://grandroundsinurology.com/genetic-testing-and-next-generation-dna-sequencing/

Genetic Testing and Next Generation DNA Sequencing – Summary:

Alan H. Bryce, MD, explains the concept of synthetic lethality in the context of BRCA-deficient tumors, as well as resistance to poly (ADP-ribose) polymerase (PARP) inhibition. He also discusses the under-utilization of inherited cancer risk syndromes in prostate cancer practice, research, and guidelines, as well as new pathways for therapeutic targeting

Abstract:

Large-scale genome sequencing of prostate cancer has led to a rapid expansion in urology regarding the genetic drivers of disease. Evidence proves DNA damage response (DDR) genes to be frequently altered, both in germline and somatic testing. The rate of alterations increase as disease progresses from locoregional to metastatic non-castrate, and then from metastatic non-castrate to metastatic castration -resistant. New systemic therapies, such as PARP inhibitors, may better target DDR alterations in up to 25% of metastatic patients.

DDR mutations can also drive familial prostate cancer risk. However, screening continues to under-utilize DDR mutations. Current screening guidelines fail to capture a substantial portion of patients with high-risk genetics. Therefore, more widespread testing for germline mutations is necessary. A variety of other recently-identified, frequently altered genes have implications for immunotherapy, targeted therapy, and treatment sequencing. Because of this, future treatment paradigms will likely incorporate germline and somatic mutation data.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual CME-accredited conference devoted to discussing and debating the latest topics in men’s health, general urology, and genitourinary cancers. The conference’s format includes more than didactic lectures. It also includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Bryce presented this lecture during the 27th PCP in 2018. Please visit this page in order to register for future PCP meetings.