Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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...
How do you advise your kidney stone patients about optimal daily fluid intake?
Measuring urine is better than counting liters of intake and shoot for 2-3 liters/day. If they aren’t getting up most nights to urinate they probably aren’t drinking enough water. When they get tired of drinking and urinating I tell them to remember the pain associated with their stone.
What is your approach to the medical management of struvite kidney stones?
It is difficult to separate medical and surgical management of struvite stones, since these stones are typically the consequence of persistent or recurring infections. Surgically, risk factors for infection need to be addressed, which may include efforts to remove any retained stone material, follow...
What dietary advice do you provide your patients with calcium oxalate nephrolithiasis?
High water intake (at least 2.5L of urine volume per day) Low sodium and low animal protein intake (high dietary sodium and high animal protein correlate with higher urine calcium) Normal dietary calcium balance around 1000mg per day (maintain bone health and ensure adequate dietary calcium to bin...
Do you use 24 hour urine stone risk profiles for purposes other than managing nephrolithiasis?
In patients with enteric risk factors for hyperoxaluria and kidney disease without a clear cause or in those with confirmed calcium oxalate deposition on kidney biopsy (even in the absence of history of kidney stones), I check 24-hour urine supersaturation. The data helps guide treatment approach to...