Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How long would you hold clomiphene before checking baseline morning testosterone levels to evaluate the need for testosterone replacement therapy initiation?
The clomiphene challenge is to initiate therapy in men with secondary hypogonadism and trial a 3-6 month course to see their symptomatic and serologic response. If gonadotrophs and testosterone normalize and the patient feels symptomatic relief and has done something to address the root cause (weigh...
In light of the recent results from STAMPEDE and LATITUDE, to which patients with newly diagnosed metastatic prostate cancer are you offering up-front abiraterone vs. up-front docetaxel?
Although I anticipate that the Stampede investigators will publish (an underpowered) comparison of their ADT plus docetaxel arm vs ADT plus abiraterone which may provide some insight, for the most part we will be in a data free zone re: this issue for some time. I suspect that clinicians will contin...
What are treatment options for elderly patients with a remote history of cystoprostatectomy with neobladder who are no longer able to empty their neobladder fully, are unable to CIC, and are beginning to have complications such as infection and rising creatinine?
The recommended management of elderly patients with this history is dependent on several factors. The fact that they are unable to drain spontaneously and unable to perform CIC limits the options for drainage. With their creatinine rising, this also suggests that limiting the contact time of excrete...
What technique or tool do you use to remove mucinous, infection stones?
In the past, we have performed percutaneous nephrolithotomy to remove mucinous, infection stones. Using the Trilogy device through the nephoscope, to fragment and aspirate stones/mucus was quite successful. Although this is significantly more invasive than standard ureteroscopy, we had a much better...
How would you manage a patient with a history of prostate radiation who is presenting with LUTS and elevated PVR?
This can be a very difficult problem, because the risk of stressing continence following prostatic resection in the radiated patient is much higher than in the non-radiated patient. Following brachytherapy, stress incontinence can occur more than half the time, and following external beam radiation ...
How do you work up and manage patients with persistent cloudy and mucus-like urine, but no obvious cause on imaging or urinalysis?
Challenging, but it greatly depends on whether the patient is symptomatic or not. Few possible etiologies: Phosphaturia Vaginal discharge, bacterial vaginosis Sterile pyuria Sexually transmitted disease (STD) Genitourinary tuberculosis (TB) If it is coming from the urine, the urinalysis (UA) shoul...
Do you routinely omit a ureteral stent after uncomplicated ureteroscopy for a small renal or ureteral stone, given randomized multicenter trial data showing significantly better patient-reported outcomes without a stent?
Yes. I also routinely omit stents for straight forward higher stone burden cases after complete stone clearance. I only place stents for more complicated cases such as residual stone fragments where staged ureteroscopy is planned, ureter is tight with passage of scope/sheath, or larger sheath was us...
For a marginal DCD kidney on perfusion, are you seeing a real reconditioning effect, or is the perfusion run mostly functioning as a viability test that tells you whether to use the organ at all?
This is not a straightforward question and therefore doesn't have a straightforward answer. The first part is that the pump numbers can be helpful to determine if it is viable, but really only if the numbers are not improving and show high resistance and poor flow. These kidneys will not do as well ...
Do you offer intralesional collagenase (Xiaflex) for Peyronie’s during the active/inflammatory phase instead of only during the stable phase given recent data of comparable safety outcomes?
I do offer CCH in acute phase as data clearly show safety and efficacy at least as good as stable. It is helpful to give men a proactive plan to unburden the mental health implications of suffering with PyD. It is not off label and therefore should not run into issues with insurance auth either.
How has your approach to de-escalating a conversation with a distressed or angry family member evolved over your career?
My approach to de-escalating conversations with distressed or angry family members has shifted from trying to solve the problem immediately to first understanding the emotion driving the conflict. Early in my career, I often responded by providing more medical information, assuming that greater clar...