Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you manage radiation cystitis in a vulvar cancer patient still receiving EBRT with known history of cystocele and who is otherwise hemodynamically stable?
For me, this is a very confusing question. First, I am not sure what is meant by "radiation cystitis." The question seems to imply that the patient is having hematuria as a component of the radiation cystitis diagnosis. In my long career, I have never seen a patient have noticeable hematuria during ...
How long do you continue a thiazide diuretic in a patient with nephrolithiasis and hypercalciuria who achieves normalization of urinary calcium excretion following therapy initiation?
This question needs to be viewed from many angles in considering the answer. At the first level, an effective therapy choice for stone formation should be continued as long as the patient remains a stone former, which is probably for the rest of their life. We should always remember that the desired...
Would you consider maintenance immunotherapy after cisplatin-gemcitabine chemotherapy and chemoRT for stage 3 bladder cancer in a patient declining cystectomy or who is a poor surgical candidate?
Great question and relevant clinical scenario. We need a clinical trial in this setting, the INSPIRE (EA8185, PI: Dr. @Dr. First Last) is an ideal trial to enroll. In the meantime, would not add "consolidation/maintenance" ICI in the absence of data in this particular setting.
How would you manage a patient with recurrent calcium phosphate nephrolithiasis who has hypercalciuria, hypocitraturia, and a urine pH greater than 6.3?
Good question! Calcium phosphate stone formers are the second most common type after calcium oxalate stone formers. The underlying problem is an elevated urine pH. Your differential diagnosis will include primary hyperparathyroidism, renal tubular acidosis, medullary sponge kidneys and the use of al...
Do you recommend ADT for a patient with hypogonadism with unfavorable or high risk prostate cancer whose PSA dropped to <1 after cessation of supplementation?
When I encounter this situation, I will measure the testosterone level off supplementation. If the testosterone is castrate level (<50 ng/dL), then I would not add ADT, as the target testosterone level has already been achieved. If the patient's testosterone level remains above the castrate threshol...
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
Do you recommend sperm banking for males prior to undergoing radiation?
To the first question in the prompt, I would recommend sperm banking for any patient who was receiving a sufficiently high radiation dose to the testes and desired fertility preservation. In my practice, this are few patients, although it is an important consideration for younger patients. To the se...
Do you recommend obtaining 24 hour urine ammonium levels in patients with recurrent uric acid nephrolithiasis?
An astute question! As you imply, uric acid stones have very little to do with uric acid! Otherwise, we would see more sodium urate, potassium urate, and ammonium urate stones, which are very rare. Uric acid (hydrogen urate) stones are highly dependent on a lower-than-normal urine pH. The two main r...
How would you treat high risk prostate cancer in a patient with autonomic bladder dysfunction?
Personally, I have not treated a large number of such patients, but they've generally had this problem due to diabetes or Parkinson's disease. However, it might be prudent to wait for the workup for an etiology before starting radiation therapy. For high risk patients, you're generally considering a...
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...