Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you perform the renorrhaphy during a partial nephrectomy?
A renorrhaphy can be performed using one or two layers. I use running 3/0 Monocryl for the deep layer and 2/0 Stratafix continuous suturing with the sliding clip technique for the cortical layer. I do not use bolsters or tissue sealants in most cases.
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...
In light of the pending overall survival data and reported declines in quality of life associated with the PSMAddition trial, how do you envision incorporating Pluvicto into the management of mHSPC?
The PSMAddition trial was a phase III trial of [177Lu]Lu-PSMA-617 (i.e., Pluvicto) combined with androgen deprivation therapy (ADT) plus an androgen receptor pathway inhibitor (ARPI) in patients with PSMA-positive metastatic hormone-sensitive prostate cancer (mHSPC). This trial randomized men with u...
How many days of preoperative antibiotics do you give a patient if they have a positive urine culture and are scheduled for ureteroscopy and laser lithotripsy?
Great question! I treat these patients as if they have a complicated urinary tract infection and begin culture-specific antibiotics 7 days before surgery through the date of surgery. I generally do not repeat testing in the interim to confirm a negative culture as long as they do not develop worseni...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
Would a high Decipher score affect your recommendation regarding the addition of ADT to XRT in a favorable intermediate risk prostate patient?
The simple answer is YES.To walk through why...1. Trials like RTOG 9408 demonstrate that there is a metastasis and OS benefit in Intermediate Risk disease from the addition of short-term ADT to RT.2. Later work from many groups showed that intermediate risk is a very heterogeneous cohort. This shoul...
How would you manage a patient who developed an intraprostatic abscess after SpaceOAR injection, prior to starting radiation?
Rectal spacer complications are rare, but still happen. In a recent review, 0.4% of patients experienced a complication resulting in an adverse event report. 13% of these reports had a CTCAE of >= 3. Some of these adverse event reports (91/981) were abscesses related to SpaceOAR placement (Millot et...
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...