Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience wi...
Do you incorporate the results of 24 hour urine chemistries that were obtained several years prior when evaluating new patients for kidney stone prevention?
I try to review all data related to stone formation in new patients, including 24 hour urine data, stone analysis and imaging studies for stone burden (past and present). If a patient has prior 24 hour urine data, they likely had prior advice on stone prevention, which is relevant to understanding t...
What is your preferred intravesical therapy for recurrent high-grade non-muscle-invasive bladder cancer when BCG is unavailable?
If BCG is not available in standard dosing due to shortage, there are some options. First, split dosing of BCG can still be effective and have lower toxicity, so that can be considered. The SWOG study compared TICE vs Tokyo strain, and it was non-inferior, so there is hope this would be on the horiz...
Assuming approval, in which patients would you choose Belzutifan + Lenvatinib (LITESPARK-011) for advanced RCC, with progression after IO therapy?
LITESPARK-011 is an interesting study as it relates to current standard practice. Presently, lenvatinib/everolimus is a well-established and potent treatment option. Each clearly contributes towards the clinical benefit observed in most patients. For instance, in the study NCT01136733 (Motzer et al....
How would you manage T3N0M0 sarcomatoid carcinoma of the prostate with adenosquamous differentiation s/p prostatectomy?
Sarcomatoid prostate cancer is an aggressive histological subtype. It may be locally aggressive, and post-operative PSA monitoring may be less helpful for this histologic subtype, which interferes with the usual trigger for initiation of salvage RT (Grignon, PMID 14976541). Despite the lack of high-...
Do you rely on urinalysis testing for microscopic hematuria as a means to assess for a ureteral stone for patients with recurrent nephrolithiasis who report mild potential stone-related pain?
I agree with answers posted already. Hematuria is not specific to a ureteral stone location.
How do you approach management of a patient with intermediate risk prostate cancer treated upfront with HIFU and intermittent ADT who is later found to have rising PSA and biopsy-proven prostate-confined recurrence?
These are frustrating situations, and ones I am now seeing frequently as focal therapies have gained traction in the United States. The approach, needless to say, is highly individualized. Often, these glands are quite abnormal in MRI appearance, and there is a concern for fibrosis. My approach is h...
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
Do you avoid potassium citrate in patients with recurrent nephrolithiasis and hypocitraturia if they also take antihistamine medications?
I know of no data showing effects of antihistamine meds on urine citrate or on the effects of potassium citrate on urine citrate. I made a Perplexity search which also found no evidence - this is not a topic I have personally researched because I have never encountered clinical issues about it. So -...
What is the best immediate and long-term management of an intraoperative iatrogenic mid-ureteral injury?
If possible, I usually like to perform a primary repair at the time of the injury. These intra-operative injuries are often relatively short in length and can be managed with a uretero-ureterostomy. If a more extensive repair is required (such as reimplant with Boari flap), I will discuss with the p...