Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is there any evidence that ivermectin suppresses the PSA level in prostate cancer?
Is this even the right question, though? ADT drops PSA very reliably and yet does not cure patients. Finasteride suppresses PSA, but we do not use it as a mainstay of cancer treatment. Even if ivermectin *did* suppress PSA, unless there is a meaningful oncologic benefit (*at least* reduced recurrenc...
Do you routinely use hemostatic agents in the renal defect after a partial nephrectomy?
Yes. I routinely employ Surgiflo/Floseal at the base of the defect. After the initial running sutures within the defect, I perform early unclamping and oversew any persistently bleeding arteries. Then I place the renorrhaphy sutures as part of the sliding clip technique, and use Surgiflo/Floseal at ...
Given results of the RADICALS trials, is LT-ADT standard of care for salvage prostate RT?
I do not think long-term ADT is established as standard of care for salvage prostate radiation, as this would require a demonstration of improved overall survival in at least specific subgroups of patients. RADICALS-HD demonstrates improvement in freedom from metastasis as well as freedom from non-p...
In an older man on tamsulosin for BPH who is presenting with recurrent falls, how do you manage the medication, in light of urinary symptom control and fall risk?
Tamsulosin carries the risk of orthostatic hypotension and falls, especially in older adults1. In the situation of an older adult man taking tamsulosin for BPH symptoms who is presenting with recurrent falls, I would first check orthostatic vitals and if positive, I would discuss this finding with t...
How do you assess the pros and cons of discontinuing a selective alpha blocker such as tamsulosin or alfuzosin in an older adult male with orthostatic hypotension and established urinary retention?
Discontinuing alpha blockers in older adults with orthostatic hypotension (OH) and urinary retention is rarely straightforward, and the decision hinges on several key points. First, it is important to understand that selective alpha-blockers (tamsulosin, alfluzosin) work by relaxing the smooth muscl...
How are you using ArteraAI in 2026 for intermediate risk patients?
I use both ArteraAI and Decipher to help with these decisions. As Dr. @Dr. First Last says, it's post-hoc based on large datasets. Artera claims to be predictive, while Decipher is just prognostic. Without going through all the data, I find it helpful for intermediate risk, where it is on the cusp o...
What is your approach to patients with persistent low libido despite normal testosterone levels after use of exogenous testosterone replacement therapy?
The key point is understanding a man’s mental health and relationship status. I will always screen for depression and strongly encourage sex therapy. My unvalidated but effective screening question is asking when their last vacation was and how their libido and erections were. It’s surprising how ma...
How do you manage a Ta pure squamous cell carcinoma of the urinary bladder?
The ideal management of non-muscle invasive bladder cancer (NMIBC) with histologic variants remains controversial. The American Urological Association and the National Comprehensive Cancer Network guidelines recommend radical cystectomy for T1 patients with variant histology based on expert opinion ...
Do you get DEXA scans routinely before starting ADT for prostate cancer or endocrine therapy for breast cancer?
When initiating long-term ADT, I order a DEXA scan, check vitamin D level, ensure adequate dietary calcium intake, and discuss weight-bearing exercise/refer to PT when appropriate. I also continue check DEXAs every 2 years unless they otherwise meet criteria for a bone-modifying agent (mCRPC with bo...
Have any studies shown that testosterone replacement therapy lowers the incidence of prostate cancer in hypogonadal men, or is the evidence still largely neutral?
This is a broad question to which I will give a broad answer.For men with hypogonadism (symptoms and signs of androgen deficiency, reproducibly low serum testosterone with an accurate, reliable assay) and no reversible cause, the epidemiological data overall do not show evidence of increased risk of...