Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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...
What steps would you take if the ileal conduit does not have enough length to reach the skin level during a robotic radical cystectomy and ileal conduit?
First, desufflate and proceed with this portion open. You may have enough length when the abdomen is totally flat (and not insufflated at all). If that doesn't work, you may cut deeper into the mesentery to let it pull up more, but watch out for the blood supply. Think about using SPY or Firefly to ...
In a patient with de novo metastatic RCC s/p Ipi/Nivo with partial response and residual viable RCC on cytoreductive nephrectomy, would you add cabozantinib or other TKI prior to disease progression?
No, committing a patient to the substantial (and frequently occurring) adverse events of anti-VEGF TKIs like cabozantinib would require convincing evidence of clinically meaningful benefit, which is currently lacking in this setting. I am supportive of well-designed trials to explore these questions...
What factors should guide the choice between fosfomycin and nitrofurantoin for uncomplicated cystitis, given the reduced efficacy of fosfomycin?
I agree with the authors you reference that, though fosfomycin is listed as a first-line option in the 2011 IDSA UTI guidelines for uncomplicated cystitis, our assessment of its efficacy has changed somewhat since then.We now have two larger randomized controlled trials that demonstrate that women r...
How much and for how long does the average patient leak after HoLEP?
It largely depends on multiple factors BMI Age of the patient Size of the prostate Fraility In general, regarding stress incontinence, 70% of patients are completely dry within 2 weeks, and 97% completely dry within 3 months. Regarding urge incontinence, it depends on whether the patient has OAB b...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
What is your approach to preventing significant hematoma and postoperative swelling following penile implant surgery?
It depends on the approach: Infrapubic - gentle mummy wrap and a 10-lb sandbag over the lower abdominal area for one hour in the PACU. Drain in the scrotum, coming out of the left inguinal area. Scrotal support. Penoscrotal - gentle mummy wrap, scrotal support, and drain in the scrotum. In cases whe...
What is your approach to managing neobladder acidosis?
Alkali supplementation is the mainstay of treatment of neobladder acidosis. Since prolonged urinary contact with the intestinal epithelium used for urinary reconstruction leads to increased ammonium reabsorption and chloride absorption in exchange for bicarbonate secretion, regular catheterization o...
What is the role for robotic pyelolithotomy in the modern era of lasers, PCNLs, and flexible and navigable suction ureteral access sheathes?
Laparoscopic or open pyelolithotomy still plays a role in regions where access to technology may be limited. For surgeons who have access to the technology mentioned (including robotics), the need for robotic pyelolithotomy would be limited to those patients undergoing robotic pyeloplasty. There may...
How do you manage a seminal vesicle recurrence after prostate brachytherapy?
Finding more of these in the PSMA era. Have managed a few patients with SBRT +/- ADT adjusting dose based on overlapping OAR if needed.