Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you prefer a running or interrupted anastomosis for the ureteroneocystostomy during renal transplant?
I prefer a running anastomosis using 4-0 absorbable suture. I universally stent for my cases and leave the stent for 3-4 weeks.
Would you take back an asymptomatic patient for stent exchange or adjustment if imaging revealed that the stent was intraparenchymal?
I would start with a question back - if the patient was asymptomatic, why was a CT scan obtained? Reimaging after stent placement rather than proceeding with definitive management implies that there is some issue with the patient that is outside of the norm. Secondly, reviewing the images carefully ...
How does a negative PSMA PET change your management when completing salvage radiation for prostate cancer?
It's important to remember that if patients are being referred early for salvage RT, most of them will have negative PSMA PET/CTs (< 50% are positive if the PSA is < 0.5). So, in these cases, you are relying on the usual factors to decide on treatment fields, dosing, and the use of ADT, including ot...
Would you repeat a midurethral sling in a patient with recent failure of a mesh, midurethral sling placed 10 years ago?
It is very unusual for mesh to "fail" over time. Rather, the patient has urinary incontinence, which should be investigated before any surgical decisions are made. If she indeed has incontinence due to sphincteric insufficiency (the pathophysiologic explanation for stress urinary incontinence), then...
Do you place patients on anti-platelet or anti-coagulant medications after a distal shunt for priapism?
I have not routinely done so in my practice. However, it should be noted that these are very infrequent cases and there is no universal/standardized recommendation. Antithrombotic therapy is not routinely recommended in the AUA – SMSNA guidelines as an adjunctive maneuver when performing distal shun...
What is your approach to interpretation of 24 hour urine stone risk studies that persistently demonstrate elevated urinary creatinine excretion despite a reliable patient who denies improper collection?
I would start with a physical examination, looking at muscle mass. Urine creatinine comes from serum creatinine, which in turn comes from muscle mass. Patients with high muscle mass will have high serum and urine creatinine.
How do you manage refractory radiation cystitis status post pelvic EBRT/BT?
Thankfully chronic radiation cystitis and specifically radiation-induced hemorrhagic cystitis is relatively rare (2-8%) [1]. However, it can be a chronic and debilitating complication after pelvic radiotherapy. In managing these patients, first, I make sure to rule out another cause of cystitis – in...
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
I would try external catheters before internal catheters for this. I would do these only in very select individuals who, despite empiric therapy, continue to have stones and have controlled for infections and other precipitating factors. 24-hour urines are helpful but not very precise and can be ver...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
For mCRPC patients who are eligible for both, how do you decide between Enzalutamide+Rad223 (EORTC 1333/PEACE-3) or Enzalutamide+Lu-PSMA-617 (ENZA-p)?
While both these studies addressed interesting questions, both enrolled patients who were ARPI-naive. We are in an era where ADT intensification is the standard of care, and hopefully, we will see an even smaller number of folks with mCRPC who would look like the patients enrolled in both these stud...