Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What techniques do you use for patients with tight scrotums during in-office vasectomies?
If, on the initial counseling visit, I know that the patient has a very tight scrotum and is anxious about the vasectomy, I may just defer performing it in the operating room of the outpatient facility. If, however, it becomes apparent only during the procedure that his vas is difficult to access du...
Do you send urine cultures and treat positive results prior to bladder botox injections?
The consensus increasingly supports not treating ASB prior to intradetrusor botulinum toxin injection. The AUA/SUNA guidelines on ASB explicitly recommend against screening or treating ASB in most clinical contexts, and this extends logically to procedures like Botox, where the risk of ascending inf...
How do you treat nocturia refractory to desmopressin?
If a patient has isolated nocturia, it's often not a urologic issue but can be a symptom of a sleep disorder or sleep apnea. If the patient has daytime OAB symptoms as well, then treat it may be time to try third line OAB treatment.
Do you rely on CT Hounsfield Units to determine stone composition in your patients with recurrent nephrolithiasis who have yet to submit a stone for laboratory based composition testing?
It is somewhat helpful if the value is low, consistent with Uric Acid stones, if higher, not specifically differentiate the calcium stone type. However, since it is part of routine CT stone protocol, it may add some useful information.
How do you interpret nodes with minimal increased uptake on PSMA PET in prostate cancer?
This question is relatively similar to another recent question on indeterminate PSMA PET (#26360), where I provided a longer answer in a bit more detail. The summary is that this essentially relies upon your clinical judgement, and there is no definitive algorithmic way to determine the true nature ...
Do you routinely check PSA before starting finasteride?
I tend to grab a PSA prior to starting higher doses of finasteride for BPH treatment, given these patients are older and may have a different risk profile for prostate cancer. I am less inclined to grab a PSA prior to starting it for younger patients using lower doses of finasteride for male pattern...
How have flexible and navigable suction ureteral access sheaths changed how you decide between URS vs PCNL for larger stones?
The introduction of suction during ureteroscopy has significantly influenced how we utilize ureteroscopy in the management of larger stones. As our stone team is quite facile with PCNL, we would often perform percutaneous nephrolithotomy for stones 1.5 cm or larger. However, ureteroscopic suction te...
In patients with muscle-invasive bladder cancer, in what clinical scenarios would you consider neoadjuvant cisplatin-based therapy in light of emerging data on enfortumab vedotin plus pembrolizumab?
Of course, we are still awaiting FDA approval of EV + Pembro in the cisplatin-eligible population, but the data from KEYNOTE-B15 presented at ASCO GU 26 are overwhelmingly positive. KEYNOTE‑B15 (EV‑304) was a randomized phase III trial in 808 cisplatin‑eligible patients with muscle‑invasive bladder ...
What is your management for intermittent bleeding and pain at the buccal mucosa graft donor site within the first postoperative week?
Gauze packing as needed. I would not intervene with surgical closure. Sponges soaked in lidocaine with epinephrine can also help in this situation. We do use a swish and spit viscous lidocaine to help with oral pain in the first few weeks after surgery. The patient should avoid foods that are hard a...
How do you evaluate exercise induced hematuria that persists after one week of cessation of exercise?
Exercise-induced hematuria typically resolves within a week. If the hematuria persists after one week of cessation of exercise, further work-up of the hematuria is warranted. First, hematuria should be confirmed by excluding myoglobinuria and march hemoglobinuria. If hematuria is confirmed, then one...