Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you manage rectal wall infiltration during a rectal spacer procedure?
At ASTRO 2023, PACE-B reported RTOG grade 2+ GI toxicity was exceedingly low at only 1/348 for 78 Gy/39 fx or 62 Gy/20 fx and only 1/363 for 36.25/5 fx. Anyone know what % of patients in PACE-B had SpaceOAR or similar products? This raises the question of whether SpaceOAR or similar products are nee...
Would you consider utilizing pembrolizumab/enfortumab as a bladder preservation approach in patients with MIBC?
Yes, I think that this is a viable approach. Data from perioperative trials, including KN-905 and EV-304, suggest very high rates of pathologic complete responses in almost two-thirds of all patients at the time of radical cystectomy. Many of these patients may not need radical cystectomy for an opt...
What duration androgen deprivation do you recommend with salvage pelvic radiotherapy for pelvic node relapse after prostatectomy?
6 months ADT, 2 years ADT, 2 years ADT + abiraterone/prednisone seems reasonable depending on the circumstances. For example, early pelvic node recurrence for pT3b Gleason 4+5 would be a higher risk than a very late recurrence of pT2 Gleason 3+3.
When interpreting a 24-hour urinary calcium, which is more accurate: 24 hour urine calcium (mg/day) or 24-hour calcium-to-creatinine ratio (mg/g)?
In my opinion, the answer is unequivocal, i.e. calcium to creatinine ratio is the only way to interpret a 24-hour urine calcium. It is essentially impossible to collect an exact urine sample of 24 hours. The only way to do this, which is often unrealistic, is for the patient to empty the bladder and...
What is your approach for stone prevention for patients with recurrent nephrolithiasis who are started on GLP-1 agonist therapy and subsequently consume less daily water intake?
There is no approach except clinical interaction to promote continued fluid intake. I have personal experience with this kind of problem and believe one can achieve a reasonable response - albeit it can require some increase in visits.
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
How does the presence of indeterminate lymphadenopathy on PSMA PET scan alter your management of unfavorable intermediate-risk prostate cancer?
Summary: In practice, I usually review the imaging myself and attempt to evaluate for common pitfalls of interpretation or evidence that may convince me of a true positive. Often, I find a second review by a blinded radiologist helpful. Unless I am highly suspicious of a false positive, I often err ...
How do you manage hot flashes in men with prostate cancer on androgen deprivation therapy?
I prescribe Effexor extended release (XR) 37.5 mg increasing to 75 mg if needed. Serves double duty since many men would benefit from an antidepressant anyway. Works for women as well.
How would you treat a patient with Gleason 8 or 9 prostate cancer, pretreatment PSA 15-24, with retroperitoneal adenopathy?
I would offer a similar approach to that described nicely by @Dr. First Last and @Dr. First Last: definitive RT+ADT+abiraterone, with SIB to the grossly positive nodes. My caveats and additions are: I start with a frank discussion with the patient re: evidence for various scenarios and general prog...
Would you recommend HRT to treat hypogonadism in a male patient in his 80s?
If the patient is symptomatic, cautious use of a small dose can be considered with close monitoring.