Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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...
How do you choose which LHRH agonist or antagonist to prescribe for ADT in patients with prostate cancer?
The choice of LHRH agonist or antagonist depends on patient factors. Most patients receive some form of leuprolide or goserelin since these allow longer intervals between injections (as compared to degarelix). Goserelin is used more for those on anticoagulation or with bleeding disorders since it is...
Do you consider MSI testing for mCRPC?
I agree that data for response to immunotherapy in MMR-deficient (dMMR) prostate cancer is limited, and we estimate the rate of dMMR in prostate cancer to be low, in the 2-3% range. Nonetheless, based on responses in other dMMR tumors, pembrolizumab is now FDA approved for all dMMR/MSI-high unresect...
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 stage patients with testicular cancer who may have CSIS disease?
This always looks easy, but you have to be careful and have patience. Some mistakes occur because providers use the PRE-orchiectomy markers or immediate post-orchiectomy markers before they have a chance to normalize. Also, providers sometimes react to low abnormal stable markers which often are fal...
Do you avoid potassium citrate in patients with recurrent nephrolithiasis and hypocitraturia if they also take antihistamine medications?
I know of no data showing effects of antihistamine meds on urine citrate or on the effects of potassium citrate on urine citrate. I made a Perplexity search which also found no evidence - this is not a topic I have personally researched because I have never encountered clinical issues about it. So -...
What is the best immediate and long-term management of an intraoperative iatrogenic mid-ureteral injury?
If possible, I usually like to perform a primary repair at the time of the injury. These intra-operative injuries are often relatively short in length and can be managed with a uretero-ureterostomy. If a more extensive repair is required (such as reimplant with Boari flap), I will discuss with the p...
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Presently, the main categories of actionable DNA based alterations in advanced prostate cancer are 1) alterations in homologous repair enzymes like BRCA2, and 2) microsatellite instability (MSI high status, mismatch repair gene deficiency). These are actionable as they can lead to the use of a thera...
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 do you interpret recent large retrospective analyses comparing radical prostatectomy vs. radiation for prostate cancer?
There have been numerous comparisons of RT vs. RP from a variety of study teams with various conclusions, and it often seems like the principal conclusion of the study is best predicted by the subspecialty from which the authors originated (urology vs. radiation oncology). As the question partially ...