Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Does the presence of perineural invasion on a prostate biopsy change your management decision?
I would consider perineural invasion as one of the "soft" criteria that may help impact treatment decisions. Previously this would have also included such things as Gleason 3+4 vs. 4+3, Gleason 8 vs. 9-10, or the percentage of positive cores. However, as these factors have now been included in the A...
What are your top takeaways from ASCO GU 2025?
In terms of practice-informing presentations in prostate cancer here are my top 3: GROUQ-PCS 9 trial (Canada, abstract 22). This trial led by Niazi et al tested whether metastasis-directed radiotherapy based on conventional imaging to up to 5 sites provided benefits in delaying rPFS or PSA progressi...
When incidental microscopic hematuria is found on routine urinalysis, how do you decide on further workup versus repeat testing?
How do you counsel patients on pelvic floor physical therapy who are initially very hesitant to try it?
I typically will inform patients that I can understand the hesitation of pursuing pelvic floor physical therapy, as it involves exercising muscles in a sensitive area of the body. However, patients who have completed pelvic floor PT have a significant improvement in their symptoms, with some studies...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
Would you pursue more dedicated stone surveillance imaging testing for a patient with recurrent nephrolithiasis who has PET-CT scans twice yearly?
Unless the patient is symptomatic, I am not sure there is a reason to. Though PET CT is not the best imaging to look for stones.
Do you recommend ADT or other systemic therapy in patients with rising PSA after prostatectomy and salvage RT and PSMA scan negative for metastatic disease?
Generally, I do not recommend systemic therapy for such patients. If doing so, it would be intermittent ADT (alone) for 6-or 9-month cycles. The EMBARK study will hopefully address this important question.
At what PSA do you initiate ADT for a biochemical recurrence after prostate radiotherapy (adjuvant, salvage, or definitive)?
Great question, and one that highlights the variability in practice and philosophy that often emerges to fill the void when hard data and concrete guidelines are lacking. I find that the PSA doubling-time (DT) often tracks with patient and provider anxiety levels; a rapid DT (<8-10 mos or so) in an ...
Would you continue serial PSMA PET scans after 2 negative scans for patients with a persistently rising PSA post-RT?
Some context would probably be helpful for this. E.g., PSA >2 is different for a patient post-prostatectomy vs. post-radiotherapy. But, in general, if clinical suspicion of cancer recurrence/progression is high, and PSMA PET is negative, one can consider the following options: There may not be a ca...
Would you recommend pregnancy testing for a female patient with recurrent nephrolithiasis for whom you are considering a CT stone scan for routine stone surveillance?
I would go with an ultrasound first and not with CT for screening.