Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
With multiple PARPi + ARSI combinations now approved, how are you selecting which combination to use for a patient with BRCA mutated mCRPC?
As of this writing, we have 3 choices for a man with mCRPC and a BRCA2 mutation who has never had a prior ARSI and is now progressing on ADT with or without docetaxel in the mHSPC setting or ADT in the nmCRPc setting. Abiraterone plus olaparib has the longest follow up and a clearly significant over...
What adjuvant therapy would you offer for a cisplatin-eligible patient with upper tract urothelial carcinoma and Lynch Syndrome?
Good question and discussed it with Dr. @Dr. First Last. We have seen data from the POUT phase 3 trial (Birtle et al., PMID 32145825) showing significant DFS benefit with adjuvant Gem/Cis vs observation after radical surgery (due to study closure the trial was not powered to show OS benefit) in pati...
In patients with hypogonadism, when do you recommend subcutaneous over intramuscular testosterone injections?
Patient's choice. Both work well when given weekly.
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...
Are you comfortable combining relugolix with enzalutamide or abiraterone?
I usually avoid these combinations. The challenge is that relugolix is not superior to other ADT methods in terms of efficacy (at least based on available data) but there are safety issues with considering these combinations. All three of these medications are substrates for similar enzymatic metabo...
Would you avoid potassium citrate initiation in a pregnant patient with hypocitraturia and recurrent calcium oxalate nephrolithiasis?
Difficult question to answer. There is no clear contraindication; however, if her urine pH is OK, I would likely avoid it. I would make sure she is adequately hydrated and would recommend having fresh squeezed Lemons to help. However, if it appears necessary to use it, I would.
What would your approach be in a man currently on treatment for high-risk prostate cancer with ADT who does not have castrate levels of testosterone?
Yes, I would try alternative agents. If using Lupron, consider relugolix, degarelix, high-dose bicalutamide, or even adding an ARSI.
Do you recommend avoiding SGLT2i use for patients with proteinuria from diabetic kidney disease if they have urinary retention requiring catheterization?
I would probably avoid SGLT-2 in such a patient because of the risk of infection. Likely, the risk is not worth the benefit.
How can you manage a patient with bilateral PCNs who requires Pluvicto administration?
We've treated several of these folks. In general, we ask the patients to ensure they are emptying the bags frequently for the first three days to minimize the volume of urine next to the skin. There have been reports of radiation dermatitis from Foley/PCN bags that are left in the same spot against ...
What is your approach to delayed or inhibited ejaculation related to SSRI sexual dysfunction?
There are several theoretical possibilities that have been suggested over time. Periactin 4mg 30 minutes prior to sex is noted as a possible intervention. I've never seen any benefit from this. Another possibility is to add Wellbutrin at regular dose which allows for additional sympathetic nervous s...