Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your approach to interpretation of 24 hour urine stone risk studies that persistently demonstrate elevated urinary creatinine excretion despite a reliable patient who denies improper collection?
I would start with a physical examination, looking at muscle mass. Urine creatinine comes from serum creatinine, which in turn comes from muscle mass. Patients with high muscle mass will have high serum and urine creatinine.
How do you manage refractory radiation cystitis status post pelvic EBRT/BT?
Thankfully chronic radiation cystitis and specifically radiation-induced hemorrhagic cystitis is relatively rare (2-8%) [1]. However, it can be a chronic and debilitating complication after pelvic radiotherapy. In managing these patients, first, I make sure to rule out another cause of cystitis – in...
Would you recommend temporary urinary catheter placement for a patient with recurrent nephrolithiasis who is unable to adequately complete a 24 hour urine study due to incontinence?
I would try external catheters before internal catheters for this. I would do these only in very select individuals who, despite empiric therapy, continue to have stones and have controlled for infections and other precipitating factors. 24-hour urines are helpful but not very precise and can be ver...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
For mCRPC patients who are eligible for both, how do you decide between Enzalutamide+Rad223 (EORTC 1333/PEACE-3) or Enzalutamide+Lu-PSMA-617 (ENZA-p)?
While both these studies addressed interesting questions, both enrolled patients who were ARPI-naive. We are in an era where ADT intensification is the standard of care, and hopefully, we will see an even smaller number of folks with mCRPC who would look like the patients enrolled in both these stud...
How do you approach management for recurrent stone formers who sleep over 8 hours per day and fail to reach 2.5 liters of daily urine output on 24 hour urine stone risk studies?
I know of no data that hours of sleep affect stone risk. So the question is what to do when a patient cannot reach a volume goal. Volume goal is set by the saturations present and stone type, and is just one factor, so I will consider the case when a 2.5-liter 24-hour volume is essential because of ...
How long do you treat retroperitoneal fibrosis with immunosuppression?
I normally treat for 9 months to a year depending on response. I have found PET CT useful in determining if there is active ongoing inflammation.
What are your recommendations in managing pudendal neuralgia/red scrotum syndrome?
Red scrotum syndrome is very challenging to treat. The list of reported treatments is long, but I have not found one to be consistently effective. Treatment selection depends significantly on patient characteristics and preferences. In my opinion, every patient with red scrotum syndrome should under...
Do you consider estrogen patches in treatment of prostate cancer?
Oral estrogenic formulation (such as DES) was historically used for androgen suppression in prostate cancer patients. This was based on the principle that estrogen decreased serum testosterone levels by suppressing luteinizing hormone production through a negative feedback loop on the hypothalamus a...
Which patients, if any, do you offer transdermal estradiol as a method of ADT instead of LHRH agonists?
My default form of ADT remains a GnRH agonist or antagonist but estradiol transdermal patches are clearly effective and safe as an alternative option for men who either 1) have significant loss of bone density/osteoporosis, 2) have significant hot flashes with traditional ADT and wish to try an alte...