Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How much proteinuria would warrant consideration of native kidney nephrectomies at the time of a kidney transplant?
We don't typically consider native nephrectomies unless the proteinuria is > 5-6 grams. We rarely end up doing native nephrectomies, though. The main problem, besides the complications associated with heavy proteinuria, is the inability to assess for recurrent disease post-transplant. This can be pa...
What is the minimum duration to be on bicalutamide prior to starting GnRH agonist in de novo metastatic prostate cancer with significant bone disease?
The onset of action for bicalutamide is rapid--typically slightly more than a day to reach maximum/peak concentration. In contrast, the pharmacological effect of leuprolide is related to the time to testosterone suppression which occurs approximately 2-4 weeks after starting. So the time to testoste...
Would you recommend avoiding intravesical (bladder) tobramycin administration in a patient with advanced chronic kidney disease?
Guess fear is absorption, build up, and toxicity. A single loading dose of an aminoglycoside is not to toxic level. Maintaining the level of risks ototoxicity, build up also nephrotoxicity. Would depend on absorption and residual GFR. Try a single loading dose, check levels after 12 or 24 hours to g...
Would you recommend adjuvant cisplatin/gemcitabine or nivolumab in a patient with muscle invasive bladder CA who proceeded to radical cystectomy first?
This is an excellent question and one we are seeing more and more in clinics these days now that the FDA has approved nivolumab for adjuvant therapy for patients with locally advanced urothelial carcinoma at high risk of recurrence after radical resection. This is based on data from CheckMate 274 wh...
How do you counsel younger patients regarding long-term radiologic monitoring of non-functional adrenal adenomas?
I do not think biology is so black and white. The risk of malignancy in adrenal masses according to size is a spectrum and certainly not zero just because at one point in time it is less than 5 cm (how about 4.5 cm?). Unless the radiologist can confidently diagnose a myelolipoma I think clinical jud...
Do you give chronic antibiotic prophylaxis for recurrent UTIs, including Pseudomonas aeruginosa, in a patient with retained ureteral stents?
If the "recurrent UTIs" are symptomatic (fever is what I would be mostly concerned about), then the stents should be changed as feasible, (I assume this has been done) and the UTIs treated as appropriate. If the UTIs continue after the change, I would just try to treat the symptomatic events as best...
How do you manage PSA progression while a patient is on Xofigo or Pluvicto?
The tl;drPSA is very much an imperfect tool for these patients. The data show that PSA may initially increase over multiple cycles before decreasing, though this is a minority of patients. Most patients whose PSA increases early have resistant disease, and you should investigate further with imaging...
Should high risk prostate cancer patients be placed on more potent ADT (abiraterone or enzalutamide) in the upfront setting with definitive RT instead of the standard LHRH agonist?
With STAMPEDE suggesting improvement with the addition of abiraterone in very high risk N0 patients, this is certainly becoming a consideration. Duke is completing a trial of concurrent abiraterone/STADT/definitive radiation for intermediate and lower high risk prostate cancer. Results forthcoming. ...
If a patient diagnosed with seminoma after orchiectomy has margin positive disease noted in the spermatic cord and no overt metastasis on imaging and normal tumor markers, how should this patient be staged?
I believe that the staging would be pT3cN0M0S0 in this case. Margin-positive disease suggests continuous rather than discontinuous spermatic cord invasion. In case this was felt to be discontinuous, NCCN v1.2024 now has a note on staging such patients as pT3 (high-risk stage I) and not as M1 (stage ...
Would you avoid starting potassium citrate in a patient with recurrent calcium oxalate nephrolithiasis and hypocitraturia if they have metabolic alkalosis?
If the metabolic alkalosis was from hypokalemia and/or thiazide, as is common in stone formers, I would not hesitate, as the potassium would be beneficial in reducing the excess renal ammonia excretion. If from other causes, everything would depend on the cause.