Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What would you offer for a very young patient with metastatic renal medullary carcinoma who has progressed on cisplatin-based chemotherapy?
Doxorubicin-based regimens (per our study here) adapted to context and EGFR-targeted therapies (see here, but do not use bevacizumab as discussed here and here) with prioritization for panitumumab-based therapy as discussed here (from 5:00 onwards) and in yesterday's IKCS: NA session on rare kidney ...
How do you approach managing patients with recurrent nephrolithiasis who have low supersaturation profiles due to polyuria and stable stone disease on imaging but do have persistent urinary abnormalities such as hyperoxaluria, hypercalciuria, and hypocitraturia?
If the stone disease is metabolically stable (no change in stone size or increase in number by serial CT imaging), I do not treat urinary chemical abnormalities. Presumably these patients have high levels of urinary inhibitors of crystallization. I encouraged them to continue their successful stone ...
Would you obtain an abdominal non-contrast CT study for further routine evaluation of stone burden in a patient with recurrent nephrolithiasis who recently completed an abdominal iodinated contrast CT study for non-stone purposes?
Often, there is no pre-contrast imaging, and stones cannot be counted well once contrast enters the kidneys. So, unless there was a pre-contrast phase, the contrast CT cannot be considered adequate for determining stone burden and new stone activity. So if either is at issue, I would obtain a non-co...
Would you add amiloride for patients with recurrent calcium nephrolithiasis who have hypercalciuria despite adherence to maximum dose thiazide, low sodium dietary intake, and low animal protein dietary intake?
Amiloride does not lower urine calcium on a chronic basis. In one set of experiments, acute loading lowered urine calcium, but the effect was very brief. I use amiloride to prevent potassium wasting from thiazides and on and off in primary hyperaldosteronism, but it will not lower urine calcium in t...
How do you advise your patients with recurrent nephrolithiasis to avoid consuming more than usual fluid volume on the day of a scheduled 24 hour urine stone risk study?
I tell them to collect on a day that represents their life as lived - how things are in general. I tell them not to show off. I tell them that if the day does not reflect their usual life, I will be misled and may make mistakes in how I treat them for stone prevention.
What chemotherapy regimen do you use for de novo metastatic squamous cell carcinoma of penile urethra?
Challenging cancer and prognosis; therapy with palliative intent (Nutrition and Palliative Care consults can help regardless of which therapy to use); in pure SCC of penile urethra, would likely consider platinum/gemcitabine or platinum/taxane as 1L therapy as a conventional chemo regimen with perio...
How do you approach patients with biochemical relapse of high-risk prostate cancer, with PSA doubling time less than 6 months?
This is a very thoughtful question. The assumption is that the patient has no evidence on conventional imaging by (CT/Bone scan) and BCR with rapidly doubling PSA after both prostatectomy and adjuvant XRT. The biology of these patients remains concerning and although STAMPEDE would include these typ...
Would you recommend enfortumab vedotin plus pembrolizumab for localized advanced non-invasive urothelial carcinoma of the renal pelvis?
Urothelial carcinoma of the renal pelvis is always challenging to stage and is often understaged. However, it would be difficult to justify systemic therapy with EV + P for non-invasive disease on the path. This patient will likely need upfront RNU followed by adjuvant therapy based on pathological ...
What is your approach to managing patients with recurrent ammonium urate kidney stones?
Pure ammonium urate stones are very unusual, and, to my knowledge, there are no studies to guide us in their treatment. Much more common are magnesium ammonium urate stones, commonly known as "struvite". These are caused by urease-producing bacteria, usually Proteus or Klebsiella. I would first chec...
How do you approach management of a patient with a retroperitoneal soft tissue mass and elevated IgG4 level when tissue biopsy is not feasible?
The question of whether to biopsy in presumed retroperitoneal fibrosis is asked in almost every case. The reason for the biopsy is to primarily rule out other causes of retroperitoneal masses, such as lymphoma, infection, and other rare variants. The mildly elevated IgG4 is not very helpful due to t...