Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your approach to managing patients with recurrent nephrolithiasis and hypercalciuria who develop sun photosensitivity following thiazide diuretic initiation?
I am afraid my answer is too prebian. If I cannot use a thiazide and I need to lower urine calcium and protein in order to prevent stones, I resort to reducing dietary calcium to about 60 mEq/day. People who do not respond to a lower diet in sodium and protein with a fall in urine calcium often have...
Would you consider offering salvage radiation to a patient with castrate resistant prostate cancer who has never had local therapy and has no evidence of lymph node or distant metastasis?
It's hard to give a great answer without knowing more information, such as the PSA, Gleason score, and T-stage at presentation, why he was treated with androgen deprivation alone up front, what AD he was treated with, how long he was under treatment before he became castrate resistant, and what is t...
Which patients would you treat with relugolix instead of injectable GnRH agonist therapy?
I would consider relugolix for patients with: 1. Intermediate-risk prostate cancer that needs a short course of androgen deprivation therapy 2. Patients with biochemical relapse that would benefit from a short course of ADT and salvage RT2.5 Patient with pre-existing cardiac comorbidities 3. Potenti...
Is the PROTEUS data enough to change your practice in the treatment of patients with high-risk localized or locally advanced prostate cancer?
The question asks if the results of PROTEUS would/should impact practice patterns...let us take a look: ADT is not recommended to be used with radical prostatectomy in prostate cancer by any guideline. Apalutamide or any ARPI are not recommended to be used with RP in prostate cancer in any guideline...
In a child with grade III-IV VUR who has a second febrile UTI while on antibiotic prophylaxis, do you move to surgical correction or continue medical management?
A second febrile UTI on ppx does not mandate surgical correction. Many factors go into whether surgery is ultimately recommended. In the example patient, I would ask about bowel and bladder habits (if male, circumcision status or phimosis). If anything can be optimized medically, I would first work ...
How long do you continue surveillance ultrasounds for antenatal hydronephrosis that's improving and does that differ if it's unilateral versus bilateral?
Until resolved, or until stably mild and the child is toilet trained.
Do you offer treatment of prostate/oligomets upfront with systemic therapy for oligometastatic de novo prostate cancer?
There's no right or wrong answer here, and I've done both options (treat everything up front and treat sequentially) based on disease sites and volume, and patient symptoms and priorities. I can share how I think through the decision-making: Do they qualify for prostate RT based on STAMPEDE and life...
How do you approach a child with a single febrile UTI and no prenatal history of hydronephrosis when deciding whether to obtain a VCUG?
Get a postnatal US. If normal consider deferring VCUG unless high risk features like sepsis on presentation, family history, or unusual organism.
In a patient with very high risk prostate cancer opting for prostatectomy, when, if ever, do you recommend neoadjuvant ADT?
I generally do not offer ADT with or without a potent ARSI prior to RP even in high risk disease. While small single arm studies have shown that a few such men can achieve a pathologic CR and that path CR/MRD is associated with better outcomes after RP, for most patients, this approach has no clear ...
Would you consider utilizing pembrolizumab/enfortumab as a bladder preservation approach in patients with MIBC?
Yes, I think that this is a viable approach. Data from perioperative trials, including KN-905 and EV-304, suggest very high rates of pathologic complete responses in almost two-thirds of all patients at the time of radical cystectomy. Many of these patients may not need radical cystectomy for an opt...