Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
At what PSA level do you offer early salvage radiotherapy?
For a patient with pT3 disease or positive margins, once the PSA is confirmed detectable, rising, and the patient is well-healed, it is appropriate to treat. Given the results from the now 7 adjuvant vs. salvage trials, delaying well past a PSA of 0.2 is associated with the need for more aggressive ...
Would you start stone preventative medications such as potassium citrate and thiazide diuretics for patients with recurrent calcium based nephrolithiasis and abnormal 24 hour urine chemistries if they no longer have calculi on most recent imaging testing?
If they have had stones previously they remain at risk of recurrent stones. Would want to know when was the last stone episode. Was there previous treatment? It would be based on the results of the 24 hr urine and how significant is the hypercalciuria, oxaluria, low the citrate and pH are. Most impo...
Do you utilize genetic testing to guide ADT for men receiving XRT for intermediate or high risk prostate cancer?
This question is currently the subject of an NRG Oncology trial (https://clinicaltrials.gov/ct2/show/NCT05050084) and I would encourage participation so that we can get a data-driven answer to this important question as soon as possible. Outside of the context of a trial, I do not currently use gene...
Do you have patients with recurrent nephrolithiasis target a certain urine volume or rather consume fluids as needed for goal of having consistent clear urine?
I think you could go either way. To prevent most types of kidney stones, 2L/day seems to be the minimum urine volume required. For cystine stone formers, I double that amount. My more compulsive patients like having a quantitative goal. The amount of fluid intake roughly equals the urine volume, abs...
Is there any evidence that spironolactone or finasteride therapy increase blood levels of testosterone?
Yes. It seems that both medications can do this at least in the short term. Spironolactone's effect may be more temporary.For spironolactone, an older article: Tidd et al., PMID 152681For finasteride: Stanczyk et al., PMID 23474436
What adjuvant therapy would you recommend for a cisplatin and IO ineligible patient with node positive urothelial carcinoma with mixed histology?
This is a difficult situation and I agree that there is evidence for adjuvant carboplatin-gemcitabine in cisplatin-ineligible patients with high-risk upper tract urothelial carcinoma, although benefit appeared more modest compared to cisplatin-gemcitabine (POUT trial). It is reasonable to extrapolat...
Do you treat muscle-invasive urothelial bladder cancer with plasmacytoid features any differently in terms of the recommendation for neoadjuvant cisplatin-based chemotherapy?
Plasmacytoid variant carcinoma is a rare aggressive variant that tends to be chemosensitive but recurs frequently and is characterized by CDH1 loss of function genomic alterations and peritoneal metastasis. In predominant plasmacytoid urothelial carcinoma, the role of neoadjuvant chemotherapy (NAC) ...
How do you reconcile discrepancies in clinical prostate cancer staging with AJCC and NCCN?
Fundamentally, I use NCCN risk categories to help steer conversations about staging and treatment options for very low vs low vs fav int vs unfav int vs high risk diseases. Therefore, I use NCCN staging in my clinical practice and notes and incorporate mpMRI into staging. I find it comforting that N...
Do you routinely recommend decreasing dietary animal protein intake in patients with recurrent calcium oxalate nephrolithiasis who are found to have hyperoxaluria on 24 hour urine studies?
This is an interesting question. I focus more on total protein intake rather than which type in my initial assessment and make sure that the patients are meeting guidelines there first (0.8-1g protein/Kg of lean body weight). I address hyperoxaluria in my review primarily through addressing the usua...
What agent and for how long would you treat a patient with asymptomatic azole-resistant C auris candiduria who is planning to undergo a urological procedure?
I would be cautious here. If there are reasonable MICs to fluconazole (SDD but achievable), this would be preferred. Intravesical amphotericin is a good option. But, if this were impossible to achieve, I would be reluctant to use IV amphotericin in any formulation, since there's a risk of harm, and ...