Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Have any studies shown that testosterone replacement therapy lowers the incidence of prostate cancer in hypogonadal men, or is the evidence still largely neutral?
This is a broad question to which I will give a broad answer.For men with hypogonadism (symptoms and signs of androgen deficiency, reproducibly low serum testosterone with an accurate, reliable assay) and no reversible cause, the epidemiological data overall do not show evidence of increased risk of...
What steps would you take if the ileal conduit does not have enough length to reach the skin level during a robotic radical cystectomy and ileal conduit?
First, desufflate and proceed with this portion open. You may have enough length when the abdomen is totally flat (and not insufflated at all). If that doesn't work, you may cut deeper into the mesentery to let it pull up more, but watch out for the blood supply. Think about using SPY or Firefly to ...
What are treatment options for elderly patients with a remote history of cystoprostatectomy with neobladder who are no longer able to empty their neobladder fully, are unable to CIC, and are beginning to have complications such as infection and rising creatinine?
The recommended management of elderly patients with this history is dependent on several factors. The fact that they are unable to drain spontaneously and unable to perform CIC limits the options for drainage. With their creatinine rising, this also suggests that limiting the contact time of excrete...
In a patient with de novo metastatic RCC s/p Ipi/Nivo with partial response and residual viable RCC on cytoreductive nephrectomy, would you add cabozantinib or other TKI prior to disease progression?
No, committing a patient to the substantial (and frequently occurring) adverse events of anti-VEGF TKIs like cabozantinib would require convincing evidence of clinically meaningful benefit, which is currently lacking in this setting. I am supportive of well-designed trials to explore these questions...
What factors should guide the choice between fosfomycin and nitrofurantoin for uncomplicated cystitis, given the reduced efficacy of fosfomycin?
I agree with the authors you reference that, though fosfomycin is listed as a first-line option in the 2011 IDSA UTI guidelines for uncomplicated cystitis, our assessment of its efficacy has changed somewhat since then.We now have two larger randomized controlled trials that demonstrate that women r...
How much and for how long does the average patient leak after HoLEP?
It largely depends on multiple factors BMI Age of the patient Size of the prostate Fraility In general, regarding stress incontinence, 70% of patients are completely dry within 2 weeks, and 97% completely dry within 3 months. Regarding urge incontinence, it depends on whether the patient has OAB b...
How would you manage T3N0M0 sarcomatoid carcinoma of the prostate with adenosquamous differentiation s/p prostatectomy?
Sarcomatoid prostate cancer is an aggressive histological subtype. It may be locally aggressive, and post-operative PSA monitoring may be less helpful for this histologic subtype, which interferes with the usual trigger for initiation of salvage RT (Grignon, PMID 14976541). Despite the lack of high-...
Under what circumstances would you treat prostate cancer without a biopsy?
I largely agree with Dr. @Dr. First Last's comments as well as a prior post on this site in which anecdotes are cited of situations which falsely appeared suggestive of prostate cancer. As contemporary guidelines recommend treatment only in patients with localized prostate cancer with > 5-10 year li...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
What is your approach to preventing significant hematoma and postoperative swelling following penile implant surgery?
It depends on the approach: Infrapubic - gentle mummy wrap and a 10-lb sandbag over the lower abdominal area for one hour in the PACU. Drain in the scrotum, coming out of the left inguinal area. Scrotal support. Penoscrotal - gentle mummy wrap, scrotal support, and drain in the scrotum. In cases whe...