Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you offer early urethroplasty to a patient with an incidentally found short bulbar urethral stricture able to accommodate a 17Fr cystoscope who has no voiding symptoms, given that delayed intervention may allow stricture progression?
With no symptoms and able to accommodate a cystoscope, I would not. 17Fr cystoscope accommodation is a generally accepted marker of “success” after treatment. With that being a starting point, in this case, there would be little potential clinical benefit. I think these are the patients to follow cl...
What would be your preferred treatment strategy for patients with NMIBC whose disease progresses after BCG plus durvalumab?
Pembrolizumab is little used in real-world practice in 2026. The response rates were lower than those of other more recently available therapies for BCG-unresponsive high-risk CIS, and the risk/benefit tradeoff is less favorable than other newly available treatments. Most urologists would treat pati...
Do you consider MSI testing for mCRPC?
I agree that data for response to immunotherapy in MMR-deficient (dMMR) prostate cancer is limited, and we estimate the rate of dMMR in prostate cancer to be low, in the 2-3% range. Nonetheless, based on responses in other dMMR tumors, pembrolizumab is now FDA approved for all dMMR/MSI-high unresect...
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
How do you differentiate between asymptomatic bacteriuria and a true urinary tract infection in a neuro-urology patient?
The short and only real answer is clinical judgment. There is no laboratory testing that can differentiate between bacteriuria (which can be protective) and true urinary tract infection. While some very limited studies have examined the use of inflammatory biomarkers in improving UTI diagnosis in th...
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...
For a patient with localized, high-risk prostate cancer (Gleason >8, staged with PSMA PET), is prostate SBRT a reasonable treatment choice, and if so, what duration of ADT would you utilize in this setting?
Yes, I offer SBRT as a reasonable option for high-risk prostate cancer. This is admittedly an extrapolation from PACE-B, which studied treatment of intermediate-risk cancer, but it seems justified in my view. Safety is well established. Efficacy is supported by PACE-B, with an asterisk coming from N...
What is your approach to the elderly patient with de novo metastatic hormone sensitive prostate cancer?
ASCO published guidelines in 2018 regarding the assessment and management of older patients with cancer, with a recent update in 2023. Among the geriatric assessment factors that are recommended to be evaluated, cognitive function, social support, and the ability to safely take medications and follo...
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
What options do you have when a patient has urinary obstruction during radiation treatment?
Here is my general practice on urinary symptom management for a man with prostate cancer undergoing RT.Urinary symptom management RT can decrease urinary symptoms in men with irritable urinary symptoms (Malik et al., PMID 20643513) - not sure of the mechanism, but it takes time to see the IPSS drop ...