Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you continue or switch therapy for someone who progressed through AR directed therapy and has a rapid rise in PSA while receiving Ra-223 for bone-dominant castrate resistant prostate cancer?
Certainly, it is reasonable to stop an AR inhibitor that is no longer clinically benefiting a patient irrespective of the use of concurrent radium-223, particularly a second AR inhibitor if there is no evidence of a response. Cross resistance between AR inhibitors is common and a rapid PSA rise sugg...
Do you avoid potassium citrate due to concerns with increasing the urine pH in patients with recurrent struvite nephrolithiasis who also have hypocitraturia?
Thanks for asking! My answer is: In general, "No", but it depends... Struvite stones can only form at un-physiologically high urine pHs. This situation occurs when urease-producing bacteria cause urinary infection. Urease splits normally occurring urinary urea to ammonium, raising the urine pH >7.0 ...
Would you consider treating a patient with prostate cancer and biopsy-proven involved inguinal nodes with radiation to the prostate/pelvis/groin?
Would favor starting with ADT plus ASRI and base subsequent treatment in 3 to 6 months based on responses ranging from prostate-only RT (like STAMPEDE for nonregional node) or definitive RT to primary and node.
How do you deal with a discordant MRI prostate after a systematic biopsy?
This is a good question and something that we are coming across more often.A few assumptions that I am making with reference to your question: When you state “discordant” MRI prostate after biopsy, I am assuming that you mean that the biopsy demonstrated something like Gleason 3+3 or maybe nothing a...
Would you start potassium citrate in a patient with recurrent nephrolithiasis of unknown stone composition who has hypocitraturia and alkaline urine pH?
I would be slow to start potassium citrate for a patient with alkaline urine and stones of unknown composition. Alkaline urine predisposes to calcium phosphate kidney stones, and potassium citrate would likely make the urine more alkaline and worsen the formation of calcium phosphate stones. First, ...
Would you start anticoagulation in a patient with RCC and related (tumor) thrombus with extension to renal vein and further?
Tumor thrombus is an intraluminal extension of tumor mass, rather than a true thrombus. There is no evidence that anticoagulation improves outcomes in tumor thrombus (Marcoux et al., Blood 2019). Primary management is surgical resection, typically as part of radical nephrectomy for localized RCC or ...
What is your approach to a patient with muscle invasive bladder cancer getting neoadjuvant gemcitabine/cisplatin who develops significant ototoxicity due to cisplatin after two cycles?
My approach would be to proceed to surgery and based on pathological response, determine if the patient is a candidate for nivolumab.For patients who cannot tolerate cisplatin, there is no recommendation for an alternate regimen in the neoadjuvant setting.If treatment-naive and cisplatin-ineligible ...
What alternative therapies do you recommend for botox non-responders?
For non-responders, I recommend waiting longer between injection sessions, trying different brands especially those with less protein associated with them such as Xeomin which has the least amount of protein, and therefore, less likely to trigger the development of neutralizing antibodies. In some c...
Is there a maximum dose of potassium citrate you would use for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I don’t think there is a maximum dose of potassium citrate. Hyperkalemia can occur, especially if GFR is impaired, and monitoring for that is important. In my experience, diarrhea is the most common dose limiting effect. Taste fatigue is common; fortunately there are multiple preparations available ...
What is your approach to managing patients with recurrent calcium oxalate nephrolithiasis since childhood who are found to be gene carriers for mutations in genes associated with primary hyperoxaluria?
Thank you for this question. In general, there is no good evidence that patients with a carrier of 1 of the 3 primary hyperoxaluria genes (AGXT, GR/HPR or HOGA1) has any phenotype consistent with primary hyperoxaluria, or that these genes are enriched in the general stone forming population. That be...