Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you recommend Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who have hypocitraturia and mild hyperkalemia for which potassium citrate is contraindicated?
First, my conflict of interest: I am one of the inventors of Moonstone so I do have a financial interest in sales of the product. But 30 mEq of Moonstone product has only 7 mEq of K, so I consider it a useful way of alkalinization if serum K is an issue. And only 10 mEq of Na, the rest Mg. By spread...
When would you recommend adjuvant radiation following cystectomy for urothelial bladder cancer?
Local-regional recurrence for patients with ≥pT3 disease after radical cystectomy is a significant problem (1) and warrants consideration of adjuvant radiation therapy in patients who are likely to tolerate such treatment. Chemotherapy has not been shown to reduce the risk of local-regional recurr...
What is your preferred initial systemic therapy approach to metastatic clear cell adenocarcinoma of the urethra (CCAU)?
Clear cell adenocarcinomas of the urethra are very rare tumors, and the cell of origin remains unclear. These may arise from the urothelial lining, or alternatively the peri urethral glads or other stromal tissues. Given its rarity, it is not surprising that no standard treatment for metastatic dise...
Will prior novel hormonal therapy affect when/how you use olaparib plus abiraterone for patients with BRCA-mutated metastatic castration resistant prostate cancer?
Yes, there is no clear data at this time that an AR/PARP inhibitor combination prolongs rPFS or OS in men with mCRPC who have progressed on a prior potent AR inhibitor, as largely these men were excluded or not included in PROpel, MAGNITUDE, or TALAPRO-2. For patients who develop mCRPC but have not ...
How would you treat a patient with RP and salvage XRT now with a PET PSMA positive node?
The question is a bit unclear, but I will assume that this patient has already had RP and salvage RT to the prostate bed only and now presents with a PSA of 4 and the PSMA-PET is positive in the pelvic nodes. In this situation, I generally recommend long-term ADT plus RT to the pelvic nodes, but I w...
Do you use oral fosfomycin as a treatment option for uncomplicated cystitis due to ESBL producing E coli?
Fosfomycin is one of the first-line drugs for uncomplicated UTI listed in the Infectious Diseases Society of America (IDSA) UTI treatment guidelines (these guidelines are currently being updated). It is the only single-dose drug approved for UTI and is an effective option. It does have activity agai...
Would you recommend cinacalcet for patients with recurrent nephrolithiasis who have hypercalciuria despite thiazide diuretic use and who also have an elevated PTH level without localizing parathyroid adenoma on imaging?
This is a tricky question with a nuanced answer. If the hyperparathyroidism is secondary, cinacalcet may have a role in treatment along with normalizing serum phosphorus and vitamin D. However, metabolically active kidney stones are unusual in advanced chronic kidney disease. If the hyperparathyroid...
How would you treat metastatic pure tubulocystic renal cell cancer?
Tubulocystic renal cell carcinoma (tcRCC) is a very rare diagnosis--particularly metastatic tcRCC. To my knowledge, there are no clinical trials that have reported on these patients even in the basket non-clear cell RCC trials such as ASPEN (Armstrong et al., PMID 26794930) and ESPN (Tannir et al., ...
What are your management strategies for patients with recurrent nephrolithiasis and hypercalciuria who develop hypercalcemia after thiazide initiation?
My first concern is why. The thiazide may have unmasked primary hyperparathyroidism. I would get a PTH level plus serum phosphorus and vitamin D with a concurrent serum calcium to see if they are concordant. If not, it’s time to image the parathyroids. If no evidence of hyperparathyroidism, and hype...
In light of ARASENS presented at GU ASCO 2022, how do you approach treatment of de novo metastatic hormone sensitive prostate cancer?
There are multiple factors that go into treatment decisions for men with mHSPC, but two of the most important are volume of disease and de novo vs relapsed disease (i.e. prior local therapy). Volume of disease is one of the major factors for deciding on the benefits of docetaxel, with very limited b...