Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you prefer still over carbonated water for your patients with recurrent nephrolithiasis who have chronically low urine volumes?
My main concern is hydration. Stone formers tend to be un-thirsty folks, and it is hard to get them to drink anything, let alone my minimum of 2L daily. Generally I recommend plain water; old research found no difference between hard and soft water. To the extent that carbonated water alkalinizes u...
Do you transition patients with recurrent nephrolithiasis and hypercalciuria off of hydrochlorothiazide in favor of an alternative thiazide diuretic?
No. Assuming the patient tolerates HCTZ well, and it is effective in lowering hypercalciuria, I continue it. Most of the thiazide research has been done using this agent. Stephen B. Erickson, MD
What is your approach to managing acidic urine in patients with recurrent uric acid nephrolithiasis who have normal urinary citrate levels?
After appropriate dietary advice from our Stone Clinic dietitian, I preferentially prescribe sodium bicarbonate tablets, teaching the patient how to adjust the dose using pH strip testing to reach the desired urinary pH. pH testing should be done frequently, as urine pH is in part dietary dependent ...
In which prostate cancer patients, if any, do you consider adding ADT to adjuvant radiation therapy following prostatectomy?
Two trials (RTOG 9601 and GETUG-AFU 16) have demonstrated a benefit to adding ADT to salvage radiotherapy, and both required a minimum PSA of 0.2 ng/ml or higher. In RTOG 9601, the subgroup of patients who appeared to benefit most from ADT were those with PSA >0.7 ng/ml, suggesting that concurrent A...
Do you recommend genetic testing for patients incidentally found to have nephrocalcinosis on imaging?
In general, yes, but it’s usually not my first step if my family history is negative for nephrocalcinosis. These patients typically have unusually alkaline urine and often pass calcium phosphate stones. I rule out primary hyperparathyroidism and incomplete distal RTA. I look for medications that can...
Can you/do you use an androgen receptor blocker alone in patients with metastatic hormone-sensitive prostate cancer who cannot tolerate GnRH-directed therapy?
Anti-androgen monotherapy for hormone-sensitive (M0 or M1) prostate cancer is not currently supported by FDA approvals or NCCN/AUA guidelines. Two recent studies that have explored enzalutamide monotherapy in patients with M0 and/or M1 hormone-sensitive prostate cancer are shown below. Enzalutamide ...
Would you offer adjuvant immunotherapy (pembrolizumab) for chromophobe RCC with R1 resection?
I have not experienced this situation yet in my own clinical practice but I would not offer adjuvant IO nor adjuvant radiation therapy for this patient. IO therapy has limited efficacy in this histology. This was shown best in the KEYNOTE-427 (monotherapy pembrolizumab in metastatic nccRCC, McDermo...
For HRRm prostate cancer, will you use olaparib alone or in combination with abiraterone?
The combination of a PARP inhibitor with a next-generation hormonal agent, including the combination of olaparib with abiraterone acetate, is not an FDA-approved combination and I do not recommend using it at this time. Both PROpel and MAGNITUDE showed a PFS benefit for the combination versus abirat...
When would you use PARP inhibitors in patients with refractory metastatic castrate resistant prostate cancer with somatic non-BRCA HRD mutations?
This is a very relevant question as clearly there is major heterogeneity in the outcomes with both olaparib and rucaparib in men with mCRPC based on their underlying germline or somatic tumor genomics. In addition, prior therapy and available alternatives including clinical trials with more or less ...
What is your general approach to treatment sequencing of available regimens in castration-resistant metastatic prostate cancer?
For mCRPC, my general approach with standard agents is a next-generation AR agent (typically started in the CSPC setting), followed by docetaxel, followed by Lu-PSMA. If disease is progressing slowly and is PSA producing, I will consider a switch from a first-line to a second-line hormonal agent, ty...