Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you routinely obtain a PSMA PET scan before definitive treatment in all patients with unfavorable intermediate-risk prostate cancer?
Yes, I think staging in these patients is essential. In addition, if considering a nerve-sparing or focal therapy, PSMA PET/CT can confirm disease localization and potentially identify off-target areas of concern.
In a frail older adult with moderate-to-severe lower urinary tract symptoms, when do you start a beta-3 agonist like vibegron over an anticholinergic?
In a frail older adult with OAB-predominant moderate-to-severe LUTS, I generally start a β3 agonist (vibegron or mirabegron) as the first-line pharmacologic option once behavioral interventions are insufficient. Behavioral therapies may include fluid management, bladder retraining, pelvic floor exer...
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
Is there a PVR cutoff or “percent empty” cutoff you use to determine if an asymptomatic patient needs a Foley catheter?
There is no universal, evidence-based cutoff that mandates Foley catheterization in an asymptomatic patient based on PVR alone. Clinical judgment integrating voiding function, upper tract status, renal function, UTI history, and patient preference guides the decision. The PVR is one data point, not ...
Do you still routinely prescribe anticholinergics for OAB in patients over 70 without baseline cognitive impairment given the concern for dementia in recent studies?
In patients >70, I generally favor a β3-agonist first because of the growing observational association between cumulative anticholinergic exposure and dementia.Anticholinergics are not absolutely contraindicated, but I would avoid chronic oxybutynin and favor a lower CNS-penetrating agent such as tr...
Is there a PVR cutoff over which you worry about urinary retention when giving bladder botox to spontaneously voiding patients with suprapontine lesions?
I am not worried about numbers, but symptoms. If the patient is improved and happy, then I am not concerned about PVR unless infections become an issue.
What interventions do you recommend for patients with a chronic catheter who have recurrent blockage due to sediment?
The first thing to do is to perform a cystoscopy to ensure that there are no stones and or significant debris that is obstructing the catheter. Particularly in the face of infection, stones may form very quickly. At the time of the cystoscopy, make sure that there are no stones and irrigate all debr...
Would you recommend a bladder outlet procedure in a patient with a large obstructing prostate but little to no bladder function on urodynamics?
Given the large obstructing prostate, an outlet procedure may be reasonable despite little to no detrusor contractility. However, the expected benefit is less predictable than in patients with preserved detrusor function. The procedure may relieve obstruction, but it cannot restore bladder contracti...
How do you counsel patients on the potential temporary and permanent side effects of finasteride?
I have a standard discussion where I highlight the very effective profile of these drugs to decrease prostate size and improve male baldness. But, I do let people know the potentially devastating side effects of libido loss and erectile dysfunction. I let them know most men recover if they stop the ...
What explains a free testosterone that seems disproportionately elevated relative to total testosterone, particularly when SHBG isn't available to interpret the ratio in a male not taking supplemental T?
It’s a tricky question as we don’t know how free or total T was measured. If the total T was a biotinized assay, which most are, the total T could actually be spuriously high, so inquiring about biotin supplements and stopping them for 3 or more days before repeating the test is a good idea. If the ...