Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you reduce the potassium citrate dose for patients with recurrent calcium oxalate nephrolithiasis who are started on the medication but experience persistently elevated urinary pH levels above 7.0?
Yes. Urine pH that high may induce the formation of calcium phosphate stones. However, it is unusual for standard doses of potassium citrate to raise urine pH that much. I suggest you get a urine culture looking for urease-producing bacteria that can metabolize urea to ammonium and grow struvite sto...
What are your treatment recommendations in a patient with de novo metastatic prostate adenocarcinoma with neuroendocrine differentiation?
Neuroendocrine prostate cancer more often arises as a mechanism of treatment resistance than de novo, but in either case, portends aggressive disease biology and androgen insensitivity. Similar to the features of “aggressive-variant” prostate cancer described by Aparicio et al., PMID 26546618, the d...
How do you advise patients with recurrent nephrolithiasis who also have chronic mild hyponatremia for which they limit daily fluid intake?
Depending on the cause of hyponatremia, as you implied, our usual recommendation for recurrent stone formers to drink more fluid may be inappropriate or contraindicated. First, I would like to know the kidney stone composition. For example, if it is uric acid, we could prevent new stone formation an...
Would you prescribe a thiazide diuretic for patients with recurrent nephrolithiasis attributed to hypercalciuria in the setting of excess dietary sodium or animal protein intake who fail or are unwilling to adhere to recommended dietary changes?
Yes. Difficulty with dietary compliance is common, but there is no sense in being punitive about non-compliance. I would use what other treatments are available. Caveat emptor! A high sodium diet coupled with a thiazide diuretic often equals hypokalemia. Potassium supplementation might be in order, ...
Do you have patients with recurrent calcium oxalate kidney stones stop taking supplements containing vitamin C if their 24 hour urine oxalate excretion is normal?
No. I am not aware of data that suggests Vitamin C would aggravate kidney stone formation in this situation. Stephen B. Erickson, MD
How would you approach a fit older (>70 years) with grade I-II, bulky, follicular lymphoma causing ureteral obstruction and renal failure?
You could also consider focal radiotherapy as we know follicular lymphoma is often very radiosensitive (and can respond quickly to RT). Depending on the trajectory of the AKI and dysfunction, I would discuss with my urology colleagues to see if there is any role for ureteral stenting to see if kidne...
What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?
You have asked a complicated question. It is certainly possible for both conditions to coexist simultaneously. It would be unusual for primary hyperparathyroidism to cause secondary hyperparathyroidism, although recurrent obstructive uropathy from stones would be a possible etiology. Similarly, seco...
What are your management strategies for patients with nephrolithiasis and hypercalciuria who have a severe sulfa drug allergy and are unable to tolerate thiazide diuretics?
This is a difficult situation. Assuming the nephrolithiasis is calcium-based, I think the patient has to lean more heavily on dietary control. Dietary sodium restriction will decrease hypercalciuria. A further increase in fluid consumption will dilute the urinary calcium concentration. We are fortun...
Has the recent presentation of RADICALS-HD changed your ADT duration recommendations for patients receiving post operative radiation therapy for prostate cancer after radical prostatectomy?
The way I interpret RADICALS is that for adverse pathology meaning GS 8 and above, T3 disease or node positive who benefit from ADT would favor 24 over 6 months and probably these are patients who benefit from nodal RT also. For a favorable type prostate fossa only RT with unclear if any additional ...
What percentage of your patients receive hydrogel SpaceOAR?
T3+ or poor KPS, we don't use SpaceOAR.