Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you continue pembrolizumab in a patient with BCG-refractory NMIBC with CIS who has a negative surveillance cystoscopy (including random biopsies) but positive urine cytology?
More important priority at this point is to evaluate the positive cytology. If the random biopsies were done with white light cystoscopy only, I would consider blue light and repeat biopsies and would also evaluate the upper tracts and prostatic urethra.
Do you routinely prescribe acetazolamide for patients with cystinuria who do not have significant urinary alkalinization or are intolerant to citrate therapy?
I have not used acetazolamide in this situation, although it makes good physiological sense, as urinary alkalinization increases urine cystine solubility. Sodium bicarbonate would be a bad idea because natriuresis increases cystinuria. I have used potassium citrate historically, and it is generally ...
What type of surveillance plan should one use to follow a young person after orchiectomy for a >3cm pure mature teratoma of the testicle?
I presume hCG and AFP were normal as well as appropriate imaging studies, thus a clinical stage I pure teratoma. These patients have a 25% probability for relapse and should be on regular surveillance. We have published on this topic previously. We prefer studies ( serum hCG, AFP, abdominal CT scan ...
What is your approach to patients with muscle-invasive bladder cancer who are ineligible for neoadjuvant cisplatin-based chemotherapy?
The data supporting the use of neoadjuvant chemotherapy for bladder cancer is derived from 2 randomized trials and a meta-analysis. The randomized trials demonstrating benefit used MVAC and CMV, respectively, both cisplatin-based combinations. The meta-analysis results support the use of neoadjuvant...
Should patients with muscle invasive node negative bladder cancer wishing to have bladder preservation receive chemoRT alone or neoadjuvant chemotherapy followed by chemoRT?
The best evidence that we have does not support neoadjuvant chemotherapy before chemo-RT for bladder cancer. One RTOG trial, admittedly underpowered, and the MRC meta-analysis suggest that, while that benefit may exist for cystectomy, it either doesn't exist or is simply too small to detect for chem...
Do you routinely check a TSH level in patients with recurrent kidney stones who have hypercalciuria of unknown cause?
No. Although hyperthyroidism is a reported cause of hypercalcemia and hypercalciuria, it must be very rare cause of nephrolithiasis. I suspect the patient would be obviously hyperthyroid on examination. Hyperparathyroidism is a much more common cause of kidney stones. In my practice, if the stone an...
What is your approach to recurrent uric acid stone formers who have a persistently acidic urine pH and are unable to tolerate potassium citrate?
I use sodium bicarbonate. I teach the patient how to titrate the dose using pH dipsticks to get the urine pH >6.0. Although sodium may increase urine calcium excretion, in uric acid stone formers, this is not an issue. Long experience with sodium bicarbonate tells us it does not raise blood pressure...
What is your approach to management of recurrent nephrolithiasis in patients with mixed composition uric acid and calcium phosphate stones?
Likely the urine pH is more typically low in such patients, since the uric acid components will dissolve during periods of higher pH. Consequently, the appearance of uric acid crystals in the stone suggests that the urine pH is more typically low. Drinking more fluid to cause more dilute urine alway...
Are there patients with recurrent nephrolithiasis for who you recommend magnesium supplementation to reduce stone risk?
While magnesium supplementation may be justified on theoretical grounds, I have never used magnesium supplements as a treatment exclusively for kidney stones. I have only ever seen or used magnesium supplementation in stone patients that had concurrent hypomagnesemia.
What is the current recommendation for using thiazide diuretics in patients with calcium oxalate stone disease, given the negative results of the NOSTONE trial?
This trial will have no effect on my practice. Seven of 10 previous studies of thiazides for stones were positive, as was a meta-analysis. My preference is for the longer-acting drugs indapamide and chlorthalidone; I haven't used HCTZ which is probably a twice-a-day drug, for some years. Note that t...