Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you sequence therapies for a patient with chemotherapy-naive metastatic castration-resistant prostate cancer who is MSI-H on tissue-based NGS?
Yes, I absolutely would use Pembrolizumab (200 mg IV q3wk, or 400 mg IV q6wk) in a MSI-high patient with mCRPC who has not yet received chemotherapy. However, I would probably postpone this until after the patient has progressed on one novel AR-directed therapy. I think that the "sweet spot" for usi...
For patients undergoing bladder preservation therapy with trimodal therapy, how do you manage the urinary urgency and frequency during and after treatment?
This can be a difficult problem to manage because I try to avoid treatment interruption if at all possible, which is different from my approach in patients with prostate cancer, where treatment interruption is a safe and effective alternative. In patients with bladder cancer, the first thing I will ...
How does the POSEIDON meta-analysis results influence your decision on which patients should receive hormone therapy with post-operative radiotherapy for recurrent prostate cancer?
POSEIDON is another landmark analysis from the MARCAP consortium. It adds to the seminal work performed in localized prostate cancer (Kishan et al., PMID 35051385), which serves as the reference study for the use and duration of ADT with radiotherapy, but now in the post-prostatectomy setting.The st...
Do you find DFS as defined in POTOMAC a clinically meaningful endpoint for high-risk NMIBC, given that low-grade recurrences manageable with repeat TURBT would have qualified as events?
In my opinion, in patients with such an early stage of disease such as NMIBC, Disease-free survival (DFS) is a meaningful endpoint. Low-grade recurrences were excluded, and therefore, the clinically meaningful endpoints were preserved.
In a patient with biochemical recurrence after radical prostatectomy for pT2 disease and a high-risk Decipher genomic classifier, with a PSA of 0.7 ng/mL, is there a rationale for administering salvage radiation therapy to the prostate fossa?
Yes, salvage RT to the prostate fossa (+ ADT/ pelvic lymph nodes) would be considered the preferred option in this circumstance, in my opinion (see NCCN 2026.3). Despite the PSA being higher than is typical in 2026 and some risk factors for not responding to RT (e.g., margin-negative resection), it ...
Would you continue serial PSMA PET scans after 2 negative scans for patients with a persistently rising PSA post-RT?
Some context would probably be helpful for this. E.g., PSA >2 is different for a patient post-prostatectomy vs. post-radiotherapy. But, in general, if clinical suspicion of cancer recurrence/progression is high, and PSMA PET is negative, one can consider the following options: There may not be a ca...
What is your approach to post-kidney transplant erythrocytosis for an asymptomatic patient already on ACEi but with Hb consistently >18?
My approach is to rule out non-transplant-associated causes of erythrocytosis (examples include obstructive sleep apnea, checking for renal artery stenosis, etc.). Once the diagnosis of post-kidney transplant erythrocytosis has been met, we typically use ACEi/ARB as you mention in the question. If t...
How do you treat decreased libido from SSRIs?
Serotonin-1 agonism will revert it in about 60% of cases. You have a choice of adding buspirone at about 30 mg bid or going to vilazodone which has already an SR1 agonism. Some bupropion, not clearly understood at about 300 mg can also do it. Or if possible, use vilazodone, bupropion, or mirtazapine...
For a patient who presents with >1L urinary retention and normal labs, do you recommend observation and serial labs or discharge with a Foley?
My usual strategy for a patient such as this is place an indwelling catheter for a period of time (at least 3 days but no issues if want to wait a bit longer - maybe a week or so) and then bring back to the office for a voiding trial. No need for serial labs unless there is a concern for post-obstru...
Is REZUM (water vapor thermotherapy for BPH) safe after EBRT?
Although I am not aware of any studies evaluating the toxicity rates in patients undergoing REZUM after RT, I am aware of a few studies reporting the toxicity of TURP after RT. For example, Liu and colleagues conducted a retrospective review of the outcomes of 1,192 patients, 246 of whom underwent a...