Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you proceed with penile prosthesis placement in a patient with a HbA1c of 9.5% based on recent literature finding that elevated HbA1c is not necessarily predictive of increased infection rates?
I would not. Although the literature is conflicting, large database and meta-analytic studies support higher infection risk with elevated preoperative HbA1c, while several high-volume multicenter studies show no predictive value. The signal is strongest at the extremes of poor control (~>8.5–10%), w...
In a young man with sickle cell disease who has presented to the ER with 3-4 episodes of recurrent ischemic priapism requiring takedown this year, when do you consider prophylactic therapy and what do you use?
First, I would encourage close follow-up with his hematologist to optimize management of his sickle cell disease (SCD). Based on data by Dr. Burnett et al., PMID 17100941 I typically start with low-dose (5 mg) daily tadalafil to help regulate the nitric oxide pathway in the phallus. I discuss variou...
Does Decipher provide any additional value in determining whether patients with metastatic hormone sensitive prostate cancer should receive chemotherapy?
Docetaxel has been part of the treatment paradigm for metastatic androgen pathway inhibitor-sensitive prostate cancer since the CHAARTED and STAMPEDE trials showed its value in addition to standard ADT, particularly in patients with "high volume" disease based on clinical features/lesion number from...
For patients with T1 bladder cancer who have severe obstructive uropathy/hydronephrosis, do you treat as high risk stage I disease, or clinically upstage and manage as a more locally advanced disease (NAC+RC)?
Clinical staging of bladder cancers with cystoscopy and imaging is associated with significant upstaging at immediate surgery nearly 25% of the time. Hydronephrosis is typically viewed as a T3 disease barring some other clear-cut cause high in the ureter such as a stone. Therefore, I prefer to have ...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
What would your approach be in a man currently on treatment for high-risk prostate cancer with ADT who does not have castrate levels of testosterone?
Yes, I would try alternative agents. If using Lupron, consider relugolix, degarelix, high-dose bicalutamide, or even adding an ARSI.
How do you approach extensive recurrent genital warts that have failed liquid nitrogen, imiquimod, 5 fluorouracil and electrodessication?
I have used 0.2 ml of Candida IL with success for recalcitrant scrotal warts (injected in 2-3 lesions). I used this study below as a reference. My patient cleared in 3 sessions (4-6 weeks apart), the study below states max 5 sessions.Nofal et al., PMID 31923442
How do you manage a patient who has a persistent urine leak after partial nephrectomy six weeks or more after drain and stent placement?
The stent is fine, but I would add a Foley catheter too for the next two weeks to see if the drainage decreases. Also, pull the drain back 2 cm, as sometimes it will actually keep the fistula open. If, with the drain pulled back, the stent is in the proper position (i.e., definitely in the renal pel...
In a patient with refractory OAB who's failed Botox once due to inadequate response, do you increase the dose, switch to sacral neuromodulation, or retry — and what actually drives that decision?
If you are confident the patient received an adequate Botox injection (i.e., you did it yourself as opposed to someone who might not have done an optimal procedure) and had an inadequate response, I would review the urodynamics result or perform urodynamics if not done already. If the patient has ve...