Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you advise your kidney stone patients about optimal daily fluid intake?
Measuring urine is better than counting liters of intake and shoot for 2-3 liters/day. If they aren’t getting up most nights to urinate they probably aren’t drinking enough water. When they get tired of drinking and urinating I tell them to remember the pain associated with their stone.
What is your approach to the medical management of struvite kidney stones?
It is difficult to separate medical and surgical management of struvite stones, since these stones are typically the consequence of persistent or recurring infections. Surgically, risk factors for infection need to be addressed, which may include efforts to remove any retained stone material, follow...
What dietary advice do you provide your patients with calcium oxalate nephrolithiasis?
High water intake (at least 2.5L of urine volume per day) Low sodium and low animal protein intake (high dietary sodium and high animal protein correlate with higher urine calcium) Normal dietary calcium balance around 1000mg per day (maintain bone health and ensure adequate dietary calcium to bin...
Do you use 24 hour urine stone risk profiles for purposes other than managing nephrolithiasis?
In patients with enteric risk factors for hyperoxaluria and kidney disease without a clear cause or in those with confirmed calcium oxalate deposition on kidney biopsy (even in the absence of history of kidney stones), I check 24-hour urine supersaturation. The data helps guide treatment approach to...
How are you managing patients with recurrent NMIBC with CIS who decline cystectomy with the recent BCG shortage?
https://suonet.org/resources/news/bcg-shortage-addressed-by-urologic-community.aspx
How would you treat margin positive, node positive (pN+) prostate cancer with detectable post-op PSA but negative PSMA-PET after radical perineal prostatectomy?
Ideally, enroll the patient in a clinical trial like NRG GU-008. Off trial, would treat with salvage RT to the prostate bed and lymph nodes with long term (2 years) ADT. You can consider an MRI to see if there's a nodule in the prostate bed to boost, which may be more likely given a positive margin....
How do you manage surveillance imaging for patients with metastatic castration-naive prostate cancer with an initial low PSA?
Low PSA progression is common at the time of radiographic progression in the mHSPC setting, particularly among men treated with potent AR inhibitors. As we recently presented in the ARCHES phase 3 study, while enzalutamide significantly improves rPFS and OS and reduces progression events, among thos...
How would you approach a patient considered to be unfit for cystectomy with recurrent NMIBC refractory to BCG, failed pembrolizumab and unable to do more intravesical Rx?
This seems to be a very difficult scenario, what are the reasons for not being able to pursue intravesical therapies? Nadofaragene firadenovec just got FDA approval, while there have been data with intravesical gemcitabine/docetaxel. We are waiting for the FDA decision on N-803/BCG combo (QUILT-3.03...
Would you consider bone antiresorptive therapy in mCRPC with only 1 lesion per PSMA scan?
This is an important question. One of the best studies to examine this is here:Francini et al., PMID 34292336 from the abiraterone chemo naive mCRPC multicenter cohort study, in which both survival and SRE free survival were improved with the use of bone resorption inhibitors, especially in men with...
How long after initiating ADT/androgen blockade is it acceptable to start docetaxel in a patient with high burden, de-novo metastatic HSPC where you are recommending triplet therapy?
In ARASENS, patients were allowed to enroll if they had received no more than 3 months of ADT prior to starting docetaxel +/- darolutamide. The biologic underpinnings suggest that the combination is most likely to be effective if given together. Therefore, I generally prefer to start the patient on ...