Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
Do you recommend sperm banking for males prior to undergoing radiation?
To the first question in the prompt, I would recommend sperm banking for any patient who was receiving a sufficiently high radiation dose to the testes and desired fertility preservation. In my practice, this are few patients, although it is an important consideration for younger patients. To the se...
Do you recommend obtaining 24 hour urine ammonium levels in patients with recurrent uric acid nephrolithiasis?
An astute question! As you imply, uric acid stones have very little to do with uric acid! Otherwise, we would see more sodium urate, potassium urate, and ammonium urate stones, which are very rare. Uric acid (hydrogen urate) stones are highly dependent on a lower-than-normal urine pH. The two main r...
How would you treat high risk prostate cancer in a patient with autonomic bladder dysfunction?
Personally, I have not treated a large number of such patients, but they've generally had this problem due to diabetes or Parkinson's disease. However, it might be prudent to wait for the workup for an etiology before starting radiation therapy. For high risk patients, you're generally considering a...
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...
Do you avoid losartan in patients with hypertension and uric acid nephrolithiasis due to the drugs uricosuric effects?
This is an important question. I continue to use losartan or other uricosuric drugs in uric acid stone formers. Control/prevention of uric acid stone formation is primarily related to raising urine pH to 6.5 (at least above 6), since uric acid solubility is so strongly dependent on pH. Any minor inc...
Would you wait a period of time before collecting a 24 hour urine stone risk study in a patient with nephrolithiasis who recently underwent a urologic stone removal procedure?
I generally recommend waiting until the patient is back to steady state, stents are out, pain controlled, and they are back to their usual diet. This time period after urologic procedure varies depending on what the procedure is and if any post-procedure complications and their management.
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
Will you now recommend enfortumab and pembrolizumab for most patients with metastatic urothelial carcinoma, regardless of platinum eligibility, based on the EV 302 presentation at ESMO 2023?
The data presented at ESMO were paradigm-shifting. Within the constraints of insurance coverage, I will offer EVP to all patients with untreated metastatic urothelial cancer who are otherwise candidates for this therapy.
How do you manage vitamin D dosing in patients with nephrolithiasis and hypercalciuria who require supplemental vitamin D for treating other medical conditions?
This is a common treatment for osteopenia/osteoporosis. For calcium stone formers, I watch for hypercalcemia and/or hypercalciuria. If present, I reduce the dose of calcium and/or vitamin-D until their urinary parameters normalize. Otherwise, I think they can take these medications safely in standar...