Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What are some measures to prevent flares of loin pain-hematuria syndrome?
Loin pain hematuria syndrome is a difficult problem because there are multiple potential causes that require individual solutions. For example, nutcracker syndrome requires decompression of the left renal vein. Recurrent kidney stones require the expertise of a urologist skilled in ureteroscopic or ...
What is your approach to treating genital lichen sclerosus that is not responding to super-potent topical steroids?
Biopsy is the next step if it was never done to rule out SCC or another alternative process since clobetasol typically works in these cases. Traditionally, methotrexate has been a standard treatment. However, more recently, I've started using Rinvoq off-label with great efficacy.
What is the optimal sequence of available therapies in patients with BRCA+/HRR mCRPC after progression on first line combinations?
We have data that chemotherapy is generally superior to next-line ARSI. However, we are still lacking definitive data on sequencing chemotherapy and PARPi. Based on my clinical experience and what can try to learn from studies regarding the toxicities of chemotherapy and PARPi, I believe that PARPi ...
Are there any instances when you use vitamin B6 to prevent kidney stones in patients with recurrent calcium oxalate nephrolithiasis who do not have primary hyperoxaluria?
I occasionally try empirical vitamin B6 in patients with hyperoxaluria that does not respond to usual dietary oxalate restriction plus low fat and higher calcium. I have not done it systematically and have only a handful of cases where it may have helped. Thus, I would not recommend routinely adding...
What is your approach to managing patients with recurrent nephrolithiasis who have 24 hour urine chemistry results that demonstrate low risk for stone formation but continue to experience stone events?
My first question is what constitutes a "kidney stone event"? If it is a stone passage, l know of no treatment that will "glue" pre-existing stones in place. Uric acid and cystine stones can be dissolved, however. If the event is the formation of new stones or the growth of preexisting stones with n...
Do you use an age cutoff for prostate brachytherapy?
There is no age cutoff (low or high) to define the appropriateness of brachytherapy.
How do you manage de novo high volume mCSPC with both BRCA2 mutation and MSI-H on somatic testing?
This is a very rare but interesting scenario. Presumably in this case, the BRCA2 mutation is a passenger event in the setting of high TMB as a result of MMRD/MSI high disease, which has been reported. Typically these BRCA alterations are monoallelic and the tumors lack homologous repair deficiency a...
In which patients with nephrocalcinosis and an incomplete distal RTA would you consider further testing for medullary sponge kidney?
Yes, definitely. The better question is how to test. Since sponge kidney is an anatomical disorder of dilated collecting ducts in the renal papillae, it's best to look anatomically. These are 3-dimensional structures and are best seen with a 3-dimensional image. We no longer have intravenous pyelogr...
For patients who progress to mCRPC on ADT+ARSI started in mCSPC setting, do you continue the ARSI if patients have had a mixed response?
A "mixed response" can mean many things and the specific circumstances are critical for decision-making here. For example, bone scan flare, or pseudoprogression, with new unconfirmed lesions, is quite common with ADT/ARSI therapy and should not be a reason for treatment discontinuation as per PCWG2/...
Would you extrapolate from EMBARK to use an ARPI other than enzalutamide in high risk biochemically recurrent prostate cancer for a patient with contraindications to enzalutamide?
This is a good question and my general answer is no, as no other ARSI has a phase 3 trial in this nmHSPC setting showing similar benefits. PRESTO was a smaller phase 2 trial of ADT/apalutamide but did not measure or report MFS or OS and was underpowered to look at these endpoints. However if a patie...