Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
If a patient has hydronephrosis in the immediate postoperative period following renal transplant, would you place a stent or nephrostomy tube?
The answer depends on the degree of hydronephrosis and whether there is obstruction. Is creatinine increasing? Immediately after transplant, recovery of ureteral peristalsis is delayed, and the collecting system may dilate somewhat. There may also be edema at the uretero-vesical junction that needs ...
Would you pursue cystoscopy and CT urogram in a young patient with one episode of gross hematuria and no other risk factors for bladder or kidney cancer?
Gross hematuria is treated very differently from microscopic hematuria. The correct board answer would be to offer a workup including upper tract imaging and cystoscopy. We would treat them like a high-risk microscopic hematuria patient. We have patients who develop bladder and kidney cancer who hav...
What steps would you take if the ileal conduit does not have enough length to reach the skin level during a robotic radical cystectomy and ileal conduit?
First, desufflate and proceed with this portion open. You may have enough length when the abdomen is totally flat (and not insufflated at all). If that doesn't work, you may cut deeper into the mesentery to let it pull up more, but watch out for the blood supply. Think about using SPY or Firefly to ...
How do you approach rising PSA following radical prostatectomy and early salvage radiation therapy?
There are several factors that I will take into consideration, including the patient's overall health, the interval from treatment to relapse, the PSA doubling time (rather than a PSA threshold), whether or not they're castrate resistant and whether or not they now have overt metastatic disease. Pat...
What treatment do you offer for patients with florid incontinence due to a patulous urethra secondary to chronic catheterization?
If you have adequate urethral length (which is usually not the case in this scenario), you could consider an obstructing fascial sling. Otherwise, the options are: SP tube, which often does not work due to the urethra being so incompetent, so UI continues Bladder neck closure + SP tube Ileal condui...
How do you manage persistent pain at the split-thickness skin graft donor site during the first postoperative week?
I have found that lidocaine patches adjacent to the area can be helpful. I also switched to a large Xeroform dressing over the donor site. I have found that this results in less oozing and discomfort, as well as fewer dressing changes.
What is your preferred treatment for patients with painful gynecomastia on anti-androgen therapy for prostate cancer?
Gynecomastia can be a significant morbidity affecting the quality of life in patients on androgen deprivation therapy, especially in patients who receive bicalutamide as monotherapy or at higher doses such as 150 mg a day. In patients who are younger and/or who may spend time in public without their...
How do you differentiate between asymptomatic bacteruria and a true urinary tract infection in pediatric patients with urinary diversions who have a positive urine culture?
This is a very good question without a perfect answer. Much research is ongoing to better understand this exact question. Currently, the best answer I can give is to rely on symptoms and the degree of pyuria. Pyuria suggests inflammation, so in the absence of pyuria, a positive culture is more likel...
How do you proceed if you cannot get a bellows reflex during stage 1 sacral neuromodulation procedure?
It depends on whether you can get great toe plantar flexion, or if the patient is awake, and if you get good sensation. If there is good "toe" and/or sensation, then it's reasonable to test that side; however, if you don't get either and based on fluoroscopy you are sure you are in S3 and depth good...
If a patient has abdominal tubing erosion within a few months of AUS placement and does not appear infected, do you need to replace the whole device?
Fortunately, this is a rare clinical scenario. The key question is whether the device is infected, which would necessitate complete explantation. If the wound and all other device components appear uninfected, then, in carefully selected cases, with appropriate informed consent, it is reasonable to ...