Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you avoid low-dose radiation CT stone scans in obese patients with recurrent nephrolithiasis given concerns for inadequate stone detection?
Given about 55% sensitivity of US, I am fine with the reduced sensitivity of low dose CT in obese patients. It is better than the alternative. I do not know off hand if trials have estimated the loss of counting accuracy in the obese, and I suspect it will depend a lot on details of patient selectio...
How do you approach systemic therapy for metastatic prostate cancer in geriatric patient when progressed to mCRPC on ADT alone?
This is an important question and requires a careful balancing of scientific and medical knowledge versus clinical skill. (1) The first key issue is the context of the question -- what is meant by "frail", what has caused the "frailty", and what is the anticipated life expectancy of the patient. If ...
Other than oxybutynin or mirabegron, what pharmacological and non-pharmacological treatments would you consider for increased urinary frequency (not caused by infection, medications, or resulting in incontinence)?
There are a lot of other treatment modalities, all with benefits and potential side effects to weigh. The place to start, of course, is with behavioral modifications like afternoon/evening fluid management, caffeine reduction, timed voiding, urgency suppression techniques ("biofeedback"), and pelvic...
How exactly would you utilize ADT via leuprolide or bicalutamide with salvage RT post prostatectomy with PSA >0.5?
The dilemma on the need for hormonal therapy in the salvage radiation setting after radical prostatectomy is a major one in current clinical practice, driven by the modest survival benefits seen in the RTOG 9601 trial with 2 years of bicalutamide (Shipley et al., PMID 28146658), but also follow up s...
Do you recommend cholestyramine for your patients with recurrent nephrolithiasis secondary to enteric hyperoxaluria?
Although it is reasonable to use it, my experience has been mixed. Sometimes, I have found a reliable fall in urine oxalate; other times, no. I have not published any research on this topic, but have reviewed the literature and in it find more or less the same as in my practice. So I can see no reas...
What is your approach to patients with recurrent nephrolithiasis and low urine volumes who struggle with increasing fluid intake following a sleeve gastrectomy procedure?
This is a difficult situation for both the patient and the provider. I think the best solution is for them to drink small quantities of fluid frequently. This creates a compliance problem. I encourage patients to have fluid regularly available, meaning that they may have to take it with them to work...
With multiple PARPi + ARSI combinations now approved, how are you selecting which combination to use for a patient with BRCA mutated mCRPC?
As of this writing, we have 3 choices for a man with mCRPC and a BRCA2 mutation who has never had a prior ARSI and is now progressing on ADT with or without docetaxel in the mHSPC setting or ADT in the nmCRPc setting. Abiraterone plus olaparib has the longest follow up and a clearly significant over...
What adjuvant therapy would you offer for a cisplatin-eligible patient with upper tract urothelial carcinoma and Lynch Syndrome?
Good question and discussed it with Dr. @Dr. First Last. We have seen data from the POUT phase 3 trial (Birtle et al., PMID 32145825) showing significant DFS benefit with adjuvant Gem/Cis vs observation after radical surgery (due to study closure the trial was not powered to show OS benefit) in pati...
In patients with hypogonadism, when do you recommend subcutaneous over intramuscular testosterone injections?
Patient's choice. Both work well when given weekly.
How do you approach incidental image findings with unclear clinical significance?
I approach them as findings, regardless of how they were acquired they need to be managed. In primary care one of the biggest drivers of malpractice cases is failure to act on a finding, just because it wasn't something you were directly looking for does not protect you. So manage the finding. Work ...