Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you ever recommend testosterone replacement for men with incomplete T recovery after ADT for prostate cancer?
I have been hesitant to agree to supplemental testosterone after prostate cancer treatment, especially within the first few years. Prostate biopsies during that time often show atypical cells that are suspicious or adenocarcinoma with treatment effect. Androgens are pro-survival and the full effects...
Do you avoid potassium citrate in patients with recurrent nephrolithiasis and hypocitraturia if they also take antihistamine medications?
I know of no data showing effects of antihistamine meds on urine citrate or on the effects of potassium citrate on urine citrate. I made a Perplexity search which also found no evidence - this is not a topic I have personally researched because I have never encountered clinical issues about it. So -...
How do you define cisplatin ineligibility for muscle invasive bladder cancer?
We traditionally have been using the "Galsky criteria" published in 2011 based on consensus. We have looked into possibly lower threshold for estimated GFR, e.g. 50 ml/min, and possibly cisplatin "split dose" on a per patient basis if otherwise a patient is fit: Koshkin et al., PMID 29576445.Sometim...
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience wi...
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
What duration of ADT do you recommend for a patient with locally treated prostate cancer who undergoes metastasis-directed radiation therapy to a single oligometastatic bone lesion?
While I agree with @Dr. First Last that very small studies like STOMP and ORIOLE suggest that a small subset of men can delay the need for ADT by 1-3 years, this is not level 1 evidence. Most men with oligometastatic HSPC will still progress with metastasis directed therapy alone over a short time h...
Are patients with MIBC and bladder neck involvement good candidates for bladder preservation with chemoradiation after maximal, but not complete, TURBT?
Both BCON and BC2001 suggest that a complete TURBT may not be essential for bladder preservation. Incomplete TURBT is a surrogate for a higher stage and predicts poorer outcomes irrespective of the modality used for treatment.Elumalai et al., PMID 36517194
What would you offer for a very young patient with metastatic renal medullary carcinoma who has progressed on cisplatin-based chemotherapy?
Doxorubicin-based regimens (per our study here) adapted to context and EGFR-targeted therapies (see here, but do not use bevacizumab as discussed here and here) with prioritization for panitumumab-based therapy as discussed here (from 5:00 onwards) and in yesterday's IKCS: NA session on rare kidney ...
How do you approach managing patients with recurrent nephrolithiasis who have low supersaturation profiles due to polyuria and stable stone disease on imaging but do have persistent urinary abnormalities such as hyperoxaluria, hypercalciuria, and hypocitraturia?
If the stone disease is metabolically stable (no change in stone size or increase in number by serial CT imaging), I do not treat urinary chemical abnormalities. Presumably these patients have high levels of urinary inhibitors of crystallization. I encouraged them to continue their successful stone ...
Would you obtain an abdominal non-contrast CT study for further routine evaluation of stone burden in a patient with recurrent nephrolithiasis who recently completed an abdominal iodinated contrast CT study for non-stone purposes?
Often, there is no pre-contrast imaging, and stones cannot be counted well once contrast enters the kidneys. So, unless there was a pre-contrast phase, the contrast CT cannot be considered adequate for determining stone burden and new stone activity. So if either is at issue, I would obtain a non-co...