Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Is it ever acceptable for high risk prostate cancer patients to be treated with upfront radical prostatectomy?
This is an excellent and timely question. There is definitely an increasing trend of patients with high-risk prostate cancer (PCa) receiving upfront radical prostatectomy (RP). Some of this is spurred by a recent, high-profile meta-analysis (https://www.ncbi.nlm.nih.gov/pubmed/26700655), which poole...
How do you decide between RPLND vs. chemotherapy in patients with Stage IIA mixed germ cell tumor as primary treatment?
I agree but would add a few comments: If there is a rising hCG or AFP above normal values, we prefer BEP X 3 rather than RPLND. If the patient > age 50, EP X 4. Also, we consider any AFP < 25 to be “ normal” despite many labs listing 0-8 as their normal range. Our group recently published data in J...
What is your approach to treating antibody-mediated rejection in a pregnant patient with a kidney transplant?
This is a very difficult situation. Presumably, this is late AMR, and to begin with, we would have very few treatment options. I would first optimize immunosuppression and consider IVIG and solumedrol, and defer further treatment until after delivery. We have not used rituximab in pregnancy. Rituxim...
When would you recommend uric acid-lowering therapy for a patient with asymptomatic hyperuricemia without comorbidities but with family history of gout?
I would not recommend treating asymptomatic hyperuricemia unless the patient has clinical gout or concern for proven urate nephropathy (such as with uric acid kidney stones). The family history component is important to acknowledge that the patient may be at greater risk in the future, however, it d...
At what PSA level do you offer early salvage radiotherapy?
For a patient with pT3 disease or positive margins, once the PSA is confirmed detectable, rising, and the patient is well-healed, it is appropriate to treat. Given the results from the now 7 adjuvant vs. salvage trials, delaying well past a PSA of 0.2 is associated with the need for more aggressive ...
Would you start stone preventative medications such as potassium citrate and thiazide diuretics for patients with recurrent calcium based nephrolithiasis and abnormal 24 hour urine chemistries if they no longer have calculi on most recent imaging testing?
If they have had stones previously they remain at risk of recurrent stones. Would want to know when was the last stone episode. Was there previous treatment? It would be based on the results of the 24 hr urine and how significant is the hypercalciuria, oxaluria, low the citrate and pH are. Most impo...
Do you utilize genetic testing to guide ADT for men receiving XRT for intermediate or high risk prostate cancer?
This question is currently the subject of an NRG Oncology trial (https://clinicaltrials.gov/ct2/show/NCT05050084) and I would encourage participation so that we can get a data-driven answer to this important question as soon as possible. Outside of the context of a trial, I do not currently use gene...
Do you have patients with recurrent nephrolithiasis target a certain urine volume or rather consume fluids as needed for goal of having consistent clear urine?
I think you could go either way. To prevent most types of kidney stones, 2L/day seems to be the minimum urine volume required. For cystine stone formers, I double that amount. My more compulsive patients like having a quantitative goal. The amount of fluid intake roughly equals the urine volume, abs...
Is there any evidence that spironolactone or finasteride therapy increase blood levels of testosterone?
Yes. It seems that both medications can do this at least in the short term. Spironolactone's effect may be more temporary.For spironolactone, an older article: Tidd et al., PMID 152681For finasteride: Stanczyk et al., PMID 23474436
What adjuvant therapy would you recommend for a cisplatin and IO ineligible patient with node positive urothelial carcinoma with mixed histology?
This is a difficult situation and I agree that there is evidence for adjuvant carboplatin-gemcitabine in cisplatin-ineligible patients with high-risk upper tract urothelial carcinoma, although benefit appeared more modest compared to cisplatin-gemcitabine (POUT trial). It is reasonable to extrapolat...