Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How do you reconcile discrepancies in clinical prostate cancer staging with AJCC and NCCN?
Fundamentally, I use NCCN risk categories to help steer conversations about staging and treatment options for very low vs low vs fav int vs unfav int vs high risk diseases. Therefore, I use NCCN staging in my clinical practice and notes and incorporate mpMRI into staging. I find it comforting that N...
Do you routinely recommend decreasing dietary animal protein intake in patients with recurrent calcium oxalate nephrolithiasis who are found to have hyperoxaluria on 24 hour urine studies?
This is an interesting question. I focus more on total protein intake rather than which type in my initial assessment and make sure that the patients are meeting guidelines there first (0.8-1g protein/Kg of lean body weight). I address hyperoxaluria in my review primarily through addressing the usua...
What agent and for how long would you treat a patient with asymptomatic azole-resistant C auris candiduria who is planning to undergo a urological procedure?
I would be cautious here. If there are reasonable MICs to fluconazole (SDD but achievable), this would be preferred. Intravesical amphotericin is a good option. But, if this were impossible to achieve, I would be reluctant to use IV amphotericin in any formulation, since there's a risk of harm, and ...
How do you follow/manage patients with metastatic prostate cancer with undetectable PSA and castration-sensitive but active disease on PSMA PET?
Summary: This is a challenging clinical scenario, and one in which I think there is currently a lot of practice variability. In such cases, I would not jump to action immediately, and I would first try to obtain some additional information. This would include repeat PSA for confirmation as well as f...
How do you manage prostate cancer in patients that cannot swallow pills?
The only one suitable for feeding tube administration is apalutamide (must be 8 French or greater feeding tube size). My oncology pharmacist suggests tablet(s) can be placed in a syringe (whole, not crushed), distilled water then added, shaken vigorously to disperse contents, administered through...
How would you approach an isolated prostate recurrence of high-risk prostate cancer following definitive EBRT?
It is important to know: 1) time from cessation of hormones and time to recurrence. Better to also have T levels. 2) velocity of PSA rise. 3) absolute PSA value Longer disease free interval, slow PSA kinetics and low PSA suggests prostate only recurrences. I have also begun to incorporate Aximun s...
What time frame, number of PSAs, and calculator do you use for calculating PSA doubling times?
I typically use only values of 0.10 ng/mL or greater, and at least 3 separate PSA values that are at least 3 weeks apart from each other. The greater the number of PSA values, the more accurate the PSADT calculation will be. I like to use the MSKCC calculator: Prostate Cancer Nomograms: PSA Doubling...
Do you prefer kidney ultrasound or a non-contrast CT scan to evaluate for nephrolithiasis in an asymptomatic patient with primary hyperparathyroidism?
I first order an ultrasound due to the lack of concern for radiation exposure and if it is equivocal then follow-up with a CT scan. Ultrasound is not as sensitive as a CT scan especially for very small stones.
What is your approach to patients who insist on testosterone replacement therapy despite normal testosterone levels on repeated labs?
I explain that with a normal testosterone level there is no indication for testosterone replacement. Hormone replacement is always about evaluating risks and benefits. With a normal testosterone level the risks outweigh the benefit. I offer to evaluate causes for patient’s symptoms such as sleep apn...
What are your top takeaways in GU Cancers from ASCO 2025?
Here are the top 3 prostate cancer studies: AMPLITUDE. LBA5006: Attard and colleagues show that the PARP inhibitor niraparib plus abiraterone/prednisone delayed rPFS in men with mHSPC (HR 0.63, p = 0.0001), meaning this is the first ARPI/PARPI successful combination in this hormone-sensitive HRRm se...