Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Given RADICALS-HD, are you completing 24 mo vs 6 mo of ADT with XRT following RP?
Initial: We know 2 years of ADT works. Adding to the classic RTOG 9601, RADICALS-HD demonstrated an improvement in the primary and clinically-relevant endpoint of MFS.Who should be offered 2 years is a more nuanced question. I rely heavily on the PSA to guide as I am influenced by the significant in...
Do you recommend treating asymptomatic Proteus urinary infections in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
Yes! Proteus species are typically rapid producers of urease, splitting urea to ammonium and raising urine pH, often into the high 7s and precipitating, magnesium, ammonium phosphate stones, otherwise known as struvite.Your patient’s Proteus infection apparently splits urea more slowly with less ele...
How would you treat a patient with history of stage I seminoma s/p orchiectomy with enlarging periaortic node and normal tumor markers on surveillance?
With respect to working up the enlarging lymph node, I agree with @Dr. First Last and @Dr. First Last above. If confident that this is seminoma recurrence, tumor markers normal, and if stage IIA or select stage IIB (select non-bulky, <=3cm) cases, our team advocates for radiation to the para-aortic ...
Are there instances when you recommend kidney stone disorder gene testing in patients suspected of having cystinuria?
If the patient has a stone analysis showing pure cystine, I consider that proof positive of homozygous cystinuria and do not recommend genetic testing for the patient. However, I suggest that first degree relatives get genetic testing for cystinuria, and, if homozygous, I recommend preventive treatm...
Do you recommend malic acid supplementation for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
F. Malic acid, like citric acid, is metabolized as a protonated acid and used as a metabolite—it produces no alkali. Malate is metabolized as an acid and in doing so takes up a proton—just as citrate does—producing new bicarbonate, and so is an alkali.Rodgers et al., PMID 24059642 reports malic acid...
Would you recommend against starting SGLT2 inhibitors in patients with a history of struvite nephrolithiasis who also have proteinuria and chronic kidney disease?
Yes! Although SGLT2 inhibitors are helpful in most patients with proteinuric chronic kidney disease, they can also exacerbate some coexistent conditions. Increasing glycosuria predisposes patients to UTIs. For patients with struvite stones, SGLT2s would likely exacerbate the infection and increase s...
How do you sequence abiraterone and enzalutamide in metastatic, castrate-resistant prostate cancer?
In my experience, abiraterone is better tolerated than enzalutamide. The main difference is fatigue. Quality of life seems no different to most of my patients when I add abiraterone to a GnRH agonist. However, patients frequently complain of substantially increased fatigue with the addition of enzal...
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...
For muscle-invasive bladder cancer with predominant (>90%) squamous differentiation, would you consider cisplatin-based neoadjuvant chemotherapy prior to radical cystectomy or upfront surgery?
While muscle-invasive bladder cancer (MIBC) patients with a minor variant histology component are treated similarly to conventional urothelial carcinoma (i.e., neoadjuvant cisplatin-based combination followed by surgery), there are no definitive data to guide the perioperative systemic therapy of th...
Would you consider enfortumab vedotin + pembrolizumab prior to surgery for a patient with urothelial carcinoma with regional nodes who is not eligible for neoadjuvant cisplatin?
The appropriate management for LN+ bladder cancer is not clear, and whether or not to use EV+pembrolizumab in this setting is also without significant data. Clinically and practically, there are so many gray areas in this question that the best path is at best charcoal-colored. Generally, systemic t...