Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
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...
How would you approach de novo metastatic castrate sensitive prostate cancer with extensive locoregional spread causing rectal compression, retroperitoneal lymphadenopathy, and PSA >3000 but no visceral or bone metastases?
It sounds like from the question that the patient has T4 disease invading the rectum. This makes the patient ineligible for surgical resection with curative intent. He might still be a candidate for curative intent radiation therapy/ADT +/- abiraterone per STAMPEDE. His highly elevated PSA is very w...
Will you offer adjuvant nivolumab for high-risk muscle invasive bladder cancer based on results of CheckMate 274?
CheckMate 274 met the co-primary endpoints of statistically significant improvements of DFS in all-comers (HR 0.70) and the PD-L1+ (HR 0.53) populations. These endpoints were presumably chosen by the investigators in discussion with the FDA for a registration trial like this, given that improved DFS...
Does your treatment strategy differ when managing patients with recurrent calcium oxalate monohydrate versus calcium oxalate dihydrate stones?
I manage calcium oxalate monohydrate and calcium oxalate dihydrate stones the same way. Based on my laboratory studies of calcium oxalate crystallization, the differentiating feature between these two stone types is likely related to differing inhibitor properties of urinary proteins; forming the di...
Do you recommend stopping triamterene in patients with recurrent kidney stones who have stone composition results consistent with calcium based stone disease?
No. Decades ago, some triamterene containing kidney stones were reported. However, I have not seen one in many years. Typically, when I start a thiazide-type diuretic for the treatment of hypercalciuria, I do not add a potassium blocker since my patients have been instructed in a sodium-restricted d...
Do you have a preferential 24-hour urine lab test between urine urea nitrogen, urine protein catabolic rate, and urine sulfate when evaluating a recurrent calcium based stone former who has hypercalciuria presumed secondary to excess animal protein intake?
No. I refer most of my stone patients to the stone clinic dietitian who takes an accurate history of dietary nutrient intakes, including protein, and makes recommendations accordingly. Stephen B. Erickson, MD
At what PSA level would you consider restaging a patient who was treated with ADT and radiation and had undetectable PSA?
The criteria for defining PSA relapse after radiation therapy remains the Phoenix criteria (see Roach et al., PMID 16798415), which is essentially nadir + a 2 point rise in serum PSA. Thus, a patient who achieves an undetectable PSA on ADT/RT but then experiences a PSA rise would not meet PSA relaps...
Are there instances when you recommend oral phosphate for patients with recurrent nephrolithiasis?
Yes. There have been two studies both done long ago looking at the effectiveness of oral phosphates in preventing kidney stones. The first using K Phos Neutral was done at Mayo and showed a decrease in the frequency of stone passage. The second, done in a California system, used K Phos Acid and show...
How long do you wait to repeat a 24 hour urine stone risk study after stopping topiramate in patient with recurrent calcium based kidney stones attributed to the medication?
Assuming normal or near normal GFR, topiramate should be effectively eliminated after approximately 5 days, and urine pH should have returned to its pretreatment level. If more data is desired, a 24-hour urine supersaturation could be collected then. Topiramate predisposes to kidney stones by inhib...
In obese men presenting with gynecomastia, elevated estrogens, and hypogonadism, what clinical factors would push you to obtain testicular and/or adrenal imaging to rule out an estrogen-producing tumor?
It is not generally necessary or useful to measure serum estradiol in the evaluation of acute (tender and/or growing) gynecomastia. The widely available estradiol assays are generally immunoassays that are not accurate at the low estradiol concentrations in men. In addition, it is not uncommon to se...