Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
How do you choose between initiating long-term therapy with mTOR inhibitors versus opting for interventional treatments such as embolization or surgery in a patient with tuberous sclerosis, experiencing flank pain, and with renal angiomyolipomas larger than 4 cm?
I have very limited experience, but mTOR has been a game changer for my (2) TS patients. Why would you wait for bleeding, pain, and embolization if you can prevent it?
Do you advise your patients with cystinuria to perform home urine pH testing?
Definitely! Keeping urine pH above 7.0 is one of the most effective ways of preventing cystine crystallization. pH testing strips can be purchased cheaply on the Internet or in “big box” stores. (Pharmacies are much more expensive). I suggest testing four times daily and adjusting the urinary alkali...
For a patient with idiopathic hypercalciuria and a history of calcium kidney stones who has not normalized 24-hr urine calcium level on thiazide diuretic, is there evidence for targeting a certain urine calcium level for decreased future risk of nephrolithiasis and osteoporosis?
A good question, and the answer depends on your definition of a "normal" urine calcium level. If you use the standard definition of abnormal, the upper 5 percentile, depending on your laboratory, you will get values for upper normal calciuria in the 250-300 mg per day. However, approximately 10% of ...
How would you treat a patient with biopsy-proven recurrent urothelial bladder cancer with M1a disease (limited to retroperitoneal nodal disease)?
Systemic therapy with either clinical trial, or chemotherapy (ideally cisplatin-based or carboplatin/gemcitabine if cisplatin-unfit), or immune checkpoint inhibitor (if it is first line treatment setting and cisplatin-unfit, options include either pembrolizumab or atezolizumab, if either 'PD-L1 high...
Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?
Yes, but with caveats. The “yes” is because hyperparathyroidism is a surgically curable disease if done by an experienced parathyroid surgeon. The caveat is if previous stone analyses have not shown a substantial calcium phosphate component, the stone formation may be due to other causes and unaffec...
Do you recommend obtaining a DEXA scan for patients with recurrent nephrolithiasis and hypercalciuria of unknown etiology?
I think this is an important question. I agree with Dr. @Dr. First Last. In my practice, if the patient is female, especially peri- or postmenopausal, I generally recommend a DEXA scan. If bone density is borderline or low, I typically refer the patient to an endocrinologist in our Bone Clinic for c...
Given the criticism of GOG 88 and in light of various other recent data, would you deliver definitive XRT in place of inguinal lymph node dissection?
Despite GOG 88 findings, a number of retrospective studies have suggested that regional prophylactic RT is an effective method of preventing groin recurrences with minimal morbidity when appropriately delivered. (Combined across retrospective series, the incidence of groin recurrence following treat...
What are your recommendations for stone prevention for patients with recurrent calcium based nephrolithiasis who consume well water with a high calcium concentration?
Drink lots of it! Seriously, studies done long ago, looking at the geography of stone formers did not correlate with water hardness (mineral content), but rather with average temperature, the incidence of stone passage being higher in the southern parts of the United States. The amount of calcium co...
Would you give immunotherapy after neoadjuvant gem-cis for bladder cancer if cystectomy is being postponed for months due to non-autoimmune/unrelated comorbidities?
Delay in cystectomy regardless of the use of neoadjuvant chemotherapy is associated with compromised survival outcomes (Chu et al., PMID 30840335) and if a patient receives neoadjuvant chemotherapy and is unable to undergo cystectomy for months due to comorbidities, there is no clear data to support...