Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your approach for patients with recurrent nephrolithiasis who you have a strong suspicion for primary hyperoxaluria though genetic testing returns without any abnormalities?
As an adult nephrologist, most of my patients with oxalosis have enteric hyperoxaluria. I suggest you take a careful history, looking for inflammatory bowel disease, removal of small bowel or surgical rerouting of the intestines. If your patient is a child, I would explore the possibility of insuran...
How would you approach treatment for a cT1N0M0 urothelial carcinoma of the ureter, high grade in a non-surgical candidate due to medical comorbidities?
Although there is limited data using radiation therapy or chemo-radiation in UTUC, in a non-surgical candidate, this may be a reasonable approach to consider in selected patients. This would be an extrapolation from the promising data from RTOG 0926, a single arm, phase II trial investigating trimod...
Is it unusual to have isolated LDH elevation and normal HCG and AFP in non-seminomatous germ cell tumor (embryonal carcinoma)?
It's hard to generalize: the details of the case matter. It is not very unusual to have an isolated LDH elevation. LDH is extremely non-specific. 101 different things can make LDH go up and this limits its usefulness as a tumor marker. Elevation of LDH on day 1 of cycle one of first-line chemotherap...
Do you recommend dietary changes to your patients with recurrent kidney stone disease who consume coffee and low oxalate teas daily?
Thank you for your question. Many patients get tired of drinking water and would prefer coffee, low-oxalate tea, or other beverages instead. Studies have shown no difference in whether the water is hard or soft. Coffee and low oxalate tea do not seem to increase stone passage either. There is some d...
Why do the most recent NCCN guidelines (Version 4.2024, 05/17/24) omit the duration of ADT for high-risk prostate cancer patients?
No idea, but version 1.2025 (accessed 12/10/2024) now includes ADT duration for high-risk, which is 12-36 months, with notes indicating, "For high-risk and very-high-risk prostate cancer treated with combination EBRT brachytherapy, a shortened duration of ADT (12 months) can be considered." For high...
How do you incorporate absolute percent pattern 4 (APP4) into your risk stratification, specifically your recommendation for ADT for intermediate prostate cancer?
Summary: The short answer is that APP4 is unlikely to improve risk prognostication to the extent to which other advanced biomarkers (GC, MMAI, etc.) do. It is also unlikely either alone or in combination with standard clinical factors to serve as a predictive biomarker. Nevertheless, it is certainly...
Based on the VESPER trial data, do you recommend the full 6 cycles or 3-4 cycles of ddMVAC for neoadjuvant muscle invasive bladder cancer treatment?
For clinically node negative MIBC: I give 4 cycles of neoadjuvant chemotherapy either (preferably) dose dense MVAC with G-CSF or Gemzar/Cisplatin. For cN+ MIBC: I tend to restage after 3 cycles and consider up to 6 cycles for patients who can tolerate induction chemo and do not have interim progress...
Do you routinely transition patients with recurrent calcium based kidney stones off of hydrochlorothiazide and onto chlorthalidone or indapamide for optimal control of hypercalciuria?
Yes, I do as they are longer acting thiazides and thus have better control over hypercalciuria. I generally start with Indapamide 1.25 mg daily and will titrate up if necessary. I prefer that as opposed to Chlorthalidone as to start with 12.5 mg Chlorthalidone, you need to cut it in half, which is n...
How do you decide between internal versus external decompression of malignant obstruction of the ureter (MUO)?
The decision between ureteral stenting and percutaneous nephrostomy placement is, by definition, an interdisciplinary one with my urologic oncology colleagues. If a ureteral stent is feasible, that typically is my preference as patients typically prefer this approach. Ultimately, the impact of local...
How should the outcomes and QOL results of the ProtecT Trial be interpreted?
The trial is a masterpiece. Quality assurance on the treatments, complete follow-up, careful cause-of-death ascertainment, pristine and long term quality of life data.My conclusions:1. The vast majority of men with low-risk and low-intermediate risk disease do not benefit from immediate treatment. I...