Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you treat a patient with RP and salvage XRT now with a PET PSMA positive node?
The question is a bit unclear, but I will assume that this patient has already had RP and salvage RT to the prostate bed only and now presents with a PSA of 4 and the PSMA-PET is positive in the pelvic nodes. In this situation, I generally recommend long-term ADT plus RT to the pelvic nodes, but I w...
Do you use oral fosfomycin as a treatment option for uncomplicated cystitis due to ESBL producing E coli?
Fosfomycin is one of the first-line drugs for uncomplicated UTI listed in the Infectious Diseases Society of America (IDSA) UTI treatment guidelines (these guidelines are currently being updated). It is the only single-dose drug approved for UTI and is an effective option. It does have activity agai...
Would you recommend cinacalcet for patients with recurrent nephrolithiasis who have hypercalciuria despite thiazide diuretic use and who also have an elevated PTH level without localizing parathyroid adenoma on imaging?
This is a tricky question with a nuanced answer. If the hyperparathyroidism is secondary, cinacalcet may have a role in treatment along with normalizing serum phosphorus and vitamin D. However, metabolically active kidney stones are unusual in advanced chronic kidney disease. If the hyperparathyroid...
How would you treat metastatic pure tubulocystic renal cell cancer?
Tubulocystic renal cell carcinoma (tcRCC) is a very rare diagnosis--particularly metastatic tcRCC. To my knowledge, there are no clinical trials that have reported on these patients even in the basket non-clear cell RCC trials such as ASPEN (Armstrong et al., PMID 26794930) and ESPN (Tannir et al., ...
What are your management strategies for patients with recurrent nephrolithiasis and hypercalciuria who develop hypercalcemia after thiazide initiation?
My first concern is why. The thiazide may have unmasked primary hyperparathyroidism. I would get a PTH level plus serum phosphorus and vitamin D with a concurrent serum calcium to see if they are concordant. If not, it’s time to image the parathyroids. If no evidence of hyperparathyroidism, and hype...
In light of ARASENS presented at GU ASCO 2022, how do you approach treatment of de novo metastatic hormone sensitive prostate cancer?
There are multiple factors that go into treatment decisions for men with mHSPC, but two of the most important are volume of disease and de novo vs relapsed disease (i.e. prior local therapy). Volume of disease is one of the major factors for deciding on the benefits of docetaxel, with very limited b...
Do you prefer still over carbonated water for your patients with recurrent nephrolithiasis who have chronically low urine volumes?
My main concern is hydration. Stone formers tend to be un-thirsty folks, and it is hard to get them to drink anything, let alone my minimum of 2L daily. Generally I recommend plain water; old research found no difference between hard and soft water. To the extent that carbonated water alkalinizes u...
Do you transition patients with recurrent nephrolithiasis and hypercalciuria off of hydrochlorothiazide in favor of an alternative thiazide diuretic?
No. Assuming the patient tolerates HCTZ well, and it is effective in lowering hypercalciuria, I continue it. Most of the thiazide research has been done using this agent. Stephen B. Erickson, MD
What is your approach to managing acidic urine in patients with recurrent uric acid nephrolithiasis who have normal urinary citrate levels?
After appropriate dietary advice from our Stone Clinic dietitian, I preferentially prescribe sodium bicarbonate tablets, teaching the patient how to adjust the dose using pH strip testing to reach the desired urinary pH. pH testing should be done frequently, as urine pH is in part dietary dependent ...
In which prostate cancer patients, if any, do you consider adding ADT to adjuvant radiation therapy following prostatectomy?
Two trials (RTOG 9601 and GETUG-AFU 16) have demonstrated a benefit to adding ADT to salvage radiotherapy, and both required a minimum PSA of 0.2 ng/ml or higher. In RTOG 9601, the subgroup of patients who appeared to benefit most from ADT were those with PSA >0.7 ng/ml, suggesting that concurrent A...