Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Do you alternate CT stone scans and renal ultrasounds for stone monitoring in your patients with recurrent nephrolithiasis with the goal of limiting radiation exposure?
No. Although I share your concern about radiation and expense, the purpose of monitoring kidney stone patients is to detect small differences in stone burden from year to year. Ultrasound is less accurate than CT for this purpose. Avoiding contrast views decreases CT radiation exposure and is my mon...
Would you use belzutifan in metastatic renal cell carcinoma with somatic mutation in VHL (VHL p.q73) without having germline VHL and/or other manifestations of VHL syndrome?
Currently, there is no proven role for belzutifan use in somatic VHL mutation RCC. However, phase III clinical trial in advanced pretreated RCC randomizing to everolimus or belzutifan is currently ongoing. Phase II trials conducted in advanced RCC have reported promising results with belzutifan ther...
How do you counsel NCCN low and very low risk prostate cancer patients who receive a high risk DECIPHER score?
I do not order Decipher in NCCN low or very low risk. I'm not sure very low risk is even a relevant category in modern practice. The 15-year results from ProtecT demonstrate excellent outcomes for those on the active monitoring arm. Critically, those patients were mostly diagnosed in the pre-MRI era...
Would you offer definitive chemoRT for bladder cancer in a patient who had previously received prostate radiation?
It has to be individualized based on location in the bladder. Bladder neck may be harder with significant overlap from previous RT field but other locations can be done with reduced volume and avoiding including prostatic urethra in volume
When do you refer patients for TURP prior to prostate radiotherapy?
Good question - my experience for both brachy and EBRT prostate cancer patients - has been the clinical narrative. That is - for patients with significant LUTS - who are already on alpha blockade prior to RT, and who are still having issues of urine flow - is to see if there is a mechanical reason -...
What is your management strategy for patients with positive lymph nodes after radical prostatectomy?
There is a good retrospective study from Milan that shows considerable benefit to postoperative radiation therapy for node postive patients. DaPozza et al published this in "European Urology 55 (2009) 1003–1011". Their conclusions state: "Our data showed excellent long-term outcome for node-positi...
Do you use potassium phosphate for patients with recurrent nephrolithiasis to acidify the urine and prevent certain types of stones?
Short answer: No. That study was done about 40 years ago, I think by the Kaiser group, and was negative. That said, they used a suboptimal dose of 250 mg bid and measured success by stone passages rather than stone growth. However, studies using neutral phosphates (K Phos Neutral) were done by my me...
What is the preferred chemotherapy regimen for a patient with bladder adenocarcinoma with signet ring features?
Signet ring cell variants are considered an aggressive phenotype of urinary bladder adenocarcinoma with poor outcome. Because of the rarity, evidence based treatment approach is unknown. There are anecdotal experience in the literature.For example, a long term survival of 90 months was reported for ...
Would you add ADT to EBRT for favorable intermediate risk patients with T1c prostate cancer by DRE and bilateral prostatic lobe involvement by MRI?
Let's break down the question: If the patient has favorable intermediate risk disease, but cT1c by DRE, then he must have either: Grade group 2 (Gleason 3+4), PSA <10, and percent positive cores <50%; or Grade group 1 (Gleason 3+3), PSA 10-20, and percent positive cores <50% For scenario 1: Havi...
In high or very high risk prostate cancer, do you utilize combined androgen blockade in patients receiving definitive RT?
Since I had initially posted this, the STAMPEDE investigators have released a new publication reporting the utility of intensified androgen axis blockade (abiraterone ± enzalutamide) in high-risk non-metastatic patients which included high-risk N0 (≈ 60%) and N1 patients (≈ 40%). For this combined p...