Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you offer neoadjuvant chemotherapy to high grade T1 urothelial carcinoma in a bladder diverticulum?
Due to anatomical considerations (lack of muscularis propria in the diverticulum wall), clinical staging is very challenging in this setting. That is a great example of how a multi-disciplinary clinic of experts, including Urologists, Med Onc, Rad Onc, Radiologists, and Pathologists, can help get a ...
When do you consider lymphadenectomy vs pelvic lymph node RT in a lymph node recurrence after prior prostatectomy or prostate-only RT?
I typically recommend a modified GETUG P07 (OLIGOPELVIS) treatment paradigm in this setting because I believe it has a favorable toxicity and short term treatment efficacy as well as the best evidence basis at this time. This regimen consists of a fractionated, extended pelvic nodal field with conco...
What is your approach to patients with recurrent nephrolithiasis and hypercalciuria who are unable to tolerate thiazide diuretics due to hyperglycemia?
I think it is a risk-benefit analysis. The answer depends on the severity of the stone disease and the severity of the hyperglycemia. Obviously, controlling hyperglycemia would have multiple benefits, and I would certainly proceed along that route. But if the calcium-based kidney stone disease is se...
How do you manage unintended hypercalciuria that results from an increase in dietary calcium intake as recommended to patients with recurrent calcium oxalate nephrolithiasis attributed to enteric hyperoxaluria?
I find this to be a common concern. As you know, the idea of treating enteric hyperoxaluria with supplemental oral calcium is to bind dietary oxalate in the gut before it can be absorbed systematically. In addition to arranging an appointment with our stone clinic (not general) dietitian to discuss...
What are your top takeaways from ASCO GU 2024?
Prostate. BRCAAway. This small but important phase 2 randomized multicenter trial of HRRm mCRPC in the first line setting demonstrated the clear synergy in delaying progression or death and inducing better response between abiraterone and olaparib as compared to either abi or olaparib monotherapy o...
Do you recommend using methionine to acidify the urine in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
I have not used it. Many of these patients have a partial renal tubular acidosis and will develop a metabolic acidemia if so treated. I suggest checking a urinary acidification test before prescribing it. Stephen B. Erickson, MD
Do you reduce the potassium citrate dose for patients with recurrent calcium oxalate nephrolithiasis who are started on the medication but experience persistently elevated urinary pH levels above 7.0?
Yes. Urine pH that high may induce the formation of calcium phosphate stones. However, it is unusual for standard doses of potassium citrate to raise urine pH that much. I suggest you get a urine culture looking for urease-producing bacteria that can metabolize urea to ammonium and grow struvite sto...
What are your treatment recommendations in a patient with de novo metastatic prostate adenocarcinoma with neuroendocrine differentiation?
Neuroendocrine prostate cancer more often arises as a mechanism of treatment resistance than de novo, but in either case, portends aggressive disease biology and androgen insensitivity. Similar to the features of “aggressive-variant” prostate cancer described by Aparicio et al., PMID 26546618, the d...
How do you advise patients with recurrent nephrolithiasis who also have chronic mild hyponatremia for which they limit daily fluid intake?
Depending on the cause of hyponatremia, as you implied, our usual recommendation for recurrent stone formers to drink more fluid may be inappropriate or contraindicated. First, I would like to know the kidney stone composition. For example, if it is uric acid, we could prevent new stone formation an...
Would you prescribe a thiazide diuretic for patients with recurrent nephrolithiasis attributed to hypercalciuria in the setting of excess dietary sodium or animal protein intake who fail or are unwilling to adhere to recommended dietary changes?
Yes. Difficulty with dietary compliance is common, but there is no sense in being punitive about non-compliance. I would use what other treatments are available. Caveat emptor! A high sodium diet coupled with a thiazide diuretic often equals hypokalemia. Potassium supplementation might be in order, ...