Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How long do you wait before reassessing a 24 hour urine calcium level in patients with recurrent nephrolithiasis, hypercalciuria, and osteoporosis who are initiated on bisphosphonate therapy?
Thank you for your excellent question. This is a relatively common concern, and yet I am aware of very little hard data. Opinions will differ; here is mine: In this scenario, it is my practice to have the patient visit with our Stone Clinic dietitian regarding dietary recommendations for calcium, so...
How do you decide between CT and ultrasound imaging tests for surveillance imaging for patients with recurrent nephrolithiasis?
I much prefer non-contrast renal CT scanning compared to ultrasound to determine metabolic stone activity (an increase in size or number of stones from previous imaging). Although more expensive, radiation exposure is low and sensitivity is high. Determining metabolic activity is important; if activ...
What approaches do you take for your patients with nephrolithiasis who undergo intermittent fasting for cultural, religious, or personal reasons?
Assuming "fasting" does not prohibit the intake of water, I encourage my patients to continue drinking water frequently, ideally at least 2 L daily, as that is the minimum amount shown in previous studies to decrease kidney stone passage. If fasting is intermittent and includes all fluids, I encoura...
Would you consider definitive concurrent chemoradiation to a patient with muscle invasive bladder cancer and a history of distal/sigmoid ulcerative colitis?
Ulcerative colitis is a relative contraindication to radiotherapy, but not absolute, in my view. UC can have a spectrum of acuity as well, from distant/non-active to active-undertreatment. For many bladder cancer patients, radical cystectomy is the primary therapy +/- neoadjuvant or adjuvant chemoth...
What is your approach to use of D-mannose for prevention of recurrent uncomplicated cystitis?
Unfortunately, in light of Hayward et al., PMID 38587819, I think there is a very limited role for the use of D-mannose for the prevention of recurrent uncomplicated cystitis. Our evidence-based options for the prevention of recurrent uncomplicated cystitis in postmenopausal women without catheters ...
What data is used to show cystectomy is superior to concurrent chemoradiation for muscle invasive bladder cancer?
In the absence of valid randomized clinical trials, Stein et al., PMID 11157016 1000+ Rad Cystectomy is often considered the benchmark article for Urologists when addressing this question. The paper is from the pre-adjuvant chemo era so some will say the survival is actually 5 to 10% higher than rep...
Is it appropriate to offer definitive trimodality therapy, as an equivalent option to neoadjuvant chemotherapy followed by radical cystectomy, in patients with muscle-invasive bladder cancer regardless of fitness or platinum eligibility?
There are now several retrospective studies utilizing advanced statistical techniques suggesting that outcomes after trimodality therapy (TMT) are very similar to those after surgery (e.g., Zlotta et al., PMID 37187202, Brück et al., PMID 37517601, and Kulkarni et al., PMID 28410011). These findings...
In a patient diagnosed with prostate cancer based on a biopsy many years ago placed on surveillance now with rising PSA, do you require repeat biopsy prior to definitive radiation treatment?
This question raises multiple important points that I will discuss, but given that the question doesnt have patient age or numerous other important factors I will speak generally with multiple assumptions being made that he is ~65yo with >10 years life expectancy, etc:1. The question is in fact wron...
Do you consider Randall's plaque as a form of nephrocalcinosis necessitating genetic testing for monogenic kidney stone disorders?
No. Randall's plaque is the infrastructure of all calcium oxalate kidney stones. It is formed beneath the uroepithelium, due to (according to preliminary research) excess reabsorption of calcium in the thick ascending limb of Henley's loop. it is composed of calcium phosphate and somehow induces the...
What maintenance therapies do you most commonly recommend for patients with improving genital lichen sclerosis?
Betamethasone dipropionate with clotrimazole cream is my treatment of choice to provide a sufficiently potent corticosteroid while mitigating the risk of secondary Candida infections. Adjust the frequency of application from daily to once weekly to every other week for severe symptoms vs maintenance...