Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
What is your approach to patients with muscle-invasive bladder cancer who are ineligible for neoadjuvant cisplatin-based chemotherapy?
The data supporting the use of neoadjuvant chemotherapy for bladder cancer is derived from 2 randomized trials and a meta-analysis. The randomized trials demonstrating benefit used MVAC and CMV, respectively, both cisplatin-based combinations. The meta-analysis results support the use of neoadjuvant...
Should patients with muscle invasive node negative bladder cancer wishing to have bladder preservation receive chemoRT alone or neoadjuvant chemotherapy followed by chemoRT?
The best evidence that we have does not support neoadjuvant chemotherapy before chemo-RT for bladder cancer. One RTOG trial, admittedly underpowered, and the MRC meta-analysis suggest that, while that benefit may exist for cystectomy, it either doesn't exist or is simply too small to detect for chem...
Do you routinely check a TSH level in patients with recurrent kidney stones who have hypercalciuria of unknown cause?
No. Although hyperthyroidism is a reported cause of hypercalcemia and hypercalciuria, it must be very rare cause of nephrolithiasis. I suspect the patient would be obviously hyperthyroid on examination. Hyperparathyroidism is a much more common cause of kidney stones. In my practice, if the stone an...
What is your approach to recurrent uric acid stone formers who have a persistently acidic urine pH and are unable to tolerate potassium citrate?
I use sodium bicarbonate. I teach the patient how to titrate the dose using pH dipsticks to get the urine pH >6.0. Although sodium may increase urine calcium excretion, in uric acid stone formers, this is not an issue. Long experience with sodium bicarbonate tells us it does not raise blood pressure...
What is your approach to management of recurrent nephrolithiasis in patients with mixed composition uric acid and calcium phosphate stones?
Likely the urine pH is more typically low in such patients, since the uric acid components will dissolve during periods of higher pH. Consequently, the appearance of uric acid crystals in the stone suggests that the urine pH is more typically low. Drinking more fluid to cause more dilute urine alway...
Are there patients with recurrent nephrolithiasis for who you recommend magnesium supplementation to reduce stone risk?
While magnesium supplementation may be justified on theoretical grounds, I have never used magnesium supplements as a treatment exclusively for kidney stones. I have only ever seen or used magnesium supplementation in stone patients that had concurrent hypomagnesemia.
What is the current recommendation for using thiazide diuretics in patients with calcium oxalate stone disease, given the negative results of the NOSTONE trial?
This trial will have no effect on my practice. Seven of 10 previous studies of thiazides for stones were positive, as was a meta-analysis. My preference is for the longer-acting drugs indapamide and chlorthalidone; I haven't used HCTZ which is probably a twice-a-day drug, for some years. Note that t...
Is bilateral hearing loss requiring hearing aids an absolute or relative contraindication for neoadjuvant cisplatin in MIBC?
For this “curative intent” neoadjuvant therapy setting, a detailed discussion with the patient is very helpful and should include the pros/cons of cisplatin based chemotherapy based on phase 3 trials data and a meta-analysis showing OS benefit as well as possible side effects, including hearing loss...
Is it safe to administer cabazitaxel to a patient with mCRPC who developed grade 3 pneumonitis from docetaxel?
In general, the answer is yes, as these are distinct therapies with distinct toxicities. Both are formulated in TWEEN80 solvent and can cause allergic reactions and anaphylaxis, and this is the only adverse event that I would strongly consider avoiding cabazitaxel if this event was experienced in a ...
Are there other therapies such as SGLT2 inhibitors or alpha lipoic acid that you are offering your patients with cystinuria who continue to have active stone disease despite conservative therapy and thiol-based agents?
I am not aware of quality trials for new agents being advocated for the treatment of cystinuria. I do not prescribe them. Generally, the failure to respond to standard therapy reflects a failure of the patient to follow the appropriate diet and titrate the usual medications as regards urine pH and c...