Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
In light of the recent results from STAMPEDE and LATITUDE, to which patients with newly diagnosed metastatic prostate cancer are you offering up-front abiraterone vs. up-front docetaxel?
Although I anticipate that the Stampede investigators will publish (an underpowered) comparison of their ADT plus docetaxel arm vs ADT plus abiraterone which may provide some insight, for the most part we will be in a data free zone re: this issue for some time. I suspect that clinicians will contin...
How do you treat newly diagnosed low volume metastatic hormone sensitive prostate cancer in light of new data from STAMPEDE presented at ESMO 2018?
In the prespecified subset of men with mHSPC and low volume of metastases (CHAARTED criteria of 4 or fewer bone metastases and no visceral metastases), there was a 32% improvement in overall survival (HR 0.68 95% CI 0.52-0.9) which was statistically significant and is clinically significant. Given t...
How do you distinguish between andropause versus pathological hypogonadism in older male patients?
The American Urological Association (AUA) guidelines state: "Men with sustained elevated prolactin levels, very low total testosterone (T) levels (<150 ng/dL) and unexplained failure to produce luteinizing hormone (LH)/follicle-stimulating hormone (FSH) warrant a pituitary magnetic resonance imaging...
Would you consider focal therapy for a patient with NCCN unfavorable intermediate risk prostate cancer, but only 1/16 cores positive, and it's from a targeted lesion biopsy?
A targeted biopsy confirms the MRI lesion is cancer so treatment should be based on imaging and not core #, core length, etc. We routinely treat MRI visible and MRI invisible GG3 with both HIFU and Cryo, depending on the location.
What technique or tool do you use to remove mucinous, infection stones?
In the past, we have performed percutaneous nephrolithotomy to remove mucinous, infection stones. Using the Trilogy device through the nephoscope, to fragment and aspirate stones/mucus was quite successful. Although this is significantly more invasive than standard ureteroscopy, we had a much better...
How do you perform the renorrhaphy during a partial nephrectomy?
A renorrhaphy can be performed using one or two layers. I use running 3/0 Monocryl for the deep layer and 2/0 Stratafix continuous suturing with the sliding clip technique for the cortical layer. I do not use bolsters or tissue sealants in most cases.
What is your approach for managing patients with recurrent nephrolithiasis and hypercalciuria who experience significant urinary frequency symptoms after starting a thiazide diuretic?
To some degree, an increase in urine volume and frequency is expected and even desirable after starting a diuretic. Diluting urinary mineral concentration is a major goal in inactivating metabolic stone disease. If frequent voiding is problematic, urological consultation might be in order, looking f...
In light of the pending overall survival data and reported declines in quality of life associated with the PSMAddition trial, how do you envision incorporating Pluvicto into the management of mHSPC?
The PSMAddition trial was a phase III trial of [177Lu]Lu-PSMA-617 (i.e., Pluvicto) combined with androgen deprivation therapy (ADT) plus an androgen receptor pathway inhibitor (ARPI) in patients with PSMA-positive metastatic hormone-sensitive prostate cancer (mHSPC). This trial randomized men with u...
How many days of preoperative antibiotics do you give a patient if they have a positive urine culture and are scheduled for ureteroscopy and laser lithotripsy?
Great question! I treat these patients as if they have a complicated urinary tract infection and begin culture-specific antibiotics 7 days before surgery through the date of surgery. I generally do not repeat testing in the interim to confirm a negative culture as long as they do not develop worseni...
Do you recommend to exchange nephrostomy tubes when a patient is diagnosed with a urinary tract infection in the absence of any overt signs of infection at the exit site?
This patient has asymptomatic bacteriuria by definition - apparently with occasional symptomatic UTI. I would not change the tube because of the ASB like I would not change a urethral catheter in the setting of ASB. And as noted the patient has already demonstrated continued ASB after changing the t...