Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How much and for how long does the average patient leak after HoLEP?
It largely depends on multiple factors BMI Age of the patient Size of the prostate Fraility In general, regarding stress incontinence, 70% of patients are completely dry within 2 weeks, and 97% completely dry within 3 months. Regarding urge incontinence, it depends on whether the patient has OAB b...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
What is your approach for patients with advanced CKD who have bilateral Bosniak 2F cysts?
I would do a baseline CT or MR, then repeat in 6 months. Going forward, every 6-12 months, depending on imaging features, patient characteristics, and preferences.
Would a high Decipher score affect your recommendation regarding the addition of ADT to XRT in a favorable intermediate risk prostate patient?
The simple answer is YES.To walk through why...1. Trials like RTOG 9408 demonstrate that there is a metastasis and OS benefit in Intermediate Risk disease from the addition of short-term ADT to RT.2. Later work from many groups showed that intermediate risk is a very heterogeneous cohort. This shoul...
How would you manage a patient who developed an intraprostatic abscess after SpaceOAR injection, prior to starting radiation?
Rectal spacer complications are rare, but still happen. In a recent review, 0.4% of patients experienced a complication resulting in an adverse event report. 13% of these reports had a CTCAE of >= 3. Some of these adverse event reports (91/981) were abscesses related to SpaceOAR placement (Millot et...
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
In the setting of prior salvage radiation therapy for rising PSA post prostatectomy, can there be any role of additional radiation therapy for isolated local recurrence in the bladder neck/prostate bed?
I have not run into this scenario. If it is visible on imaging (ultrasound +/- CT or MRI) I would explore the possibility of HDR, 13.5 Gy x 2. Careful consideration would need to be given to the location of the recurrence and anatomy. Technically it may be challenging due to scar tissue and the limi...
Do you recommend a metabolic evaluation in a kidney transplant patient with no prior history of nephrolithiasis who is found to have donor derived kidney stones?
Thanks for an interesting question. It would help if we knew the relevant donor medical history, such as dietary indiscretions or enteric hyperoxalutia, which would not be issues in the recipient. Since this information is typically not available, I would collect two 24-hour urinary supersaturation ...
How would you treat a young man with a history of stage IA testicular pure seminoma s/p radical orchiectomy who has a solitary left inguinal lymph node recurrence and normal tumor markers?
Relapse in an inguinal node is somewhat unusual in testicular cancer unless there has been prior scrotal violation or surgery for maldescent. Trans-scrotal biopsy of the testis is usually an incorrect approach, as it can cause a different pattern of spread (to the inguinal nodes). Thus, I would not ...
How do you assess the pros and cons of discontinuing a selective alpha blocker such as tamsulosin or alfuzosin in an older adult male with orthostatic hypotension and established urinary retention?
Discontinuing alpha blockers in older adults with orthostatic hypotension (OH) and urinary retention is rarely straightforward, and the decision hinges on several key points. First, it is important to understand that selective alpha-blockers (tamsulosin, alfluzosin) work by relaxing the smooth muscl...