Http Dx Doi Org 10 1089 End 2004 18 677, Oct 1, 2004
To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric an... more To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.
Http Dx Doi Org 10 1089 End 2006 0296, Oct 17, 2007
Radiofrequency ablation (RFA) has emerged as a minimally invasive nephron-sparing treatment for s... more Radiofrequency ablation (RFA) has emerged as a minimally invasive nephron-sparing treatment for small (<4-cm) renal tumors. Post-RFA complications have been reported. We describe a patient who developed complete renal-pelvic obstruction after RFA. To our knowledge, this is the first such case to be reported and the second reported renal-unit loss as the result of collecting-system obstruction after RFA.
Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort ... more Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. In total, 386 patients were ...
International Journal of Radiation Oncology*Biology*Physics, 2015
In patients with muscle-invasive bladder cancer, local-regional failure (LF) has been reported to... more In patients with muscle-invasive bladder cancer, local-regional failure (LF) has been reported to occur in up to 20% of patients following radical cystectomy. The goals of this study were to describe patterns of LF, as well as assess factors associated with LF in a cohort of patients with pT3-4 bladder cancer. This information may have implications towards the use of adjuvant radiation therapy. Patients with pathologic T3-4 N0-1 bladder cancer were examined from an institutional radical cystectomy database. Preoperative demographics and pathologic characteristics were examined. Outcomes included overall survival and LF. Local-regional failures were defined using follow-up imaging reports and scans, and the locations of LF were characterized. Variables were tested by univariate and multivariate analysis for association with LF and overall survival. A total of 334 patients had pT3-4 and N0-1 disease after radical cystectomy and bilateral pelvic lymph node dissection. Of these, 46% received perioperative chemotherapy. The median age was 71 years old, and median follow-up was 11 months. On univariate analysis, margin status, pT stage, and pN stage, were all associated with LF (P<.05), however, on multivariate analysis, only pT and pN stages were significantly associated with LF (P<.05). Three strata of risk were defined, including low-risk patients with pT3N0 disease, intermediate-risk patients with pT3N1 or pT4N0 disease, and high-risk patients with pT4N1 disease, who had a 2-year incidence of LF of 12%, 33%, and 72%, respectively. The most common sites of pelvic relapse included the external and internal iliac lymph nodes (LNs) and obturator LN regions. Notably, 34% of patients with LF had local-regional only disease at the time of recurrence. Patients with pT4 or N1 disease have a 2-year risk of LF that exceeds 30%. These patients may be the most likely to benefit from local adjuvant therapies.
To examine the effect of surgical approach on regional lymphadenectomy (LND) performance and inpa... more To examine the effect of surgical approach on regional lymphadenectomy (LND) performance and inpatient complications for radical nephroureterectomy (NU) using a national administrative database. The National Inpatient Sample (2009-2012) was used to identify patients who underwent NU for urothelial carcinoma. Cohorts were stratified by performance of LND. Covariates included patient demographics, comorbidity, hospital characteristics, hospital volume, performance of LND, surgical approach (open [ONU], laparoscopic [LNU], or robotic [RNU]), and complications. Multivariable logistic regression was used to identify factors associated with LND performance and complications. A weighted population of 14,059 (85%) without LND and 2,560 (15%) with LND was identified. LND was more common in RNU (27%) compared with ONU (15%) and LNU (10%) (P<0.01). On multivariable analysis, when compared with ONU, RNU was associated with increased odds of LND performance (odds ratio [OR] = 1.9, 95% CI: [1....
International journal of urology : official journal of the Japanese Urological Association, Jan 6, 2015
To determine the time to bladder cancer diagnosis from initial infection-like symptoms and its im... more To determine the time to bladder cancer diagnosis from initial infection-like symptoms and its impact on cancer outcomes. Using Surveillance, Epidemiology and End Results-Medicare, we designed a retrospective cohort study identifying beneficiaries aged ≥66 years diagnosed with bladder cancer from 2007 to 2009. Patients were required to have a hematuria or urinary tract infection claim within 1 year of bladder cancer diagnosis (n = 21 216), and have 2 years of prior Medicare data (n = 18 956) without any precedent hematuria, bladder cancer or urinary tract infection claims (n = 12 195). The number of days to bladder cancer diagnosis was measured, as well as the impact of sex and presenting symptom on time to diagnosis, pathology, and oncological outcomes. The mean time to bladder cancer diagnosis was 72.2 days in women versus 58.9 days in men (P < 0.001). A logistic regression model identified the greatest predictors of ≥pT2 pathology were both women (odds ratio 2.08, 95% confiden...
OBJECTIVES To determine the impact of body mass index (BMI) on perioperative functional and oncol... more OBJECTIVES To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI. METHODS Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal
Left ventricular assist device (LVAD) is an option for the surgical management of severe heart fa... more Left ventricular assist device (LVAD) is an option for the surgical management of severe heart failure, and radical cystectomy remains the standard of care for muscle-invasive bladder cancer. Given a complicated population in terms of comorbidities and management for patients with an LVAD, there is little experience with major urologic procedures, which require balancing the benefits of surgery with considerable perioperative risks. We report our experience performing the first radical cystectomy with ileal conduit in a patient with an LVAD and muscle-invasive bladder cancer.
We sought to assess the association of temporal, socioeconomic and environmental factors with bla... more We sought to assess the association of temporal, socioeconomic and environmental factors with bladder cancer mortality in the United States. Our hypothesis was that bladder cancer mortality is associated with distinct environmental and socioeconomic factors, with their effects varying by region, race and gender. The National Cancer Institute age-adjusted county-level bladder cancer mortality from 1950 to 2007 was analyzed to identify clusters of increased bladder cancer death using the Getis-Ord Gi* statistic. Socioeconomic, clinical and environmental data were assessed using geographically-weighted spatial regression analysis adjusting for spatial autocorrelation. County-level socioeconomic, clinical and environmental data were obtained from national databases including the United States Census, Centers for Disease Control, National Center for Health Statistics, and County Health Rankings. Bladder cancer mortality hot spots and risk factors for bladder cancer death differed signifi...
Prior to the introduction of the ileal conduit more than four decades ago, the options for urinar... more Prior to the introduction of the ileal conduit more than four decades ago, the options for urinary diversion after cystectomy were extremely limited. Cutaneous pyelostomies and ureterostomies were common forms of urinary diversion. Direct cutaneous anastomoses of ...
To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthot... more To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthotopic neobladder (ONB) after radical cystectomy focusing on success rates for patients who require multiple treatments. Patients who underwent treatment for cystoscopically confirmed BNC in an ONB from 2007 to 2014 were studied. Treatment information included procedure type, use of adjuvant clean intermittent catheterization (CIC) and follow-up procedures. Procedures followed by additional interventions were categorized as failures. Success was defined as no additional surgical procedure with at least one year of follow-up. Procedures were classified by number of prior endoscopic treatments. Seventy-one patients underwent 155 individual endoscopic procedures (146 urethrotomy, 3 dilation and 6 transurethral resection of bladder neck). All patients were male without prior radiation. Median follow-up after initial endoscopic treatment was 26.8 months (IQR: 16.6-51.7), and time to recurrence ...
Medical Imaging 2001: Visualization, Display, and Image-Guided Procedures, 2001
Spinal surgery is often necessary to ease back pain symptoms. Neuronavigation (NN) allows the sur... more Spinal surgery is often necessary to ease back pain symptoms. Neuronavigation (NN) allows the surgeon to localize the position of his instruments in 3D using pre-operative CT scans registered to intra-operative marker positions in cranial surgeries. However, this tool is unavailable ...
Http Dx Doi Org 10 1089 End 2004 18 677, Oct 1, 2004
To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric an... more To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.
Http Dx Doi Org 10 1089 End 2006 0296, Oct 17, 2007
Radiofrequency ablation (RFA) has emerged as a minimally invasive nephron-sparing treatment for s... more Radiofrequency ablation (RFA) has emerged as a minimally invasive nephron-sparing treatment for small (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;4-cm) renal tumors. Post-RFA complications have been reported. We describe a patient who developed complete renal-pelvic obstruction after RFA. To our knowledge, this is the first such case to be reported and the second reported renal-unit loss as the result of collecting-system obstruction after RFA.
Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort ... more Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. In total, 386 patients were ...
International Journal of Radiation Oncology*Biology*Physics, 2015
In patients with muscle-invasive bladder cancer, local-regional failure (LF) has been reported to... more In patients with muscle-invasive bladder cancer, local-regional failure (LF) has been reported to occur in up to 20% of patients following radical cystectomy. The goals of this study were to describe patterns of LF, as well as assess factors associated with LF in a cohort of patients with pT3-4 bladder cancer. This information may have implications towards the use of adjuvant radiation therapy. Patients with pathologic T3-4 N0-1 bladder cancer were examined from an institutional radical cystectomy database. Preoperative demographics and pathologic characteristics were examined. Outcomes included overall survival and LF. Local-regional failures were defined using follow-up imaging reports and scans, and the locations of LF were characterized. Variables were tested by univariate and multivariate analysis for association with LF and overall survival. A total of 334 patients had pT3-4 and N0-1 disease after radical cystectomy and bilateral pelvic lymph node dissection. Of these, 46% received perioperative chemotherapy. The median age was 71 years old, and median follow-up was 11 months. On univariate analysis, margin status, pT stage, and pN stage, were all associated with LF (P&amp;amp;lt;.05), however, on multivariate analysis, only pT and pN stages were significantly associated with LF (P&amp;amp;lt;.05). Three strata of risk were defined, including low-risk patients with pT3N0 disease, intermediate-risk patients with pT3N1 or pT4N0 disease, and high-risk patients with pT4N1 disease, who had a 2-year incidence of LF of 12%, 33%, and 72%, respectively. The most common sites of pelvic relapse included the external and internal iliac lymph nodes (LNs) and obturator LN regions. Notably, 34% of patients with LF had local-regional only disease at the time of recurrence. Patients with pT4 or N1 disease have a 2-year risk of LF that exceeds 30%. These patients may be the most likely to benefit from local adjuvant therapies.
To examine the effect of surgical approach on regional lymphadenectomy (LND) performance and inpa... more To examine the effect of surgical approach on regional lymphadenectomy (LND) performance and inpatient complications for radical nephroureterectomy (NU) using a national administrative database. The National Inpatient Sample (2009-2012) was used to identify patients who underwent NU for urothelial carcinoma. Cohorts were stratified by performance of LND. Covariates included patient demographics, comorbidity, hospital characteristics, hospital volume, performance of LND, surgical approach (open [ONU], laparoscopic [LNU], or robotic [RNU]), and complications. Multivariable logistic regression was used to identify factors associated with LND performance and complications. A weighted population of 14,059 (85%) without LND and 2,560 (15%) with LND was identified. LND was more common in RNU (27%) compared with ONU (15%) and LNU (10%) (P<0.01). On multivariable analysis, when compared with ONU, RNU was associated with increased odds of LND performance (odds ratio [OR] = 1.9, 95% CI: [1....
International journal of urology : official journal of the Japanese Urological Association, Jan 6, 2015
To determine the time to bladder cancer diagnosis from initial infection-like symptoms and its im... more To determine the time to bladder cancer diagnosis from initial infection-like symptoms and its impact on cancer outcomes. Using Surveillance, Epidemiology and End Results-Medicare, we designed a retrospective cohort study identifying beneficiaries aged ≥66 years diagnosed with bladder cancer from 2007 to 2009. Patients were required to have a hematuria or urinary tract infection claim within 1 year of bladder cancer diagnosis (n = 21 216), and have 2 years of prior Medicare data (n = 18 956) without any precedent hematuria, bladder cancer or urinary tract infection claims (n = 12 195). The number of days to bladder cancer diagnosis was measured, as well as the impact of sex and presenting symptom on time to diagnosis, pathology, and oncological outcomes. The mean time to bladder cancer diagnosis was 72.2 days in women versus 58.9 days in men (P < 0.001). A logistic regression model identified the greatest predictors of ≥pT2 pathology were both women (odds ratio 2.08, 95% confiden...
OBJECTIVES To determine the impact of body mass index (BMI) on perioperative functional and oncol... more OBJECTIVES To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI. METHODS Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal
Left ventricular assist device (LVAD) is an option for the surgical management of severe heart fa... more Left ventricular assist device (LVAD) is an option for the surgical management of severe heart failure, and radical cystectomy remains the standard of care for muscle-invasive bladder cancer. Given a complicated population in terms of comorbidities and management for patients with an LVAD, there is little experience with major urologic procedures, which require balancing the benefits of surgery with considerable perioperative risks. We report our experience performing the first radical cystectomy with ileal conduit in a patient with an LVAD and muscle-invasive bladder cancer.
We sought to assess the association of temporal, socioeconomic and environmental factors with bla... more We sought to assess the association of temporal, socioeconomic and environmental factors with bladder cancer mortality in the United States. Our hypothesis was that bladder cancer mortality is associated with distinct environmental and socioeconomic factors, with their effects varying by region, race and gender. The National Cancer Institute age-adjusted county-level bladder cancer mortality from 1950 to 2007 was analyzed to identify clusters of increased bladder cancer death using the Getis-Ord Gi* statistic. Socioeconomic, clinical and environmental data were assessed using geographically-weighted spatial regression analysis adjusting for spatial autocorrelation. County-level socioeconomic, clinical and environmental data were obtained from national databases including the United States Census, Centers for Disease Control, National Center for Health Statistics, and County Health Rankings. Bladder cancer mortality hot spots and risk factors for bladder cancer death differed signifi...
Prior to the introduction of the ileal conduit more than four decades ago, the options for urinar... more Prior to the introduction of the ileal conduit more than four decades ago, the options for urinary diversion after cystectomy were extremely limited. Cutaneous pyelostomies and ureterostomies were common forms of urinary diversion. Direct cutaneous anastomoses of ...
To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthot... more To examine the outcomes of endoscopic procedures for bladder neck contracture (BNC) in the orthotopic neobladder (ONB) after radical cystectomy focusing on success rates for patients who require multiple treatments. Patients who underwent treatment for cystoscopically confirmed BNC in an ONB from 2007 to 2014 were studied. Treatment information included procedure type, use of adjuvant clean intermittent catheterization (CIC) and follow-up procedures. Procedures followed by additional interventions were categorized as failures. Success was defined as no additional surgical procedure with at least one year of follow-up. Procedures were classified by number of prior endoscopic treatments. Seventy-one patients underwent 155 individual endoscopic procedures (146 urethrotomy, 3 dilation and 6 transurethral resection of bladder neck). All patients were male without prior radiation. Median follow-up after initial endoscopic treatment was 26.8 months (IQR: 16.6-51.7), and time to recurrence ...
Medical Imaging 2001: Visualization, Display, and Image-Guided Procedures, 2001
Spinal surgery is often necessary to ease back pain symptoms. Neuronavigation (NN) allows the sur... more Spinal surgery is often necessary to ease back pain symptoms. Neuronavigation (NN) allows the surgeon to localize the position of his instruments in 3D using pre-operative CT scans registered to intra-operative marker positions in cranial surgeries. However, this tool is unavailable ...
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