Joseph Brito - Academia.edu (original) (raw)

Papers by Joseph Brito

Prostate International, 2022

Prostate Cancer Imaging, 2018

Urologic Oncology: Seminars and Original Investigations, 2020

Improvements in chemistry, molecular biology, genetics, and bioinformatics have allowed broad use... more Improvements in chemistry, molecular biology, genetics, and bioinformatics have allowed broad use of transcriptomic profiling. Understanding the population of ribonucleic acid (RNA) transcripts can provide important clinical information relevant to kidney cancer care. This includes a better understanding of kidney cancer subtype and distinct clusters within these categories. RNA-sequencing (RNA-seq) is typically done on a region within the tumor, which represents thousands to millions of heterogeneous cells and various components of the microenvironment. Computational tools can deconvolute these populations to provide insight into the microenvironment. Specific signatures of hypoxia, proliferation, angiogenesis and immune infiltration can predict response and survival. Prognostic signatures can risk stratify tumors to aid in identification of patients who might derive benefit from adjuvant therapy. As the cost of sequencing continues to decline and improved bioinformatic tools are developed, the barriers to clinical use of transcriptomic data continue to crumble. Here we review the current literature around the use of transcriptomics in kidney cancer diagnosis and management.

Journal of Clinical Oncology, 2016

e16126Background: Subclassificaiton of papillary RCC (pRCC) into type 1 and type 2 has been recog... more e16126Background: Subclassificaiton of papillary RCC (pRCC) into type 1 and type 2 has been recognized as an independent negative prognostic factor. Little investigation has determined the effect o...

Urology, 2019

Objectives: To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studie... more Objectives: To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studies using the novel pH low insertion peptide (pHLIP) variant 3 (Var3) conjugated to indocyanine green (ICG) have demonstrated high sensitivity and specificity for imaging of bladder urothelial carcinoma. Here, we describe a novel approach for the imaging of UTUC using ICG-Var3 pHLIP. Methods: Twelve ex-vivo upper urinary tract specimens were irrigated with ICG-Var 3 pHLIP for fifteen minutes and then examined using a white light laparoscopic camera followed by near infrared fluorescent (NIRF) imaging using a Stryker 1588 AIM imaging system. Standard histopathologic evaluation was performed and findings were correlated with white light and ICG-Var3 NIRF imaging. One patient who underwent radical nephrectomy for renal cell carcinoma was used as a negative control. Results: Nineteen lesions were identified on histopathologic evaluation in ten patients, including 82% high-grade urothelial carcinoma and 18% low-grade urothelial carcinoma. Nineteen (100%) malignant lesions were identified using NIRF imaging, while 15 (78.9%) lesions were identified using conventional white light examination. The sensitivity of ICG-Var3 pHLIP NIRF imaging was 100% compared to 78.9% white light examination. Both modalities are 100% specific. Benign collecting systems and ureters did not show uptake of the pHLIP construct. Conclusions: In this feasibility study, the ICG-Var3 pHLIP imaging agent demonstrated superior diagnostic performance compared to conventional white light examination. While additional studies are required for validation and in-vivo translation, pHLIP-based imaging represents a promising tool to improve the evaluation and management of upper tract urothelial carcinoma.

Urologic Oncology: Seminars and Original Investigations, 2018

Objectives: Kidney masses suspicious for malignancy are frequently detected by cross-sectional im... more Objectives: Kidney masses suspicious for malignancy are frequently detected by cross-sectional imaging; however, little is known about the burden of surgical treatment for tumors found to be benign following excision. Material and methods: We queried the National Inpatient Sample to identify records of individuals who received surgical treatment for renal neoplasms between 2004 and 2014. We characterized temporal treatment trends, patient demographics, treatment related complications, and charges. Results: We identified 7,099 (8.5%) and 76,892 (91.5%) patients who were treated for benign and malignant tumors, respectively. Benign masses accounted for 14.8% of partial and 5.5% of radical nephrectomies. The rates of surgery for benign tumors have remained steady (P = 0.058). The frequency of inpatient death was higher in those with malignant disease (0.63% vs. 0.18%, P < 0.0001). Median length of stay was longer for individuals with malignant renal tumors (4.86 vs. 4.12 days, P < 0.0001). The total discharge bill adjusting for inflation for benign or malignant renal surgery increased each year (R 2 = 0.428, R 2 = 0.719, P = 0.001, P = 0.0311, respectively). As of 2014, the estimated national inpatient cost of management for benign renal tumors was 153milliondollars(153 million dollars (153milliondollars(55,573/individual). Conclusions: 8.5% of inpatient renal surgical admissions are performed for benign masses. There has been a trend toward decreased operative management for benign renal tumors over time. Surgical management remains a significant economic burden. Efforts to prospectively evaluate modalities for pretreatment identification should be further pursued.

The Journal of Urology, 2018

INTRODUCTION AND OBJECTIVES: Nutritional status is increasingly recognized as an important predic... more INTRODUCTION AND OBJECTIVES: Nutritional status is increasingly recognized as an important predictor of prognosis and surgical outcomes in cancer patients. We evaluated the impact of preoperative malnutrition on the development of surgical complications and mortality following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS: Using data from The American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30 day postoperative complications and overall mortality following RNU over years 2005-2015. Preoperative variables suggestive of poor nutritional status included hypoalbuminemia (<3.5 g/dL), weight loss 6 months before surgery (>10%), and low body mass index (BMI). The overall complication rate was calculated, and predictors of complications and mortality were identified using multivariable logistic regression models. RESULTS: A total of 1,200 patients were identified who underwent RNU for UTUC. The overall complication rate was 20.5% (n¼246) and mortality rate was 1.75% (n¼21). On univariate analysis, patients who had a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4% p<0.001) and weight loss (3.7% vs. 1.0% p¼0.003). After controlling for age, sex, race and medical comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (OR 2.09 95% CI 1.29-3.38 p¼0.003), whereas weight loss and BMI were not significant predictors (Figure 1A). Hypoalbuminemia was also found to be significant independent predictor of mortality (OR 4.31 95% CI 1.45-12.79 p¼0.008) on multivariable regression analysis (Figure 1B). CONCLUSIONS: Preoperative hypoalbuminemia is a significant predictor of surgical complications and mortality following RNU for UTUC. This finding supports the importance of preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes.

Prostate cancer and prostatic diseases, Jun 1, 2018

The incremental morbidity of lymph node dissection (LND) among men undergoing radical prostatecto... more The incremental morbidity of lymph node dissection (LND) among men undergoing radical prostatectomy remains uncertain. We therefore evaluated the association of LND with perioperative morbidity among men undergoing minimally invasive radical prostatectomy (MIRP). We identified 29,012 men aged 35-89 who underwent MIRP from 2010-2015 in the National Surgical Quality Improvement Program (NSQIP) database, of whom 47% underwent concomitant LND. The associations of LND with 30-day perioperative morbidity and mortality were evaluated using logistic regression, adjusted for patient features. Median age at surgery was 63 (IQR 57, 67) years. There were statistically significant, but clinically insignificant, differences in several baseline characteristics stratified by performance of LND, including older age at surgery (p < 0.001), higher American Society of Anesthesiology (ASA) class (p < 0.001), and longer operative time (p < 0.001) for men who underwent LND. Overall, 30-day compl...

Reviews in urology, 2017

Prostate cancer screening and diagnosis has been guided by prostate-specific antigen levels for t... more Prostate cancer screening and diagnosis has been guided by prostate-specific antigen levels for the past 25 years, but with the most recent US Preventive Services Task Force screening recommendations, as well as concerns regarding overdiagnosis and overtreatment, a new wave of prostate cancer biomarkers has recently emerged. These assays allow the testing of urine, serum, or prostate tissue for molecular signs of prostate cancer, and provide information regarding both diagnosis and prognosis. In this review, we discuss 12 commercially available biomarker assays approved for the diagnosis and treatment of prostate cancer. The results of clinical validation studies and clinical decision-making studies are presented. This information is designed to assist urologists in making clinical decisions with respect to ordering and interpreting these tests for different patients. There are numerous fluid and biopsy-based genomic tests available for prostate cancer patients that provide the phys...

The Canadian journal of urology, 2017

Gross hematuria is a common urologic problem which often requires surgical intervention. While ge... more Gross hematuria is a common urologic problem which often requires surgical intervention. While generally a safe procedure, clot evacuation can have serious complications. Here we describe the case of an 85-year-old male who developed extensive subcutaneous emphysema following a small extraperitoneal bladder perforation during a clot evacuation. While our patient did well with expectant management, subcutaneous emphysema can lead to serious complications and any endourologic procedure should be stopped once crepitus is noted.

Urologic Oncology: Seminars and Original Investigations, 2017

The role of lymph node dissection (LND) in the management of renal cell carcinoma has been contro... more The role of lymph node dissection (LND) in the management of renal cell carcinoma has been controversial. Older studies provided initial support to a potential survival benefit in resection of lymph node metastases, and several predictive models were developed to identify patients with lymph node involvement. However, the only randomized trial on the subject did not report a survival benefit to LND in the nonmetastatic setting. Several studies have recently reexplored the therapeutic benefit of LND. In both nonmetastatic and metastatic settings, LND does not appear to be associated with a survival benefit. Moreover, it does not appear that LND confers a survival advantage to patients at increased risk of lymph node metastases, such as those with preoperative radiographic lymphadenopathy or across increasing probability of lymph node disease. Among patients with clinically isolated lymph node metastases, the majority develop disease progression following surgical resection, suggesting a high prevalence of occult systemic disease. Lymph node metastases appear to have prognostic value in both nonmetastatic and metastatic settings. LND may, therefore, have an increasingly important staging role in the management of renal cell carcinoma.

Human Pathology, 1980

Normal semilunar valves develop at the downstream end of the embryonic cardiac tube by remodeling... more Normal semilunar valves develop at the downstream end of the embryonic cardiac tube by remodeling of the endocardial cushion material. Two valves, each with three commissures, form by subdivision of the two larger (lateral) of the four endocardial cushions. In dfis study congenitally malformed semihmar valves from autopsy heart specimens were reviewed to determine whether the lesions could be explained as deviations of normal valvulogenesis. The morphological spectrum of raphes and their occasional occurrence at the site of separation between die two lateral cushions, an obligatory conmfissure, suggested that they are usually dm result of fusion of previously formed commissures. In 306 hearts there were 316 nmlformed semihmar valves: 208 puhnonic and 108 aortic. Four categories of lesions were found: (1) 27 atretic valves could not be interpreted; (2) 6 valves were quadricuspid with an extra commissure; (3) 45 valves showed failure of formation of one (44) or two (1) commissures; and (4)238 valves showed fusion of one (156), two (22), or three (60) commissures as indicated by the presence of raphes. In 27 instances an atretic valve was too small to evaluate. Thus, evidence that three leaflets had at one time been present, as determined by the count of commissures plus raphes, was found in 82 per cent of interpretable valves. Several associated congenital cardiac lesions (coarctation of the aorta, transposition of the great vessels, tetralogy of Fallot, mitral atresia) exhibited a highly significant association with either aortic or pulmonic valvular malformations. The findings suggest that the majority of congenital malformations of the semilunar valves are due to lesions acquired in utero subsequent to normal valvulogenesis. Disproportionate flow reduction of the right or left side of the heart may be a factor in the development of malformations in the respective semilunar valve.

European Urology Supplements, 2017

Journal of Endourology Case Reports, 2016

A twenty-eight-year-old female with a history of suprapubic pain and recurrent urinary tract infe... more A twenty-eight-year-old female with a history of suprapubic pain and recurrent urinary tract infections presents for urology referral with a kidney, ureter, and bladder radiograph showing a 4.4 cm bladder calculus and 6.5 cm distal left ureteral stone. She underwent effective cystolitholapaxy of the bladder stone. Endourologic attempt (left ureteroscopy) was unsuccessful because of ureteral stone burden. Findings at ureteroscopy revealed a duplicated system on the left with the lower pole moiety joining just proximal to the ureteral orifice. The stone was found to be in the upper pole moiety ureter. An open ureterolithotomy was performed with intraoperative ureteroscopic laser lithotripsy and common sheath ureteral reimplant. Furthermore, a previously placed stent was found to be encrusted at the time of the ureterolithotomy. Effective ureteroscopy and lasering were performed through the ureterotomy up to the renal pelvis of the upper pole ureter.

Human Pathology, 2017

Prostate cancer management changed in recent times given the recommendation against PSA-screening... more Prostate cancer management changed in recent times given the recommendation against PSA-screening, adherence to active surveillance, and "cytoreductive" surgery. We

The Journal of Urology, 2016

Journal of Endourology, 2016

Introduction: The American Urological Association (AUA) guidelines recommend partial nephrectomy ... more Introduction: The American Urological Association (AUA) guidelines recommend partial nephrectomy (PN) as the gold standard for treatment of small renal masses (SRMs). This study examines the change in utilization of partial and radical nephrectomies at teaching and nonteaching institutions from 2003 to 2012. Materials and Methods: The data sample for this study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2012. International Classification of Diseases, Ninth Revision and Clinical Modification codes were used to identify patients undergoing PN and radical nephrectomy for renal masses limited to the renal parenchyma. Teaching hospitals were defined, but not limited to any institution with an American Medical Association-approved residency program. Linear regression, bivariate, multivariate, and odds ratio analysis were used to demonstrate statistical significance. Results: 39,685 patients were identified in teaching hospitals, and 22,239 were identified in nonteaching hospitals. Prior to the 2009 AUA guidelines, cumulative rates of PN were 33% vs 20% in teaching vs nonteaching hospitals (p < 0.0001) compared with postguideline rates of 48% vs 33% in teaching vs nonteaching hospitals (p < 0.0001). Conclusions: During the 10-year study period, the use of PN to treat SRMs has significantly increased in both teaching hospitals and in nonacademic centers; however, these changes are occurring at a slower rate in nonteaching hospitals.

The Journal of Urology, 2016

with detailed and validated clinicopathologic data for all patients with newly-diagnosed CaP. For... more with detailed and validated clinicopathologic data for all patients with newly-diagnosed CaP. For this analysis, we identified all men who underwent RP for clinically low-risk CaP (defined as clinical stage T1 or T2a, prostate specific antigen (PSA) <10 ng/mL, and biopsy Gleason score 6) from 1/2011 through 8/2015. We compared differences in the frequency of adverse pathologic outcomes (e.g., Gleason score upgrading, seminal vesicle involvement, positive surgical margins) among patients selecting initial RP versus initial AS with subsequent transition to RP. RESULTS: During this interval, 2,858 patients with low-risk CaP were entered into the MUSIC registry. Among this group, 778 (27%) and 1,359 (48%) patients selected initial RP and initial AS, respectively. AS patients were older (63.4 vs. 60.1 years, p<0.001) with similar PSA levels (5.4 vs. 5.0 ng/mL, p¼0.08 for initial AS and RP groups, respectively), but less likely to have clinical T2a disease (5.1% vs 14.5%, p¼0.02). Among the AS cohort, the median follow-up was 506 days (IQR 280-793 days), and 79 (5.8%) transitioned to RP. Men managed with initial AS were more likely to have a pathological Gleason Score 7; however there were no other differences between these groups with respect to adverse pathology outcomes (Table 1). CONCLUSIONS: Patients with low risk CaP that enter AS have higher grade disease at RP compared to those undergoing initial RP. The lack of differences in other pathologic outcomes suggests that the surveillance process may be appropriately identifying patients with more aggressive cancers prior to stage progression.

Prostate International, 2022

Prostate Cancer Imaging, 2018

Urologic Oncology: Seminars and Original Investigations, 2020

Improvements in chemistry, molecular biology, genetics, and bioinformatics have allowed broad use... more Improvements in chemistry, molecular biology, genetics, and bioinformatics have allowed broad use of transcriptomic profiling. Understanding the population of ribonucleic acid (RNA) transcripts can provide important clinical information relevant to kidney cancer care. This includes a better understanding of kidney cancer subtype and distinct clusters within these categories. RNA-sequencing (RNA-seq) is typically done on a region within the tumor, which represents thousands to millions of heterogeneous cells and various components of the microenvironment. Computational tools can deconvolute these populations to provide insight into the microenvironment. Specific signatures of hypoxia, proliferation, angiogenesis and immune infiltration can predict response and survival. Prognostic signatures can risk stratify tumors to aid in identification of patients who might derive benefit from adjuvant therapy. As the cost of sequencing continues to decline and improved bioinformatic tools are developed, the barriers to clinical use of transcriptomic data continue to crumble. Here we review the current literature around the use of transcriptomics in kidney cancer diagnosis and management.

Journal of Clinical Oncology, 2016

e16126Background: Subclassificaiton of papillary RCC (pRCC) into type 1 and type 2 has been recog... more e16126Background: Subclassificaiton of papillary RCC (pRCC) into type 1 and type 2 has been recognized as an independent negative prognostic factor. Little investigation has determined the effect o...

Urology, 2019

Objectives: To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studie... more Objectives: To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studies using the novel pH low insertion peptide (pHLIP) variant 3 (Var3) conjugated to indocyanine green (ICG) have demonstrated high sensitivity and specificity for imaging of bladder urothelial carcinoma. Here, we describe a novel approach for the imaging of UTUC using ICG-Var3 pHLIP. Methods: Twelve ex-vivo upper urinary tract specimens were irrigated with ICG-Var 3 pHLIP for fifteen minutes and then examined using a white light laparoscopic camera followed by near infrared fluorescent (NIRF) imaging using a Stryker 1588 AIM imaging system. Standard histopathologic evaluation was performed and findings were correlated with white light and ICG-Var3 NIRF imaging. One patient who underwent radical nephrectomy for renal cell carcinoma was used as a negative control. Results: Nineteen lesions were identified on histopathologic evaluation in ten patients, including 82% high-grade urothelial carcinoma and 18% low-grade urothelial carcinoma. Nineteen (100%) malignant lesions were identified using NIRF imaging, while 15 (78.9%) lesions were identified using conventional white light examination. The sensitivity of ICG-Var3 pHLIP NIRF imaging was 100% compared to 78.9% white light examination. Both modalities are 100% specific. Benign collecting systems and ureters did not show uptake of the pHLIP construct. Conclusions: In this feasibility study, the ICG-Var3 pHLIP imaging agent demonstrated superior diagnostic performance compared to conventional white light examination. While additional studies are required for validation and in-vivo translation, pHLIP-based imaging represents a promising tool to improve the evaluation and management of upper tract urothelial carcinoma.

Urologic Oncology: Seminars and Original Investigations, 2018

Objectives: Kidney masses suspicious for malignancy are frequently detected by cross-sectional im... more Objectives: Kidney masses suspicious for malignancy are frequently detected by cross-sectional imaging; however, little is known about the burden of surgical treatment for tumors found to be benign following excision. Material and methods: We queried the National Inpatient Sample to identify records of individuals who received surgical treatment for renal neoplasms between 2004 and 2014. We characterized temporal treatment trends, patient demographics, treatment related complications, and charges. Results: We identified 7,099 (8.5%) and 76,892 (91.5%) patients who were treated for benign and malignant tumors, respectively. Benign masses accounted for 14.8% of partial and 5.5% of radical nephrectomies. The rates of surgery for benign tumors have remained steady (P = 0.058). The frequency of inpatient death was higher in those with malignant disease (0.63% vs. 0.18%, P < 0.0001). Median length of stay was longer for individuals with malignant renal tumors (4.86 vs. 4.12 days, P < 0.0001). The total discharge bill adjusting for inflation for benign or malignant renal surgery increased each year (R 2 = 0.428, R 2 = 0.719, P = 0.001, P = 0.0311, respectively). As of 2014, the estimated national inpatient cost of management for benign renal tumors was 153milliondollars(153 million dollars (153milliondollars(55,573/individual). Conclusions: 8.5% of inpatient renal surgical admissions are performed for benign masses. There has been a trend toward decreased operative management for benign renal tumors over time. Surgical management remains a significant economic burden. Efforts to prospectively evaluate modalities for pretreatment identification should be further pursued.

The Journal of Urology, 2018

INTRODUCTION AND OBJECTIVES: Nutritional status is increasingly recognized as an important predic... more INTRODUCTION AND OBJECTIVES: Nutritional status is increasingly recognized as an important predictor of prognosis and surgical outcomes in cancer patients. We evaluated the impact of preoperative malnutrition on the development of surgical complications and mortality following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS: Using data from The American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30 day postoperative complications and overall mortality following RNU over years 2005-2015. Preoperative variables suggestive of poor nutritional status included hypoalbuminemia (<3.5 g/dL), weight loss 6 months before surgery (>10%), and low body mass index (BMI). The overall complication rate was calculated, and predictors of complications and mortality were identified using multivariable logistic regression models. RESULTS: A total of 1,200 patients were identified who underwent RNU for UTUC. The overall complication rate was 20.5% (n¼246) and mortality rate was 1.75% (n¼21). On univariate analysis, patients who had a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4% p<0.001) and weight loss (3.7% vs. 1.0% p¼0.003). After controlling for age, sex, race and medical comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (OR 2.09 95% CI 1.29-3.38 p¼0.003), whereas weight loss and BMI were not significant predictors (Figure 1A). Hypoalbuminemia was also found to be significant independent predictor of mortality (OR 4.31 95% CI 1.45-12.79 p¼0.008) on multivariable regression analysis (Figure 1B). CONCLUSIONS: Preoperative hypoalbuminemia is a significant predictor of surgical complications and mortality following RNU for UTUC. This finding supports the importance of preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes.

Prostate cancer and prostatic diseases, Jun 1, 2018

The incremental morbidity of lymph node dissection (LND) among men undergoing radical prostatecto... more The incremental morbidity of lymph node dissection (LND) among men undergoing radical prostatectomy remains uncertain. We therefore evaluated the association of LND with perioperative morbidity among men undergoing minimally invasive radical prostatectomy (MIRP). We identified 29,012 men aged 35-89 who underwent MIRP from 2010-2015 in the National Surgical Quality Improvement Program (NSQIP) database, of whom 47% underwent concomitant LND. The associations of LND with 30-day perioperative morbidity and mortality were evaluated using logistic regression, adjusted for patient features. Median age at surgery was 63 (IQR 57, 67) years. There were statistically significant, but clinically insignificant, differences in several baseline characteristics stratified by performance of LND, including older age at surgery (p < 0.001), higher American Society of Anesthesiology (ASA) class (p < 0.001), and longer operative time (p < 0.001) for men who underwent LND. Overall, 30-day compl...

Reviews in urology, 2017

Prostate cancer screening and diagnosis has been guided by prostate-specific antigen levels for t... more Prostate cancer screening and diagnosis has been guided by prostate-specific antigen levels for the past 25 years, but with the most recent US Preventive Services Task Force screening recommendations, as well as concerns regarding overdiagnosis and overtreatment, a new wave of prostate cancer biomarkers has recently emerged. These assays allow the testing of urine, serum, or prostate tissue for molecular signs of prostate cancer, and provide information regarding both diagnosis and prognosis. In this review, we discuss 12 commercially available biomarker assays approved for the diagnosis and treatment of prostate cancer. The results of clinical validation studies and clinical decision-making studies are presented. This information is designed to assist urologists in making clinical decisions with respect to ordering and interpreting these tests for different patients. There are numerous fluid and biopsy-based genomic tests available for prostate cancer patients that provide the phys...

The Canadian journal of urology, 2017

Gross hematuria is a common urologic problem which often requires surgical intervention. While ge... more Gross hematuria is a common urologic problem which often requires surgical intervention. While generally a safe procedure, clot evacuation can have serious complications. Here we describe the case of an 85-year-old male who developed extensive subcutaneous emphysema following a small extraperitoneal bladder perforation during a clot evacuation. While our patient did well with expectant management, subcutaneous emphysema can lead to serious complications and any endourologic procedure should be stopped once crepitus is noted.

Urologic Oncology: Seminars and Original Investigations, 2017

The role of lymph node dissection (LND) in the management of renal cell carcinoma has been contro... more The role of lymph node dissection (LND) in the management of renal cell carcinoma has been controversial. Older studies provided initial support to a potential survival benefit in resection of lymph node metastases, and several predictive models were developed to identify patients with lymph node involvement. However, the only randomized trial on the subject did not report a survival benefit to LND in the nonmetastatic setting. Several studies have recently reexplored the therapeutic benefit of LND. In both nonmetastatic and metastatic settings, LND does not appear to be associated with a survival benefit. Moreover, it does not appear that LND confers a survival advantage to patients at increased risk of lymph node metastases, such as those with preoperative radiographic lymphadenopathy or across increasing probability of lymph node disease. Among patients with clinically isolated lymph node metastases, the majority develop disease progression following surgical resection, suggesting a high prevalence of occult systemic disease. Lymph node metastases appear to have prognostic value in both nonmetastatic and metastatic settings. LND may, therefore, have an increasingly important staging role in the management of renal cell carcinoma.

Human Pathology, 1980

Normal semilunar valves develop at the downstream end of the embryonic cardiac tube by remodeling... more Normal semilunar valves develop at the downstream end of the embryonic cardiac tube by remodeling of the endocardial cushion material. Two valves, each with three commissures, form by subdivision of the two larger (lateral) of the four endocardial cushions. In dfis study congenitally malformed semihmar valves from autopsy heart specimens were reviewed to determine whether the lesions could be explained as deviations of normal valvulogenesis. The morphological spectrum of raphes and their occasional occurrence at the site of separation between die two lateral cushions, an obligatory conmfissure, suggested that they are usually dm result of fusion of previously formed commissures. In 306 hearts there were 316 nmlformed semihmar valves: 208 puhnonic and 108 aortic. Four categories of lesions were found: (1) 27 atretic valves could not be interpreted; (2) 6 valves were quadricuspid with an extra commissure; (3) 45 valves showed failure of formation of one (44) or two (1) commissures; and (4)238 valves showed fusion of one (156), two (22), or three (60) commissures as indicated by the presence of raphes. In 27 instances an atretic valve was too small to evaluate. Thus, evidence that three leaflets had at one time been present, as determined by the count of commissures plus raphes, was found in 82 per cent of interpretable valves. Several associated congenital cardiac lesions (coarctation of the aorta, transposition of the great vessels, tetralogy of Fallot, mitral atresia) exhibited a highly significant association with either aortic or pulmonic valvular malformations. The findings suggest that the majority of congenital malformations of the semilunar valves are due to lesions acquired in utero subsequent to normal valvulogenesis. Disproportionate flow reduction of the right or left side of the heart may be a factor in the development of malformations in the respective semilunar valve.

European Urology Supplements, 2017

Journal of Endourology Case Reports, 2016

A twenty-eight-year-old female with a history of suprapubic pain and recurrent urinary tract infe... more A twenty-eight-year-old female with a history of suprapubic pain and recurrent urinary tract infections presents for urology referral with a kidney, ureter, and bladder radiograph showing a 4.4 cm bladder calculus and 6.5 cm distal left ureteral stone. She underwent effective cystolitholapaxy of the bladder stone. Endourologic attempt (left ureteroscopy) was unsuccessful because of ureteral stone burden. Findings at ureteroscopy revealed a duplicated system on the left with the lower pole moiety joining just proximal to the ureteral orifice. The stone was found to be in the upper pole moiety ureter. An open ureterolithotomy was performed with intraoperative ureteroscopic laser lithotripsy and common sheath ureteral reimplant. Furthermore, a previously placed stent was found to be encrusted at the time of the ureterolithotomy. Effective ureteroscopy and lasering were performed through the ureterotomy up to the renal pelvis of the upper pole ureter.

Human Pathology, 2017

Prostate cancer management changed in recent times given the recommendation against PSA-screening... more Prostate cancer management changed in recent times given the recommendation against PSA-screening, adherence to active surveillance, and "cytoreductive" surgery. We

The Journal of Urology, 2016

Journal of Endourology, 2016

Introduction: The American Urological Association (AUA) guidelines recommend partial nephrectomy ... more Introduction: The American Urological Association (AUA) guidelines recommend partial nephrectomy (PN) as the gold standard for treatment of small renal masses (SRMs). This study examines the change in utilization of partial and radical nephrectomies at teaching and nonteaching institutions from 2003 to 2012. Materials and Methods: The data sample for this study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2003 to 2012. International Classification of Diseases, Ninth Revision and Clinical Modification codes were used to identify patients undergoing PN and radical nephrectomy for renal masses limited to the renal parenchyma. Teaching hospitals were defined, but not limited to any institution with an American Medical Association-approved residency program. Linear regression, bivariate, multivariate, and odds ratio analysis were used to demonstrate statistical significance. Results: 39,685 patients were identified in teaching hospitals, and 22,239 were identified in nonteaching hospitals. Prior to the 2009 AUA guidelines, cumulative rates of PN were 33% vs 20% in teaching vs nonteaching hospitals (p < 0.0001) compared with postguideline rates of 48% vs 33% in teaching vs nonteaching hospitals (p < 0.0001). Conclusions: During the 10-year study period, the use of PN to treat SRMs has significantly increased in both teaching hospitals and in nonacademic centers; however, these changes are occurring at a slower rate in nonteaching hospitals.

The Journal of Urology, 2016

with detailed and validated clinicopathologic data for all patients with newly-diagnosed CaP. For... more with detailed and validated clinicopathologic data for all patients with newly-diagnosed CaP. For this analysis, we identified all men who underwent RP for clinically low-risk CaP (defined as clinical stage T1 or T2a, prostate specific antigen (PSA) <10 ng/mL, and biopsy Gleason score 6) from 1/2011 through 8/2015. We compared differences in the frequency of adverse pathologic outcomes (e.g., Gleason score upgrading, seminal vesicle involvement, positive surgical margins) among patients selecting initial RP versus initial AS with subsequent transition to RP. RESULTS: During this interval, 2,858 patients with low-risk CaP were entered into the MUSIC registry. Among this group, 778 (27%) and 1,359 (48%) patients selected initial RP and initial AS, respectively. AS patients were older (63.4 vs. 60.1 years, p<0.001) with similar PSA levels (5.4 vs. 5.0 ng/mL, p¼0.08 for initial AS and RP groups, respectively), but less likely to have clinical T2a disease (5.1% vs 14.5%, p¼0.02). Among the AS cohort, the median follow-up was 506 days (IQR 280-793 days), and 79 (5.8%) transitioned to RP. Men managed with initial AS were more likely to have a pathological Gleason Score 7; however there were no other differences between these groups with respect to adverse pathology outcomes (Table 1). CONCLUSIONS: Patients with low risk CaP that enter AS have higher grade disease at RP compared to those undergoing initial RP. The lack of differences in other pathologic outcomes suggests that the surveillance process may be appropriately identifying patients with more aggressive cancers prior to stage progression.