Michael Palese | The Mount Sinai School of Medicine (original) (raw)

Papers by Michael Palese

The Journal of Urology, Apr 1, 2013

PubMed, Jun 20, 2007

Objective: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for... more Objective: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. Methods: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. Results: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. Conclusion: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.

Journal of Endourology, Jun 14, 2023

JSLS, 2018

Background and Objectives: The learning curve for achieving desirable perioperative outcomes in r... more Background and Objectives: The learning curve for achieving desirable perioperative outcomes in robot-assisted partial nephrectomy (RAPN) has not been well studied. Information is available regarding "trifecta" outcomes of no complications, no positive margins, warm ischemia time (WIT) of Յ25 minutes, and a Յ15% decrease in postoperative glomerular filtration rate (GFR). This study was conducted to assess the impact of the learning curve on surgical outcomes in patients undergoing RAPN. Methods: We reviewed 131 consecutive patients who underwent RAPN by a single, fellowship-trained surgeon from October 2007 through June 2015. Patients were divided into 4 subgroups, and mean perioperative values were compared. The learning curve was evaluated as the time it took the surgeon to attain a trifecta outcome. Results: Means for the RENAL Nephrometry Score, procedure length, WIT, and estimated blood loss (EBL) were 5.3 Ϯ 1.2, 172.1 Ϯ 43.5 minutes, 22.7 Ϯ 7.0 minutes, and 267.2 Ϯ 341.8 mL, respectively. Significance was noted for differences in WIT (P ϭ .50), postoperative creatinine (P ϭ .006), postoperative estimated (e)GFR (P ϭ .40), and percentage change in creatinine (P ϭ .023). The learning curve for achieving positive outcomes was noted in Ͼ61-90 cases after 66-80 months of performing minimally invasive partial nephrectomy surgeries at a rate of 20 cases per year. Conclusion: RAPN is a safe, feasible procedure with slightly better surgical outcomes than laparoscopic partial nephrectomy (LPN). In the hands of an experienced surgeon, the learning curve for achieving trifecta outcomes can involve a significant number of cases over several years.

The Journal of Urology, Apr 1, 2016

The Journal of Urology, Apr 1, 2018

The analytic sample consisted of 1,363 U.S. men aged above 40 in the National Health and Nutritio... more The analytic sample consisted of 1,363 U.S. men aged above 40 in the National Health and Nutrition Examination Survey 2007-2008 cycle. Men who had previous diagnoses of PCa or prostatitis and men exposed to manipulations that might have affected PSA levels were excluded. Multivariate logistic regression analyses were used to evaluate the independent association between PSA levels and metformin use by adjusting for potential confounders. RESULTS: The mean PSA level of the overall population was 1.8 (SD¼3.1) ng/ml. There were no differences in PSA levels according to the presence of diabetes (p¼0.517). Among patients with diabetes, metformin users exhibited significantly lower PSA levels compared to non-metformin users after adjusting for potential confounders (OR¼0.790; 95% CI 0.666-0.938; p¼0.007). However, there was no significant difference in PSA levels in men on duration of metformin use when stratified by either 1 year or 5 years or by Pearson 0 s coefficient. CONCLUSIONS: A negative association between serum PSA levels and metformin use was observed in patients with diabetes. Duration of metformin use did not influence PSA levels. Further studies are warranted to elucidate whether the reduction in PSA level with metformin truly reflects reduced risk of PCa development and progression.

The Journal of Urology, Apr 1, 2015

The Journal of Urology, Apr 1, 2004

universally adopted and been felt to promote living donor transplantation. In this study we exami... more universally adopted and been felt to promote living donor transplantation. In this study we examined the impact of laparoscopic nephrectomy on living donor transplantation within an single geographical region. METHODS: Transplant activity from a single center performing all renal transplants (cadaveric and living donor) for a geographically discrete population of 3.5 million people was reviewed. During the 10 year period to October 2003 a total of 241 living donor transplants were performed. From March 2000 donors were offered both laparoscopic and open nephrectomy. Patients decided on their preferred operation following an intensive information session which included continuously updated data from international series as well as the units experience with both procedures. RESULTS: Up to 1995 living donors contributed only 6% of all transplants. A progressive increase subsequently occurred to plateau from 1998 at the current level of 35% of transplants. Following introduction of laparoscopic donor nephrectomy a total of 135(51 laparoscopic, 74 open) living donor transplants were performed. Post-operative haemorrhage required return to theatre and transfusion following one open nephrectomy. Median operative time in the laparoscopic group was 2.47 hrs (range 2.02-3.5) compared to 2.5 hrs (range 2.17-2.78, p>0.05) with open surgery. The median time from ligation of the renal artery to perfusion was 2mins (1-5) with laparoscopy and 3rnins (2-4, p>0.05) with open surgery. There was no difference in the vascular anastomosis times-median 40.8 ruins (range 29.4-58.2) with laparoscopy compared to 45.0 mins (39-76.2, p> 0.05). Immediate graft function occurred in all cases with no significant differences in serum creatinine at 1 and 6 months. One transplant in the laparoscopic group was re-explored for poor perfusion which related to atheromatous disease of the recipient iliac artery. Graft loss occurred in 2 recipients in the open donor group due to refractory rejection CONCLUSIONS: Laparoscopic and open donor nephrectomy appear comparable in terms of operative times and transplant outcome. Many living donors will continue to elect for an open procedure when presented with the known outcomes of both open and laparoscopic surgery. Within a geographical region the availability of laparoscopic nephrectomy has not influenced the rate of living donor transplantation.

The Journal of Urology, Apr 1, 2004

The Journal of Urology, Apr 1, 2004

The Journal of Urology, Apr 1, 2016

to externalise it. Adequate tension can then be applied to straighten the ureter to aid placement... more to externalise it. Adequate tension can then be applied to straighten the ureter to aid placement of a stent. METHODS: We retrospectively reviewed patients undergoing a Rendezvous procedure for ureteric discontinuities, treated between 2005 and 2014 at our Institution and completing at least a 12 monthfollow up. We divided patients into two groups: late oncological/postsurgical stricture (group A), or early post-surgical obstruction, leakage or detachment (group B). If appropriate, we performed a retrograde study +/-rigid ureteroscopy to assess the stricture after 3 month from the procedure, followed by a MAG3 renogram at 6 and 12 months. RESULTS: 32 patients underwent a Rendezvous procedure, 22 in group A (Mean age 59.35, range: 49-74), 10 in group B (Mean age 52.44, range: 36-63). Strictures were successfully stented in 18 out of 22 patient (82%) in the group A, 7 out of 10 in group B (70%). After successful stenting, at 12 month 9/18 of group A required no further interventions and were stent free (50%), 5 (28%) were maintained with long term stenting. Only 2 (11%) required major reconstruction, 2 patients (11%) died during follow up from malignancy. In group B, 4/8 (50%) were stent free with no further interventions, 3/ 8 (38%) were maintained on long term stenting, only 1 required reconstruction. CONCLUSIONS: With a combined antegrade and retrograde approach, the majority of complex ureteric stricture can be bridged and stented, avoiding major surgery in unfavourable circumstances and allows time for stabilisation and recovery of the patient. Interestingly, if successful, further interventions later may be unnecessary in up to 50% of patients. This is particularly useful in elderly patients with malignant stricture, but also in young patients with benign discontinuities and a good blood supply to the ureter.

European Urology, Mar 1, 2008

Objectives: Only minimal literature exists on consequences of shock wave therapy (SWT) on erectil... more Objectives: Only minimal literature exists on consequences of shock wave therapy (SWT) on erectile function in treatment of Peyronie's disease (PD). This study was undertaken to define SWT impact at varied energy/dose levels at different time points on functional and structural changes in erectile tissue. Methods: In 45 rats 2000 shock waves (sw) at 2 BAR were applied to the penis weekly sorted by one, two, and three sessions (high-dose/energy level, HD-1, HD-2, HD-3). Each group was followed for 1, 7, or 28 d before measuring intracavernosal pressure (ICP) and mean arterial pressure (MAP). Fifteen control animals (C1, C7, C28) underwent anesthesia alone. Another 15 animals were exposed to three SWT sessions applying 1000 sw at 1 BAR and analyzed identically (low-dose/energy level, LD-3-1,-7,-28). Terminal deoxynucleotidyl transferase biotin-dUTP nick-end labeling assay was used to define the apoptotic index (AI) and Masson's trichrome (MT) staining was prepared to evaluate smooth muscle-to-collagen ratios. Results: ICP/MAP ratios for all C groups displayed a mean of 64%. All SWT groups demonstrated significantly reduced ICP/MAP ratios compared to their corresponding C groups (p < 0.05). The LD-3 groups showed a trend toward improved ICP/MAP ratios. LD-3-28 demonstrated significant recovery compared to HD-3-28 (55 AE 8% vs. 41 AE 10%, p = 0.004), but remained reduced compared to C28 (63 AE 5%, p = 0.03). No statistical differences were seen for MT staining in SWT groups compared to C (p > 0.05). AIs for the LD-3 groups were significantly lower compared to the HD-3 groups (p < 0.001), but all AIs were significantly increased compared to C groups (p < 0.01). Conclusions: Overall, at both energy/dose levels, SWT resulted in a time-and treatment-dependent reduction of ICP/MAP ratios, which might be mediated partly through apoptosis and collagenization of corporal smooth muscle.

Urology, Aug 1, 2005

Objectives. To investigate whether a delay in nephroureterectomy for patients with transitional c... more Objectives. To investigate whether a delay in nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract owing to ureteroscopic biopsy and/or laser tumor ablation affects postoperative disease status. Methods. Of 155 patients diagnosed with upper tract transitional cell carcinoma at our institution from 1993 to 2003, 121 underwent nephroureterectomy. We compared the postoperative disease status of patients who underwent nephroureterectomy on the basis of positive cytology findings and filling defect on contrast imaging (no ureteroscopy; n ϭ 34) to patients who underwent nephroureterectomy after ureteroscopic biopsy (n ϭ 75) and patients who underwent nephroureterectomy after ureteroscopic biopsy and laser tumor ablation (n ϭ 12). Results. At a mean follow-up of 38.7 months, 29 (85.3%) of 34 patients who underwent nephroureterectomy on the basis of contrast imaging and urinary cytology alone were disease free compared with 61 (81.3%) of 75 patients who underwent ureteroscopic biopsy before nephroureterectomy (P ϭ 0.18). The mean time from biopsy to nephroureterectomy for these 75 patients was 28 days, and the mean follow-up after nephroureterectomy was 40.1 months. Finally, 10 (83.3%) of 12 patients who underwent ureteroscopic biopsy and laser tumor ablation before nephroureterectomy were disease free at a mean follow-up of 37.2 months. The mean time from ureteroscopic biopsy to nephroureterectomy in this group was 196 days. No significant difference was found in the postoperative disease status between patients undergoing nephroureterectomy after ablation and those who proceeded to nephroureterectomy after endoscopic biopsy or those who did not undergo ureteroscopy before nephroureterectomy (P ϭ 0.16). Conclusions. Ureteroscopy with biopsy and/or tumor ablation before nephroureterectomy did not adversely affect the postoperative disease status.

Urology, Dec 1, 2016

OBJECTIVE To elucidate the evolving trends in subspecialization related to individual practice wi... more OBJECTIVE To elucidate the evolving trends in subspecialization related to individual practice within inpatient urology over a 31-year period spanning from 1982 to 2012. METHODS We conducted a retrospective cohort study by querying the centralized New York State data on partial nephrectomy, radical nephrectomy, radical prostatectomy, and radical cystectomy procedures for all inpatient encounters in the state of New York for the years 1982-2012 using the Statewide Planning and Research Cooperative System dataset. All encounters involving 1 of the procedures were identified and the AMA Masterfile was used to identify all physicians who have completed residencies in urology. We performed descriptive analyses to determine the quantity of cases, quantity of patients, and distribution of the cases among operating physicians. High-volume urologists, defined as the top 5% of urologists in terms of caseload, were identified, and the distributions of their procedures was analyzed. RESULTS The proportion of procedures completed by high-volume urologists increased significantly for all procedures. The number of identified urologists involved in radical cystectomy and radical nephrectomy has declined since 1982, with the number of identified urologists involved in partial nephrectomy and radical prostatectomy beginning a continuous decline from 2004 to 1999, respectively. During the 31-year time period, the number of cases increased for all procedures. CONCLUSION A smaller group of urologists is performing a larger proportion of cases for each studied procedure, reflecting a trend toward subspecialization.

Urology, Jul 1, 2022

OBJECTIVES To analyze the utilization and safety of same-day (SDD) versus standard-length dischar... more OBJECTIVES To analyze the utilization and safety of same-day (SDD) versus standard-length discharge (SLD) for transurethral resection (TURP), holmium laser enucleation (HoLEP), and GreenLight photovaporization (GL-PVP) of the prostate. METHODS Using the 2015-2019 ACS-NSQIP files, the annual proportion of TURP, HoLEP, and GL-PVP performed with SDD (length of stay [LOS] = 0 days) was calculated. Patients were stratified by LOS into SDD and SLD (TURP: LOS = 1-3 days, HoLEP and GL-PVP: LOS = 1-2 days); those with longer LOS were excluded. Patients were matched 1:1 by age, BMI, ASA score, and modified Charlson Comorbidity Index score. We compared 30-day unplanned readmissions, reoperations, and Clavien-Dindo (CD) complications between SLD and SDD, and evaluated predictors of adverse outcomes using logistic regression. RESULTS Most GL-PVP patients underwent SDD, compared to a minority of TURP and HoLEP patients. SDD utilization increased, remained stable, and decreased over time for HoLEP, TURP, and GL-PVP, respectively. For 46,898 included cases (31,872 TURP, 2,901 HoLEP, 12,125 GL-PVP), rates of reoperation, CD I/II, or CD IV complications were comparable before and after matching. Compared to SLD, 30-day unplanned readmission rates for matched SDD patients were lower following TURP (3.48% vs. 4.25%, p=0.013) and HoLEP (1.93% vs. 4.43%, p=0.003). On multivariate regression, SLD correlated with unplanned readmission after TURP and HoLEP for both unmatched and matched cohorts. CONCLUSIONS For appropriately selected patients, SDD after TURP, HoLEP, and GL-PVP did not confer increased risk of 30-day complications, suggesting patient selection for SDD is being done with appropriate safety nationally.

World Journal of Urology, Jan 3, 2021

Purpose Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guideline... more Purpose Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guidelines recommend Rezum for prostates < 80 cc, but little data exist describing outcomes in patients with prostates ≥ 80 cc. We compare outcomes after Rezum between men with small < 80 cc (SP) and large ≥ 80 cc prostates (LP). Methods Patients undergoing Rezum between Jan 2017-Feb 2020 were subdivided by prostate volume (< 80, ≥ 80 cc). Outcomes were documented pre-and postoperatively. Descriptive analyses of urodynamics data (Qmax, PVR), symptom scores (AUA-SS, SHIM), disease management (medications, catheterization, retreatments), and clinical outcomes were conducted. Results 36 (17.6%) men had prostates ≥ 80 cc (LP mean prostate size 106.8 cc). LP men had improved Qmax and PVR postoperatively; those with longitudinal follow-up exhibited improved Qmax, PVR, and AUA-SS. After one year, alphablocker usage decreased significantly (LP 94.44-61.11%, p = 0.001, SP 73.96-46.15%, p = 0.001); other medication usage and self-catheterization rates remained unchanged. Compared to SP patients, differences in passing trial void (LP 94.44%, SP 93.45%), postoperative UTI (LP 19.44%, SP 10.12%), ED visits (LP 22.22%, SP 17.86%), readmissions (LP 8.33%, SP 4.76%), and retreatment (LP 8.33%, SP 4.76%) were insignificant. However, mean days to foley removal (LP 9, SP 5.71, p = 0.003) and urosepsis rates (LP 5.56%, SP 0.00%, p = 0.002) differed. Conclusion In select LP patients, Rezum provided short-term symptomatic relief and improved voiding function comparable to SP patients. Postoperatively, though alpha-blocker usage decreased significantly, use of other medications did not change, and nearly two-thirds of patients still needed alpha-blockade. Further efforts should explore the possibility of expanding Rezum's inclusion criteria.

The Journal of Urology, Apr 1, 2018

age, gender, or years of practice. Urologists reported a poor level of competence in providing en... more age, gender, or years of practice. Urologists reported a poor level of competence in providing endocrine care (1.91) and performing GCS (1.87), as well as relatively weak self-reported fund of knowledge (2.64) and overall clinical competence (2.09) in TG care. CONCLUSIONS: Despite growing education and awareness of TG-specific medical issues, many urologists report deficiencies in requisite knowledge and comfort in providing adequate, culturally competent care for these patients. TG health is here to stay and competency in this new and evolving aspect of our field should be a goal for urologists trained in the US and around the world.

Journal of Endourology, Dec 1, 2022

The Journal of Urology, Sep 1, 2021

INTRODUCTION AND OBJECTIVE:Historically, patients with symptomatic benign prostatic hyperplasia (... more INTRODUCTION AND OBJECTIVE:Historically, patients with symptomatic benign prostatic hyperplasia (BPH) underwent either transurethral resection of the prostate (TURP) or simple prostatectomy. Howeve...

The Journal of Urology, Apr 1, 2018

The Journal of Urology, Apr 1, 2013

PubMed, Jun 20, 2007

Objective: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for... more Objective: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. Methods: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. Results: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. Conclusion: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.

Journal of Endourology, Jun 14, 2023

JSLS, 2018

Background and Objectives: The learning curve for achieving desirable perioperative outcomes in r... more Background and Objectives: The learning curve for achieving desirable perioperative outcomes in robot-assisted partial nephrectomy (RAPN) has not been well studied. Information is available regarding "trifecta" outcomes of no complications, no positive margins, warm ischemia time (WIT) of Յ25 minutes, and a Յ15% decrease in postoperative glomerular filtration rate (GFR). This study was conducted to assess the impact of the learning curve on surgical outcomes in patients undergoing RAPN. Methods: We reviewed 131 consecutive patients who underwent RAPN by a single, fellowship-trained surgeon from October 2007 through June 2015. Patients were divided into 4 subgroups, and mean perioperative values were compared. The learning curve was evaluated as the time it took the surgeon to attain a trifecta outcome. Results: Means for the RENAL Nephrometry Score, procedure length, WIT, and estimated blood loss (EBL) were 5.3 Ϯ 1.2, 172.1 Ϯ 43.5 minutes, 22.7 Ϯ 7.0 minutes, and 267.2 Ϯ 341.8 mL, respectively. Significance was noted for differences in WIT (P ϭ .50), postoperative creatinine (P ϭ .006), postoperative estimated (e)GFR (P ϭ .40), and percentage change in creatinine (P ϭ .023). The learning curve for achieving positive outcomes was noted in Ͼ61-90 cases after 66-80 months of performing minimally invasive partial nephrectomy surgeries at a rate of 20 cases per year. Conclusion: RAPN is a safe, feasible procedure with slightly better surgical outcomes than laparoscopic partial nephrectomy (LPN). In the hands of an experienced surgeon, the learning curve for achieving trifecta outcomes can involve a significant number of cases over several years.

The Journal of Urology, Apr 1, 2016

The Journal of Urology, Apr 1, 2018

The analytic sample consisted of 1,363 U.S. men aged above 40 in the National Health and Nutritio... more The analytic sample consisted of 1,363 U.S. men aged above 40 in the National Health and Nutrition Examination Survey 2007-2008 cycle. Men who had previous diagnoses of PCa or prostatitis and men exposed to manipulations that might have affected PSA levels were excluded. Multivariate logistic regression analyses were used to evaluate the independent association between PSA levels and metformin use by adjusting for potential confounders. RESULTS: The mean PSA level of the overall population was 1.8 (SD¼3.1) ng/ml. There were no differences in PSA levels according to the presence of diabetes (p¼0.517). Among patients with diabetes, metformin users exhibited significantly lower PSA levels compared to non-metformin users after adjusting for potential confounders (OR¼0.790; 95% CI 0.666-0.938; p¼0.007). However, there was no significant difference in PSA levels in men on duration of metformin use when stratified by either 1 year or 5 years or by Pearson 0 s coefficient. CONCLUSIONS: A negative association between serum PSA levels and metformin use was observed in patients with diabetes. Duration of metformin use did not influence PSA levels. Further studies are warranted to elucidate whether the reduction in PSA level with metformin truly reflects reduced risk of PCa development and progression.

The Journal of Urology, Apr 1, 2015

The Journal of Urology, Apr 1, 2004

universally adopted and been felt to promote living donor transplantation. In this study we exami... more universally adopted and been felt to promote living donor transplantation. In this study we examined the impact of laparoscopic nephrectomy on living donor transplantation within an single geographical region. METHODS: Transplant activity from a single center performing all renal transplants (cadaveric and living donor) for a geographically discrete population of 3.5 million people was reviewed. During the 10 year period to October 2003 a total of 241 living donor transplants were performed. From March 2000 donors were offered both laparoscopic and open nephrectomy. Patients decided on their preferred operation following an intensive information session which included continuously updated data from international series as well as the units experience with both procedures. RESULTS: Up to 1995 living donors contributed only 6% of all transplants. A progressive increase subsequently occurred to plateau from 1998 at the current level of 35% of transplants. Following introduction of laparoscopic donor nephrectomy a total of 135(51 laparoscopic, 74 open) living donor transplants were performed. Post-operative haemorrhage required return to theatre and transfusion following one open nephrectomy. Median operative time in the laparoscopic group was 2.47 hrs (range 2.02-3.5) compared to 2.5 hrs (range 2.17-2.78, p>0.05) with open surgery. The median time from ligation of the renal artery to perfusion was 2mins (1-5) with laparoscopy and 3rnins (2-4, p>0.05) with open surgery. There was no difference in the vascular anastomosis times-median 40.8 ruins (range 29.4-58.2) with laparoscopy compared to 45.0 mins (39-76.2, p> 0.05). Immediate graft function occurred in all cases with no significant differences in serum creatinine at 1 and 6 months. One transplant in the laparoscopic group was re-explored for poor perfusion which related to atheromatous disease of the recipient iliac artery. Graft loss occurred in 2 recipients in the open donor group due to refractory rejection CONCLUSIONS: Laparoscopic and open donor nephrectomy appear comparable in terms of operative times and transplant outcome. Many living donors will continue to elect for an open procedure when presented with the known outcomes of both open and laparoscopic surgery. Within a geographical region the availability of laparoscopic nephrectomy has not influenced the rate of living donor transplantation.

The Journal of Urology, Apr 1, 2004

The Journal of Urology, Apr 1, 2004

The Journal of Urology, Apr 1, 2016

to externalise it. Adequate tension can then be applied to straighten the ureter to aid placement... more to externalise it. Adequate tension can then be applied to straighten the ureter to aid placement of a stent. METHODS: We retrospectively reviewed patients undergoing a Rendezvous procedure for ureteric discontinuities, treated between 2005 and 2014 at our Institution and completing at least a 12 monthfollow up. We divided patients into two groups: late oncological/postsurgical stricture (group A), or early post-surgical obstruction, leakage or detachment (group B). If appropriate, we performed a retrograde study +/-rigid ureteroscopy to assess the stricture after 3 month from the procedure, followed by a MAG3 renogram at 6 and 12 months. RESULTS: 32 patients underwent a Rendezvous procedure, 22 in group A (Mean age 59.35, range: 49-74), 10 in group B (Mean age 52.44, range: 36-63). Strictures were successfully stented in 18 out of 22 patient (82%) in the group A, 7 out of 10 in group B (70%). After successful stenting, at 12 month 9/18 of group A required no further interventions and were stent free (50%), 5 (28%) were maintained with long term stenting. Only 2 (11%) required major reconstruction, 2 patients (11%) died during follow up from malignancy. In group B, 4/8 (50%) were stent free with no further interventions, 3/ 8 (38%) were maintained on long term stenting, only 1 required reconstruction. CONCLUSIONS: With a combined antegrade and retrograde approach, the majority of complex ureteric stricture can be bridged and stented, avoiding major surgery in unfavourable circumstances and allows time for stabilisation and recovery of the patient. Interestingly, if successful, further interventions later may be unnecessary in up to 50% of patients. This is particularly useful in elderly patients with malignant stricture, but also in young patients with benign discontinuities and a good blood supply to the ureter.

European Urology, Mar 1, 2008

Objectives: Only minimal literature exists on consequences of shock wave therapy (SWT) on erectil... more Objectives: Only minimal literature exists on consequences of shock wave therapy (SWT) on erectile function in treatment of Peyronie's disease (PD). This study was undertaken to define SWT impact at varied energy/dose levels at different time points on functional and structural changes in erectile tissue. Methods: In 45 rats 2000 shock waves (sw) at 2 BAR were applied to the penis weekly sorted by one, two, and three sessions (high-dose/energy level, HD-1, HD-2, HD-3). Each group was followed for 1, 7, or 28 d before measuring intracavernosal pressure (ICP) and mean arterial pressure (MAP). Fifteen control animals (C1, C7, C28) underwent anesthesia alone. Another 15 animals were exposed to three SWT sessions applying 1000 sw at 1 BAR and analyzed identically (low-dose/energy level, LD-3-1,-7,-28). Terminal deoxynucleotidyl transferase biotin-dUTP nick-end labeling assay was used to define the apoptotic index (AI) and Masson's trichrome (MT) staining was prepared to evaluate smooth muscle-to-collagen ratios. Results: ICP/MAP ratios for all C groups displayed a mean of 64%. All SWT groups demonstrated significantly reduced ICP/MAP ratios compared to their corresponding C groups (p < 0.05). The LD-3 groups showed a trend toward improved ICP/MAP ratios. LD-3-28 demonstrated significant recovery compared to HD-3-28 (55 AE 8% vs. 41 AE 10%, p = 0.004), but remained reduced compared to C28 (63 AE 5%, p = 0.03). No statistical differences were seen for MT staining in SWT groups compared to C (p > 0.05). AIs for the LD-3 groups were significantly lower compared to the HD-3 groups (p < 0.001), but all AIs were significantly increased compared to C groups (p < 0.01). Conclusions: Overall, at both energy/dose levels, SWT resulted in a time-and treatment-dependent reduction of ICP/MAP ratios, which might be mediated partly through apoptosis and collagenization of corporal smooth muscle.

Urology, Aug 1, 2005

Objectives. To investigate whether a delay in nephroureterectomy for patients with transitional c... more Objectives. To investigate whether a delay in nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract owing to ureteroscopic biopsy and/or laser tumor ablation affects postoperative disease status. Methods. Of 155 patients diagnosed with upper tract transitional cell carcinoma at our institution from 1993 to 2003, 121 underwent nephroureterectomy. We compared the postoperative disease status of patients who underwent nephroureterectomy on the basis of positive cytology findings and filling defect on contrast imaging (no ureteroscopy; n ϭ 34) to patients who underwent nephroureterectomy after ureteroscopic biopsy (n ϭ 75) and patients who underwent nephroureterectomy after ureteroscopic biopsy and laser tumor ablation (n ϭ 12). Results. At a mean follow-up of 38.7 months, 29 (85.3%) of 34 patients who underwent nephroureterectomy on the basis of contrast imaging and urinary cytology alone were disease free compared with 61 (81.3%) of 75 patients who underwent ureteroscopic biopsy before nephroureterectomy (P ϭ 0.18). The mean time from biopsy to nephroureterectomy for these 75 patients was 28 days, and the mean follow-up after nephroureterectomy was 40.1 months. Finally, 10 (83.3%) of 12 patients who underwent ureteroscopic biopsy and laser tumor ablation before nephroureterectomy were disease free at a mean follow-up of 37.2 months. The mean time from ureteroscopic biopsy to nephroureterectomy in this group was 196 days. No significant difference was found in the postoperative disease status between patients undergoing nephroureterectomy after ablation and those who proceeded to nephroureterectomy after endoscopic biopsy or those who did not undergo ureteroscopy before nephroureterectomy (P ϭ 0.16). Conclusions. Ureteroscopy with biopsy and/or tumor ablation before nephroureterectomy did not adversely affect the postoperative disease status.

Urology, Dec 1, 2016

OBJECTIVE To elucidate the evolving trends in subspecialization related to individual practice wi... more OBJECTIVE To elucidate the evolving trends in subspecialization related to individual practice within inpatient urology over a 31-year period spanning from 1982 to 2012. METHODS We conducted a retrospective cohort study by querying the centralized New York State data on partial nephrectomy, radical nephrectomy, radical prostatectomy, and radical cystectomy procedures for all inpatient encounters in the state of New York for the years 1982-2012 using the Statewide Planning and Research Cooperative System dataset. All encounters involving 1 of the procedures were identified and the AMA Masterfile was used to identify all physicians who have completed residencies in urology. We performed descriptive analyses to determine the quantity of cases, quantity of patients, and distribution of the cases among operating physicians. High-volume urologists, defined as the top 5% of urologists in terms of caseload, were identified, and the distributions of their procedures was analyzed. RESULTS The proportion of procedures completed by high-volume urologists increased significantly for all procedures. The number of identified urologists involved in radical cystectomy and radical nephrectomy has declined since 1982, with the number of identified urologists involved in partial nephrectomy and radical prostatectomy beginning a continuous decline from 2004 to 1999, respectively. During the 31-year time period, the number of cases increased for all procedures. CONCLUSION A smaller group of urologists is performing a larger proportion of cases for each studied procedure, reflecting a trend toward subspecialization.

Urology, Jul 1, 2022

OBJECTIVES To analyze the utilization and safety of same-day (SDD) versus standard-length dischar... more OBJECTIVES To analyze the utilization and safety of same-day (SDD) versus standard-length discharge (SLD) for transurethral resection (TURP), holmium laser enucleation (HoLEP), and GreenLight photovaporization (GL-PVP) of the prostate. METHODS Using the 2015-2019 ACS-NSQIP files, the annual proportion of TURP, HoLEP, and GL-PVP performed with SDD (length of stay [LOS] = 0 days) was calculated. Patients were stratified by LOS into SDD and SLD (TURP: LOS = 1-3 days, HoLEP and GL-PVP: LOS = 1-2 days); those with longer LOS were excluded. Patients were matched 1:1 by age, BMI, ASA score, and modified Charlson Comorbidity Index score. We compared 30-day unplanned readmissions, reoperations, and Clavien-Dindo (CD) complications between SLD and SDD, and evaluated predictors of adverse outcomes using logistic regression. RESULTS Most GL-PVP patients underwent SDD, compared to a minority of TURP and HoLEP patients. SDD utilization increased, remained stable, and decreased over time for HoLEP, TURP, and GL-PVP, respectively. For 46,898 included cases (31,872 TURP, 2,901 HoLEP, 12,125 GL-PVP), rates of reoperation, CD I/II, or CD IV complications were comparable before and after matching. Compared to SLD, 30-day unplanned readmission rates for matched SDD patients were lower following TURP (3.48% vs. 4.25%, p=0.013) and HoLEP (1.93% vs. 4.43%, p=0.003). On multivariate regression, SLD correlated with unplanned readmission after TURP and HoLEP for both unmatched and matched cohorts. CONCLUSIONS For appropriately selected patients, SDD after TURP, HoLEP, and GL-PVP did not confer increased risk of 30-day complications, suggesting patient selection for SDD is being done with appropriate safety nationally.

World Journal of Urology, Jan 3, 2021

Purpose Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guideline... more Purpose Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guidelines recommend Rezum for prostates < 80 cc, but little data exist describing outcomes in patients with prostates ≥ 80 cc. We compare outcomes after Rezum between men with small < 80 cc (SP) and large ≥ 80 cc prostates (LP). Methods Patients undergoing Rezum between Jan 2017-Feb 2020 were subdivided by prostate volume (< 80, ≥ 80 cc). Outcomes were documented pre-and postoperatively. Descriptive analyses of urodynamics data (Qmax, PVR), symptom scores (AUA-SS, SHIM), disease management (medications, catheterization, retreatments), and clinical outcomes were conducted. Results 36 (17.6%) men had prostates ≥ 80 cc (LP mean prostate size 106.8 cc). LP men had improved Qmax and PVR postoperatively; those with longitudinal follow-up exhibited improved Qmax, PVR, and AUA-SS. After one year, alphablocker usage decreased significantly (LP 94.44-61.11%, p = 0.001, SP 73.96-46.15%, p = 0.001); other medication usage and self-catheterization rates remained unchanged. Compared to SP patients, differences in passing trial void (LP 94.44%, SP 93.45%), postoperative UTI (LP 19.44%, SP 10.12%), ED visits (LP 22.22%, SP 17.86%), readmissions (LP 8.33%, SP 4.76%), and retreatment (LP 8.33%, SP 4.76%) were insignificant. However, mean days to foley removal (LP 9, SP 5.71, p = 0.003) and urosepsis rates (LP 5.56%, SP 0.00%, p = 0.002) differed. Conclusion In select LP patients, Rezum provided short-term symptomatic relief and improved voiding function comparable to SP patients. Postoperatively, though alpha-blocker usage decreased significantly, use of other medications did not change, and nearly two-thirds of patients still needed alpha-blockade. Further efforts should explore the possibility of expanding Rezum's inclusion criteria.

The Journal of Urology, Apr 1, 2018

age, gender, or years of practice. Urologists reported a poor level of competence in providing en... more age, gender, or years of practice. Urologists reported a poor level of competence in providing endocrine care (1.91) and performing GCS (1.87), as well as relatively weak self-reported fund of knowledge (2.64) and overall clinical competence (2.09) in TG care. CONCLUSIONS: Despite growing education and awareness of TG-specific medical issues, many urologists report deficiencies in requisite knowledge and comfort in providing adequate, culturally competent care for these patients. TG health is here to stay and competency in this new and evolving aspect of our field should be a goal for urologists trained in the US and around the world.

Journal of Endourology, Dec 1, 2022

The Journal of Urology, Sep 1, 2021

INTRODUCTION AND OBJECTIVE:Historically, patients with symptomatic benign prostatic hyperplasia (... more INTRODUCTION AND OBJECTIVE:Historically, patients with symptomatic benign prostatic hyperplasia (BPH) underwent either transurethral resection of the prostate (TURP) or simple prostatectomy. Howeve...

The Journal of Urology, Apr 1, 2018