To evaluate the surgical performance of the new Greenlight XPS-180W laser system (American Medica... more To evaluate the surgical performance of the new Greenlight XPS-180W laser system (American Medical Systems, Minnetonka, MI) and the effect of prostate volume (PV), in comparison with the former HPS-120W system, for the treatment of benign prostatic hyperplasia by photoselective vaporization of the prostate.
We sought to examine the surgical trends and utilization of treatment for mixed urinary incontine... more We sought to examine the surgical trends and utilization of treatment for mixed urinary incontinence among female Medicare beneficiaries. Data was obtained from a 5% national random sample of outpatient and carrier claims from 2000 to 2011. Included were female patients 65 and older, diagnosed with mixed urinary incontinence, who underwent surgical treatment identified by Current Procedural Terminology, Fourth Edition (CPT-4) codes. Urodynamics (UDS) before initial and secondary procedure were also identified using CPT-4 codes. Procedural trends and utilization of UDS were analyzed. Utilization of UDS increased during the study period, from 38.4% to 74.0% prior to initial surgical intervention, and from 28.6% to 62.5% preceding re-intervention. Sling surgery (63.0%) and injectable bulking agents (28.0%) were the most common surgical treatments adopted, followed by sacral nerve stimulation (SNS) (4.8%) and Burch (4.0%) procedures. Re-intervention was performed in 4.0% of patients ini...
We present our initial experience with performing robotic-assisted prostatectomies in men with a ... more We present our initial experience with performing robotic-assisted prostatectomies in men with a 3-piece inflatable penile prosthesis with a pelvic reservoir. Four patients underwent transperitoneal robotic-assisted radical prostatectomies with a penile prosthetic implant in place. The reservoir was left inflated for easy identification. A flaccid reservoir may be more difficult to identify, and be prone to damage. The reservoir was left attached to the abdominal wall. Dissection was performed outside the fibrous capsule of the reservoir. The tissue around the capsule of the reservoir peeled off without difficulty. Cutting current close to the capsule can be used if needed as per American Medical System with no limit to voltage. The penile prosthesis is then inflated to empty the reservoir creating more prevesical space and preventing the reservoir from obscuring visualization. The remaining portion of the procedure is completed using our standard technique. After completing the urethrovesical anastomosis using the 16 French Foley, the prosthesis is cycled under direct vision and the penile prosthesis is deflated (reservoir full). The prosthesis is not used for 6 weeks to prevent stretching of the urethrovesical anastomosis. All patients (n = 4) had no reported complications and all prostheses are functioning properly. The margin status was negative postoperatively. Robotic prostatectomy is technically feasible in patients with inflatable penile prostheses by surgeons experienced in robotic surgery. However, the presence of an indwelling penile prosthesis does increase the complexity of surgery.
We report a case of primary granulocytic sarcoma (GS) of the left adrenal gland, with no evidence... more We report a case of primary granulocytic sarcoma (GS) of the left adrenal gland, with no evidence of hematologic involvement. To our knowledge, this is the first case of granulocytic sarcoma of the adrenal gland.
To present our technique for the management of an enlarged median lobe when the ureteral orifices... more To present our technique for the management of an enlarged median lobe when the ureteral orifices are close to the bladder neck during robotic-assisted radical prostatectomy. From January 2005 to January 2007, we performed over 600 robotic assisted radical prostatectomies. We had 63 patients (10%) with enlarged medium lobes. Of these patients, two (5.7%) had their ureteral orifices in close proximity to the bladder neck. An additional patient, without a median lobe, had his orifices very close to the bladder neck. To aid in the management of their median lobes, all three patients had bilateral placement of ureteral catheters manually by the daVinci robot. We present our technique of robotic-assisted catheter insertion during robotic prostatectomy to protect the ureteral orifice from damage, precluding the use of a cystoscope. All three patients, underwent successful robotic-assisted radical prostatectomy (RALP) aided by intraoperative placement of either a double J ureteral catheters or open ended ureteral catheters that were removed after completion of the anastamosis. All three had normal cystograms before Foley catheter removal. All three patients were continent with follow up PSAs < 0.1. The presence of a median lobe slightly increased the operative time required for bladder neck dissection or anastomosis (including reconstruction). There was no difference in complications such as urine leaks and bladder neck contractures. Continence after RALP was not significantly different in men with large median lobes. Management of ureteral orifices that are too close to the bladder neck with or without large medium lobes can be successfully performed with the uses of ureteral catheters placed robotically with the da Vinci robot. The presence of a median lobe does not alter outcomes in patients who undergo robot-assisted laparoscopic prostatectomy.
Overactive bladder (OAB) is a diffi cult condition to live with and is very costly to the communi... more Overactive bladder (OAB) is a diffi cult condition to live with and is very costly to the community. OAB affects 16% of the adult population and rises with increasing age. We describe the necessary steps in evaluation and behavioral therapy prior to initiating medical therapy. There are several medications that have been used for the treatment of patients who suffer from OAB. This manuscript discusses the popular agents used for OAB, with a focus on the recent clinical trials on darifenacin.
Wilm's tumor, or nephroblastoma, ... more Wilm's tumor, or nephroblastoma, is a common renal tumor among children. Few cases of Wilm's tumor have been reported in women during pregnancy. The authors present a rare case of a pregnant female, who underwent laparoscopic excision of a large Wilm's tumor. The authors have also provided a review of the current literature.
Many aging men will experience both erectile dysfunction (ED) and benign prostatic hyperplasia (B... more Many aging men will experience both erectile dysfunction (ED) and benign prostatic hyperplasia (BPH), resulting in lower urinary tract symptoms (LUTS). Basic and clinical evidence suggests common pathogenic mechanisms underlying both LUTS and ED. Decreases in the nitric oxide-cyclic guanosine monophosphate (NO-cGMP) pathway with age result in decreased levels of intracellular cGMP and calcium, leading to diminished smooth muscle relaxation of the bladder and prostate and worsening LUTS. Phosphodiesterase type 5 inhibitors as monotherapy in combination with α-blockers have shown efficacy in treating both LUTS and ED. Tadalafil has recently been approved by the US Food and Drug Administration for the treatment of LUTS secondary to BPH, with or without concomitant ED.
To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes betwe... more To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes between procedures using and not using mesh. All inclusive, population based cohort study. Statewide surgical care captured in the New York Statewide Planning and Research Cooperative System. Women who underwent prolapse repair procedures in New York state from 2008 to 2011. 90 day safety events and reinterventions within one year, after propensity score matching. Categorical, time to event, and subgroup analyses (<65 and ≥ 65 year age groups) were conducted. Of 27,991 patients in total, 7338 and 20, 653 underwent prolapse repair procedures with and without mesh, respectively. Mesh use increased by 44.7%, from 1461 procedures in 2008 to 2114 procedures in 2011. Most patients in the cohort were younger than 65 years (62.3% (n=17,424/27, 991)). However, more patients were aged 65 years and older in the mesh group than in the non-mesh group (44.3% (n=3249) v 35.4% (n=7318)). Complications aft...
Primary soft tissue sarcomas of the genitourinary tract are rarely seen, especially in the semina... more Primary soft tissue sarcomas of the genitourinary tract are rarely seen, especially in the seminal vesicle. While sarcomas have been reported in the seminal vesicle, this is the first report of a smooth muscle neoplasm, of uncertain malignant potential, involving the seminal vesicle. The finding was incidental, following robotic-assisted radical retropubic prostatectomy for prostate cancer. To our knowledge, this is also the first report of a primary seminal vesicle tumor found following radical prostatectomy. A clinical case review and a brief review of the literature are presented.
We sought to investigate recent trends in mesh use for pelvic organ prolapse (POP)-related recons... more We sought to investigate recent trends in mesh use for pelvic organ prolapse (POP)-related reconstruction procedures. Using the 2001 to 2011 5% Medicare claims database, we identified POP diagnoses and related procedures. Transvaginal mesh use and sacrocolpopexy were first reported in 2005 and 2004, respectively. 613,160 cases of vaginal and abdominal POP repair procedures were identified. The majority of procedures involved multiple compartments. The rate of mesh use increased dramatically from 2% of repairs in 2005 to 35% by 2008. After the FDA warning in 2008, mesh use plateaued and then decreased in 2011. Mesh was more commonly used in younger (OR 0.722, p<0.001), white (OR 0.712-0.791 for other races, p<0.001) women in the South (OR 0.741-0.848 for non-South regions, p<0.001). Starting in 2008, the rate of sacrocolpopexy procedures almost doubled yearly until 2011. Sacrocolpopexy was more common in younger patients (49% in women <70 years) and in white women (88%); ...
ABSTRACT Benign prostatic hyperplasia (BPH) is a commonly occurring condition, affecting a vast n... more ABSTRACT Benign prostatic hyperplasia (BPH) is a commonly occurring condition, affecting a vast number of men worldwide, and particularly in North America. Lower urinary tract symptoms (LUTS) are the bothersome consequences of bladder outlet obstruction that can result from BPH, and are likely to reduce the quality of life of individuals afflicted by this condition. The metabolic syndrome (MetS) is a condition characterized by a constellation of inter-related clinical findings that have recently increased in frequency. Recent studies have suggested that the MetS may be a contributor to BPH. Important associations between BPH and MetS include the relationship between LUTS and increased body habitus, as measured by obesity and waist circumference. Cardiovascular risk factors, which are important components of the MetS, may also be associated with BPH. The exact pathophysiology and mechanisms of these relationships however are yet to be determined. Likely contenders include a pro-inflammatory state, changes in testosterone level, and increased autonomic activity.
ABSTRACT Although alpha-blockers, 5-alpha-reductase inhibitors and prostatectomy are clearly effi... more ABSTRACT Although alpha-blockers, 5-alpha-reductase inhibitors and prostatectomy are clearly efficacious treatment options for men with LUTS/BPH, these therapies are less than perfect. This has led to the investigation of new treatment options for men with LUTS/BPH. Three of these new treatment options include anticholinergics, phosphodiesterase-5-inhibitors (PDE5I), and botulinum toxin A (BoNT-A). Of these, anticholinergics and PDE5I have demonstrated a clear efficacy in appropriately selected patients. On the other hand, despite initial promising data , recent studies have not supported a clear efficacy with intraprostatic BoNT-A. The literature on anticholinergics, PDE5I, and BoNT-A is reviewed. Areas for future research within the field are then presented along with guidelines for prescribing these therapies.
a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w... more a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m DOI of original article: http://dx.
Sacral neuromodulation (SNM) (InterStim®, Medtronic, Inc., Minneapolis, MN) has been used as a tr... more Sacral neuromodulation (SNM) (InterStim®, Medtronic, Inc., Minneapolis, MN) has been used as a treatment for both urinary and bowel control. There are limited data in the literature regarding trends of utilization of SNM. We sought to explore disparities in utilization among Medicare beneficiaries. A 5% national random sample of Medicare claims for 2001, 2004, 2007, and 2010 was queried. All patients with an International Classification of Diseases, 9(th) Edition (ICD-9) diagnosis code representing a potential urologic indication for SNM were included. Patients who underwent SNM implantation were identified using Current Procedure Terminology (CPT-4) codes. Statistical tests used included the χ(2), Fisher tests, and multivariate logistic regression using SAS v9.3 (SAS Institute Inc., Cary, NC) and SPSS v20 (IBM Corp., Armonk, NY). A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with SNM. The percentage of these patients who ultimately...
To evaluate the surgical performance of the new Greenlight XPS-180W laser system (American Medica... more To evaluate the surgical performance of the new Greenlight XPS-180W laser system (American Medical Systems, Minnetonka, MI) and the effect of prostate volume (PV), in comparison with the former HPS-120W system, for the treatment of benign prostatic hyperplasia by photoselective vaporization of the prostate.
We sought to examine the surgical trends and utilization of treatment for mixed urinary incontine... more We sought to examine the surgical trends and utilization of treatment for mixed urinary incontinence among female Medicare beneficiaries. Data was obtained from a 5% national random sample of outpatient and carrier claims from 2000 to 2011. Included were female patients 65 and older, diagnosed with mixed urinary incontinence, who underwent surgical treatment identified by Current Procedural Terminology, Fourth Edition (CPT-4) codes. Urodynamics (UDS) before initial and secondary procedure were also identified using CPT-4 codes. Procedural trends and utilization of UDS were analyzed. Utilization of UDS increased during the study period, from 38.4% to 74.0% prior to initial surgical intervention, and from 28.6% to 62.5% preceding re-intervention. Sling surgery (63.0%) and injectable bulking agents (28.0%) were the most common surgical treatments adopted, followed by sacral nerve stimulation (SNS) (4.8%) and Burch (4.0%) procedures. Re-intervention was performed in 4.0% of patients ini...
We present our initial experience with performing robotic-assisted prostatectomies in men with a ... more We present our initial experience with performing robotic-assisted prostatectomies in men with a 3-piece inflatable penile prosthesis with a pelvic reservoir. Four patients underwent transperitoneal robotic-assisted radical prostatectomies with a penile prosthetic implant in place. The reservoir was left inflated for easy identification. A flaccid reservoir may be more difficult to identify, and be prone to damage. The reservoir was left attached to the abdominal wall. Dissection was performed outside the fibrous capsule of the reservoir. The tissue around the capsule of the reservoir peeled off without difficulty. Cutting current close to the capsule can be used if needed as per American Medical System with no limit to voltage. The penile prosthesis is then inflated to empty the reservoir creating more prevesical space and preventing the reservoir from obscuring visualization. The remaining portion of the procedure is completed using our standard technique. After completing the urethrovesical anastomosis using the 16 French Foley, the prosthesis is cycled under direct vision and the penile prosthesis is deflated (reservoir full). The prosthesis is not used for 6 weeks to prevent stretching of the urethrovesical anastomosis. All patients (n = 4) had no reported complications and all prostheses are functioning properly. The margin status was negative postoperatively. Robotic prostatectomy is technically feasible in patients with inflatable penile prostheses by surgeons experienced in robotic surgery. However, the presence of an indwelling penile prosthesis does increase the complexity of surgery.
We report a case of primary granulocytic sarcoma (GS) of the left adrenal gland, with no evidence... more We report a case of primary granulocytic sarcoma (GS) of the left adrenal gland, with no evidence of hematologic involvement. To our knowledge, this is the first case of granulocytic sarcoma of the adrenal gland.
To present our technique for the management of an enlarged median lobe when the ureteral orifices... more To present our technique for the management of an enlarged median lobe when the ureteral orifices are close to the bladder neck during robotic-assisted radical prostatectomy. From January 2005 to January 2007, we performed over 600 robotic assisted radical prostatectomies. We had 63 patients (10%) with enlarged medium lobes. Of these patients, two (5.7%) had their ureteral orifices in close proximity to the bladder neck. An additional patient, without a median lobe, had his orifices very close to the bladder neck. To aid in the management of their median lobes, all three patients had bilateral placement of ureteral catheters manually by the daVinci robot. We present our technique of robotic-assisted catheter insertion during robotic prostatectomy to protect the ureteral orifice from damage, precluding the use of a cystoscope. All three patients, underwent successful robotic-assisted radical prostatectomy (RALP) aided by intraoperative placement of either a double J ureteral catheters or open ended ureteral catheters that were removed after completion of the anastamosis. All three had normal cystograms before Foley catheter removal. All three patients were continent with follow up PSAs &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.1. The presence of a median lobe slightly increased the operative time required for bladder neck dissection or anastomosis (including reconstruction). There was no difference in complications such as urine leaks and bladder neck contractures. Continence after RALP was not significantly different in men with large median lobes. Management of ureteral orifices that are too close to the bladder neck with or without large medium lobes can be successfully performed with the uses of ureteral catheters placed robotically with the da Vinci robot. The presence of a median lobe does not alter outcomes in patients who undergo robot-assisted laparoscopic prostatectomy.
Overactive bladder (OAB) is a diffi cult condition to live with and is very costly to the communi... more Overactive bladder (OAB) is a diffi cult condition to live with and is very costly to the community. OAB affects 16% of the adult population and rises with increasing age. We describe the necessary steps in evaluation and behavioral therapy prior to initiating medical therapy. There are several medications that have been used for the treatment of patients who suffer from OAB. This manuscript discusses the popular agents used for OAB, with a focus on the recent clinical trials on darifenacin.
Wilm&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s tumor, or nephroblastoma, ... more Wilm&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s tumor, or nephroblastoma, is a common renal tumor among children. Few cases of Wilm&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s tumor have been reported in women during pregnancy. The authors present a rare case of a pregnant female, who underwent laparoscopic excision of a large Wilm&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s tumor. The authors have also provided a review of the current literature.
Many aging men will experience both erectile dysfunction (ED) and benign prostatic hyperplasia (B... more Many aging men will experience both erectile dysfunction (ED) and benign prostatic hyperplasia (BPH), resulting in lower urinary tract symptoms (LUTS). Basic and clinical evidence suggests common pathogenic mechanisms underlying both LUTS and ED. Decreases in the nitric oxide-cyclic guanosine monophosphate (NO-cGMP) pathway with age result in decreased levels of intracellular cGMP and calcium, leading to diminished smooth muscle relaxation of the bladder and prostate and worsening LUTS. Phosphodiesterase type 5 inhibitors as monotherapy in combination with α-blockers have shown efficacy in treating both LUTS and ED. Tadalafil has recently been approved by the US Food and Drug Administration for the treatment of LUTS secondary to BPH, with or without concomitant ED.
To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes betwe... more To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes between procedures using and not using mesh. All inclusive, population based cohort study. Statewide surgical care captured in the New York Statewide Planning and Research Cooperative System. Women who underwent prolapse repair procedures in New York state from 2008 to 2011. 90 day safety events and reinterventions within one year, after propensity score matching. Categorical, time to event, and subgroup analyses (<65 and ≥ 65 year age groups) were conducted. Of 27,991 patients in total, 7338 and 20, 653 underwent prolapse repair procedures with and without mesh, respectively. Mesh use increased by 44.7%, from 1461 procedures in 2008 to 2114 procedures in 2011. Most patients in the cohort were younger than 65 years (62.3% (n=17,424/27, 991)). However, more patients were aged 65 years and older in the mesh group than in the non-mesh group (44.3% (n=3249) v 35.4% (n=7318)). Complications aft...
Primary soft tissue sarcomas of the genitourinary tract are rarely seen, especially in the semina... more Primary soft tissue sarcomas of the genitourinary tract are rarely seen, especially in the seminal vesicle. While sarcomas have been reported in the seminal vesicle, this is the first report of a smooth muscle neoplasm, of uncertain malignant potential, involving the seminal vesicle. The finding was incidental, following robotic-assisted radical retropubic prostatectomy for prostate cancer. To our knowledge, this is also the first report of a primary seminal vesicle tumor found following radical prostatectomy. A clinical case review and a brief review of the literature are presented.
We sought to investigate recent trends in mesh use for pelvic organ prolapse (POP)-related recons... more We sought to investigate recent trends in mesh use for pelvic organ prolapse (POP)-related reconstruction procedures. Using the 2001 to 2011 5% Medicare claims database, we identified POP diagnoses and related procedures. Transvaginal mesh use and sacrocolpopexy were first reported in 2005 and 2004, respectively. 613,160 cases of vaginal and abdominal POP repair procedures were identified. The majority of procedures involved multiple compartments. The rate of mesh use increased dramatically from 2% of repairs in 2005 to 35% by 2008. After the FDA warning in 2008, mesh use plateaued and then decreased in 2011. Mesh was more commonly used in younger (OR 0.722, p<0.001), white (OR 0.712-0.791 for other races, p<0.001) women in the South (OR 0.741-0.848 for non-South regions, p<0.001). Starting in 2008, the rate of sacrocolpopexy procedures almost doubled yearly until 2011. Sacrocolpopexy was more common in younger patients (49% in women <70 years) and in white women (88%); ...
ABSTRACT Benign prostatic hyperplasia (BPH) is a commonly occurring condition, affecting a vast n... more ABSTRACT Benign prostatic hyperplasia (BPH) is a commonly occurring condition, affecting a vast number of men worldwide, and particularly in North America. Lower urinary tract symptoms (LUTS) are the bothersome consequences of bladder outlet obstruction that can result from BPH, and are likely to reduce the quality of life of individuals afflicted by this condition. The metabolic syndrome (MetS) is a condition characterized by a constellation of inter-related clinical findings that have recently increased in frequency. Recent studies have suggested that the MetS may be a contributor to BPH. Important associations between BPH and MetS include the relationship between LUTS and increased body habitus, as measured by obesity and waist circumference. Cardiovascular risk factors, which are important components of the MetS, may also be associated with BPH. The exact pathophysiology and mechanisms of these relationships however are yet to be determined. Likely contenders include a pro-inflammatory state, changes in testosterone level, and increased autonomic activity.
ABSTRACT Although alpha-blockers, 5-alpha-reductase inhibitors and prostatectomy are clearly effi... more ABSTRACT Although alpha-blockers, 5-alpha-reductase inhibitors and prostatectomy are clearly efficacious treatment options for men with LUTS/BPH, these therapies are less than perfect. This has led to the investigation of new treatment options for men with LUTS/BPH. Three of these new treatment options include anticholinergics, phosphodiesterase-5-inhibitors (PDE5I), and botulinum toxin A (BoNT-A). Of these, anticholinergics and PDE5I have demonstrated a clear efficacy in appropriately selected patients. On the other hand, despite initial promising data , recent studies have not supported a clear efficacy with intraprostatic BoNT-A. The literature on anticholinergics, PDE5I, and BoNT-A is reviewed. Areas for future research within the field are then presented along with guidelines for prescribing these therapies.
a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w... more a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m DOI of original article: http://dx.
Sacral neuromodulation (SNM) (InterStim®, Medtronic, Inc., Minneapolis, MN) has been used as a tr... more Sacral neuromodulation (SNM) (InterStim®, Medtronic, Inc., Minneapolis, MN) has been used as a treatment for both urinary and bowel control. There are limited data in the literature regarding trends of utilization of SNM. We sought to explore disparities in utilization among Medicare beneficiaries. A 5% national random sample of Medicare claims for 2001, 2004, 2007, and 2010 was queried. All patients with an International Classification of Diseases, 9(th) Edition (ICD-9) diagnosis code representing a potential urologic indication for SNM were included. Patients who underwent SNM implantation were identified using Current Procedure Terminology (CPT-4) codes. Statistical tests used included the χ(2), Fisher tests, and multivariate logistic regression using SAS v9.3 (SAS Institute Inc., Cary, NC) and SPSS v20 (IBM Corp., Armonk, NY). A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with SNM. The percentage of these patients who ultimately...
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