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Sun A, Williams AO, Rojanasarot S, Moore G, McGovern AM, Hargens LM, Turner E, Babbar P. Downstream Revenue Realized by Facilities Placing Inflatable Penile Prosthesis in Medicare Beneficiaries to Treat Erectile Dysfunction. Urology 2024:S0090-4295(24)00290-5. [PMID: 38677374 DOI: 10.1016/j.urology.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/01/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVES To quantify the incremental downstream revenue generated from subsequent treatment of men who received an inflatable penile prosthesis (IPP) to treat erectile dysfunction (ED), compared to men without ED. METHODS The 100% Medicare Standard Analytic Files were used to conduct a retrospective claims analysis of the 5-year revenue generated by patients receiving IPP to treat their ED, compared to a propensity-matched cohort of men without ED. Men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology® 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021, and who had continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and five years post-index IPP discharge date were included in the study. Men without ED but with comparable characteristics were identified and used as a comparator group. Revenue received by hospitals from Medicare was defined as the sum of payments for patient services, other payor-paid amounts, patient deductibles, copayments, and coinsurance. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) are reported. RESULTS After matching, there were 2,905 men with ED who received an IPP and 7,462 men without ED. The IPP cohort showed a significantly higher 5-year cumulative revenue (mean=$34,571 [SD=$50,234]) compared to the men without ED (mean=$3,189 [SD=$11,527]). When stratified by diagnosis type, the differences in revenue were $10,258 for circulatory disease, $2,646 for diabetes, $2,013 for urology, and $1,043 for prostate cancer. Significantly more IPP patients had at least one health encounter for these conditions over the 5-year follow-up period than their matched controls (55.0% versus 7.8% for circulatory, 46.7% versus 16.8% for urology, 19.3% versus 3.6% for diabetes, and 19.0% versus 3.0% for prostate cancer). CONCLUSIONS Men with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly ten times as much, compared to men without ED, excluding the initial cost of the IPP procedure. The presence of ED, coupled with IPP usage, is associated with significantly increased healthcare revenue across a range of medical conditions compared to men without ED. These findings emphasize the financial implications for advanced ED programs to improve access to necessary care for these patients. Healthcare facilities may leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED.
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Affiliation(s)
- Andrew Sun
- Urology Partners of North Texas, Arlington, TX, USA
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Abstract
The extensive arsenal of bioactive molecules secreted by mesenchymal stem cells (MSCs), known as the secretome, has demonstrated considerable therapeutic benefit in regenerative medicine. Investigation into the therapeutic potential of the secretome has enabled researchers to replicate the anti-inflammatory, pro-angiogenic and trophic effects of stem cells without the need for the cells themselves. Furthermore, treatment with the MSC secretome could circumvent hurdles associated with cellular therapy, including oncogenic transformation, immunoreactivity and cost. Thus, a clear rationale exists for investigating the therapeutic potential of the MSC secretome in regenerative urology. Indeed, preclinical studies have demonstrated the therapeutic benefits of the MSC secretome in models of stress urinary incontinence, renal disease, bladder dysfunction and erectile dysfunction. However, the specific mechanisms underpinning therapeutic activity are unclear and require further research before clinical translation. Improvements in current proteomic methods used to characterize the secretome will be necessary to provide further insight into stem cells and their secretome in regenerative urology.
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Affiliation(s)
- Daniel Z Sun
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. .,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA. .,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Benjamin Abelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paurush Babbar
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Margot S Damaser
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.,Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
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Sun AY, Babbar P, Gill BC, Angermeier KW, Montague DK. Penile Prosthesis in Solid Organ Transplant Recipients-A Matched Cohort Study. Urology 2018; 117:86-88. [PMID: 29656065 DOI: 10.1016/j.urology.2018.03.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether patients with solid organ transplant (SOT) are at higher risk of developing complications after inflatable penile prosthesis (IPP) implantation. METHODS We retrospectively reviewed outcomes data for all patients with SOT who underwent IPP placement at our institution. A cohort of age-matched IPP recipients without SOT were used as controls. RESULTS We identified 26 patients who underwent SOT and IPP between 1999 and 2015, and 26 controls. Transplants included heart (3), liver (2), kidney only (17), and kidney and pancreas (4). Mean follow-up time after IPP placement was 29.5 months (SOT group) and 13.5 months (controls). Age at IPP did not significantly differ between groups (53.7 + 8.1 vs 56.4 + 9.0, P = .26), nor did body mass index (30.3 + 5.5 vs 30.2 + 4.7, P = .92), history of prostatectomy (7.7% vs 15.4%, P = .39), rectal surgery (3.9% vs 3.9%, P = 1.00), hyperlipidemia (69.2% vs 69.2%, P = 1.00), hypertension (92.3% vs 76.9%, P = .25), or heart disease (57.7% vs 30.8%, P = .093). Peripheral vascular disease was more common in transplant patients (26.9% vs 3.9%, P = .021), as were stroke (19.2% vs 0.0%, P = .05) and diabetes (84.6% vs 53.6%, P = .016). No significant differences in IPP reoperation rates existed between patients with vs without SOT (11.5% vs 11.5%, P = 1.00), nor did they differ by organ transplanted (P = 1.00). No differences in IPP reoperation rate existed between 2-piece vs 3-piece IPP models (P = .47). CONCLUSION Outcomes of IPP implantation in patients with SOT are similar to those of nontransplant patients. Patients with SOT should be considered suitable candidates for penile prosthesis.
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Affiliation(s)
- Andrew Y Sun
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH.
| | - Paurush Babbar
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
| | - Bradley C Gill
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
| | | | - Drogo K Montague
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH
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Khanna A, Monga M, Gao T, Nguyen A, Babbar P, Schold J, Abouassaly R. MP89-20 POST-OPERATIVE EMERGENCY ROOM VISITS AFTER URINARY STONE SURGERY: VARIATION BASED ON SURGICAL MODALITY. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Crane A, Eltemamy M, Jacobsen D, Coy T, Babbar P, Ponziano M, Poggio E, Fatica R, Krishnamurthi V. MP61-09 CLEVELAND CLINIC KIDNEY TRANSPLANT RECIPIENT READMISSION EXPERIENCE. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Crane A, Eltemamy M, Coy T, Babbar P, Jacobsen D, Ponziano M, Poggio E, Wee A, Fatica R, Krishnamurthi V. MP61-10 IDENTIFICATION OF PREVENTABLE READMISSIONS AND IMPLEMENTATION OF INTENSIVE STANDARDIZED FOLLOW-UP IN KIDNEY TRANSPLANT RECIPIENTS. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Babbar P, Yerram N, Sun A, Hemal S, Murthy P, Bryk D, Nandanan N, Nyame Y, Caveney M, Nelson R, Berglund R. Robot-assisted ureteral reconstruction - current status and future directions. Urol Ann 2018; 10:7-14. [PMID: 29416268 PMCID: PMC5791461 DOI: 10.4103/ua.ua_94_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.
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Affiliation(s)
- Paurush Babbar
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Nitin Yerram
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Andrew Sun
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Sij Hemal
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Prithvi Murthy
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Darren Bryk
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Naveen Nandanan
- Division of Urology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Yaw Nyame
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Maxx Caveney
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Ryan Nelson
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
| | - Ryan Berglund
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland, Ohio, USA
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Nelson RJ, Dagenais J, Maurice MJ, Chavalia JSS, Ramirez D, Caputo PA, Babbar P, Yerram NK, Kaouk JH. Robotic cold ischemia achieves comparable functional outcomes to open cold ischemia during partial nephrectomy for complex kidney tumors. Urol Ann 2018; 10:386-390. [PMID: 30386091 PMCID: PMC6194797 DOI: 10.4103/ua.ua_91_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives: To compare the perioperative and functional outcomes after open and robotic partial nephrectomy performed with cold ischemia. Methods: A retrospective chart review was completed of consecutive patients who underwent partial nephrectomy with renal hypothermia between January 2011 and September 2016. The study cohort included both open (Open Cold Ischemia, OCI; n=170) and robotic (Robotic Cold Ischemia, RCI; n=31) patients with complex renal masses (R.E.N.A.L. score >7) who did not meet exclusion criteria. A modified intracorporeal technique 1 was utilized for the introduction of ice slush at the time of hilar clamping in the RCI group. Statistical testing was performed to compare key perioperative and functional outcomes after ensuring equilibration of both groups by clinicodemographic criteria. Results: Both groups were statistically equivalent with respect to baseline characteristics. Median GFR preservation postoperatively was 86.7% for the open group and 86.6% in the robotic group (p=0.49). Cold ischemia time (CIT) in the open group was 35 minutes compared to 28 minutes (p = 0.03) in the robotic group. LOS was significantly shorter by 2 days (p < 0.01) in the robotic group. Positive margins was noted to be 17 (10%) in the open group and 2 (6.5%) patients in the robotic group (p=0.48). Conclusions: We demonstrate an effective and simplified method of intracorporeal ice cooling during robotic partial nephrectomy. Our data suggests that results with this approach compare favorably to open cold ischemia technique. Intracorporeal ice cooling can be considered when performing complex partial nephrectomies with ischemia times expected to exceed 25 minutes.
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Affiliation(s)
- Ryan J Nelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Julien Dagenais
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Matthew J Maurice
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Jaya Sai S Chavalia
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Daniel Ramirez
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Peter A Caputo
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Paurush Babbar
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Nitin K Yerram
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
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Babbar P, Yerram N, Crane A, Sun D, Ericson K, Sun A, Khanna A, Wood H, Stephenson A, Angermeier K. Penile-sparing modalities in the management of low-stage penile cancer. Urol Ann 2018; 10:1-6. [PMID: 29416267 PMCID: PMC5791443 DOI: 10.4103/ua.ua_93_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Penile-sparing modalities are gaining widespread adoption for the management of low-stage penile cancer due to an increasing demonstration of sound oncologic, cosmetic, sexual, psychosocial, and quality of life outcomes. This review aims to provide a comprehensive overview of the respective treatment options in the armamentarium of the practicing urologist in dealing with this rare but problematic condition.
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Affiliation(s)
- Paurush Babbar
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nitin Yerram
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Alice Crane
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Daniel Sun
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kyle Ericson
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Andrew Sun
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Abhinav Khanna
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hadley Wood
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Andrew Stephenson
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kenneth Angermeier
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Nelson RJ, Reese JH, Babbar P, Kaouk JH. Robotic Retrocaval Metastasectomy After an Ipsilateral Radical Nephrectomy. Urology 2017; 107:270. [PMID: 28982624 DOI: 10.1016/j.urology.2017.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/12/2017] [Accepted: 04/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Robotic management of a retrocaval metastasis can be challenging because of prior surgery leading to scarring and obscure surgical planes around vital structures. We present our robotic approach and technique to manage a large retrocaval, biopsy-proven, metastatic mass after previous laparoscopic right radical nephrectomy with concomitant adrenalectomy 10 years ago. METHODS We present a 62-year-old man who previously underwent a laparoscopic right radical nephrectomy for pT1bNxMx chromophobe renal cell carcinoma (RCC) in 2007. Surveillance imaging in November 2016 indicated a 5-cm retrocaval mass, and biopsy confirmed the metastasis. The patient was positioned in standard robotic positioning for right renal surgery. Meticulous dissection was required to free the duodenum and inferior vena cava from the mass, enabling the mass to be lifted anteriorly. Posteriorly, a labyrinth of vessels required hem-o-lok clips before excision, which allowed complete extraction of the mass. RESULTS Operative time was 234 minutes and estimated blood loss was 40 cc. Final pathology revealed a right 5 cm × 3.1 cm metastatic RCC, chromophobe-type, lymph node. The surgical margins were negative for tumor. CONCLUSION We present a successful surgical outcome of a robotic retrocaval metastasectomy for recurrent RCC, chromophobe type. At the time of publication, the patient continues to remain cancer free. Incorporating the da Vinci robotic platform allows for excellent visualization and access to difficult surgical locations while providing patients with the least invasive approach. A high degree of robotic experience is necessary before attempting this procedure, given the adherence of the mass to the inferior vena cava and duodenum.
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Affiliation(s)
- Ryan J Nelson
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Jeremy H Reese
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Paurush Babbar
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Jihad H Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
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Yerram NK, Arora HC, Khanna A, Ericson K, Sun AY, Babbar P, Nandanan N, Stephenson AJ. Testicular seminoma: oncologic rationale and role of surgery in treatment. Clin Adv Hematol Oncol 2017; 15:708-715. [PMID: 28949942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Seminomas account for approximately 50% of all cases of testicular cancer. Testicular cancer is a highly curable disease that can be broadly classified as either seminomatous or nonseminomatous; the management and treatment of the 2 forms vary widely. Although surgery plays a large role in the management of nonseminoma, its role in the management of seminoma is much more limited. Most clinicians in the United States choose orchiectomy followed by surveillance for patients with stage I seminomatous disease, and chemotherapy or radiation-followed by surgery for the management of residual masses-for patients with disease that is stage II and higher. Recently, clinicians have proposed a larger role for surgery in stage II seminoma to avoid the long-term toxic effects of chemotherapy and radiation therapy. In this review, we discuss the oncologic rationale for the treatment of seminoma, the role of surgery, and the use of minimally invasive operative techniques for retroperitoneal lymph node dissection.
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Affiliation(s)
- Nitin K Yerram
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Hans C Arora
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Abhinav Khanna
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Kyle Ericson
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Andrew Y Sun
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | - Paurush Babbar
- Department of Urology, Cleveland Clinic, Cleveland, Ohio
| | | | - Andrew J Stephenson
- Department of Urology, Cleveland Clinic, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Ivanishchev AV, Churikov AV, Ivanishcheva IA, Ushakov AV, Sneha MJ, Babbar P, Dixit A. Models of lithium transport as applied to determination of diffusion characteristics of intercalation electrodes. RUSS J ELECTROCHEM+ 2017. [DOI: 10.1134/s1023193517070047] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Arora H, Elshafei A, Nyame Y, Sun D, Liang H, Yerram N, Greene D, Grimberg D, Gupta K, Agrawal S, Isharwal S, Babbar P, Sun A, Fareed K, Gong M, Berglund R, Klein E, Stephenson A, Purysko A, Jones JS. MP38-12 PROPENSITY SCORE ANALYSIS OF PATHOLOGICAL OUTCOME AT RADICAL PROSTATECTOMY FOR MAGNETIC RESONANCE IMAGING-TRANSRECTAL ULTRASOUND FUSION PROSTATE BIOPSY VERSUS UNTARGETED EXTENDED TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.1165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.
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Affiliation(s)
- Ryan J Nelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jaya Sai S Chavali
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nitin Yerram
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paurush Babbar
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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Nyame YA, Babbar P, Aboumohamed AA, Mori RL, Flechner SM, Modlin CS. Ex-vivo partial nephrectomy after living donor nephrectomy: Surgical technique for expanding kidney donor pool. Urol Ann 2017; 9:107-109. [PMID: 28216945 PMCID: PMC5308027 DOI: 10.4103/0974-7796.198913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Renal transplantation has profound improvements in mortality, morbidity, and overall quality of life compared to renal replacement therapy. This report aims to illustrate the use of ex-vivo partial nephrectomy in a patient with a renal angiomyolipoma prior to living donor transplantation. The surgical outcomes of the donor nephrectomy and recipient transplantation are reported with 2 years of follow-up. Both the donor and recipient are healthy and without any significant comorbidities. In conclusion, urologic techniques such as partial nephrectomy can be used to expand the living donor pool in carefully selected and well informed transplant recipients. Our experience demonstrated a safe and positive outcome for both the recipient and donor, and is consistent with other reported outcomes in the literature.
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Affiliation(s)
- Yaw A Nyame
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
| | - Paurush Babbar
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
| | - Ahmed A Aboumohamed
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
| | - Ryan L Mori
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
| | - Stuart M Flechner
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
| | - Charles S Modlin
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
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Nyame YA, Zargar H, Ramirez D, Ganesan V, Babbar P, Villers A, Haber GP. Robotic-assisted Laparoscopic Bilateral Nerve Sparing and Apex Preserving Cystoprostatectomy in Young Men With Bladder Cancer. Urology 2016; 94:259-64. [PMID: 27132504 DOI: 10.1016/j.urology.2016.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/18/2016] [Accepted: 04/22/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe our technique and outcomes of robotic-assisted nerve-sparing cystoprostatectomy with prostatic apex preservation and orthotopic ileal conduit urinary diversion in young men undergoing robotic-assisted radical cystectomy (RARC) for the management of urothelial carcinoma. MATERIALS AND METHODS Young men (<40 years old) with the diagnosis of urothelial carcinoma undergoing RARC with orthotopic neobaldder formation were eligible for our technique of nerve-sparing cystoprostatectomy with prostatic apex preservation at the time of orthotopic ileal conduit urinary diversion. During the apical prostatic dissection step of the RARC, the plane of dissection is directed under the dorsal vein complex and through anterior prostatic fibromuscular stroma. This plane is further carried through the prostatic urethra, transecting the most caudal aspect of prostatic peripheral zone posteriorly, to create a long urethra and a posterior urethral plate formed by peripheral zone of the prostate, which serves as a robust, long stump for the subsequent vesicourethral anastomosis. RESULTS From January 2013 to January 2014, 3 men were treated with RARC and intracorporeal neobladder urinary diversion based on the described technique. There were no intraoperative complications. Two patients experienced grade II complications postoperatively. Pathologic assessment demonstrated negative surgical margins in all 3 cases. With mean follow-up time of 28.2 months, 2 out of 3 patients are free from disease recurrence. All patients report daytime urinary continence with no pad usage and potency without the need for phosphodiesterase-5 inhibitors. CONCLUSION RARC with bilateral nerve and apical preservation can be performed safely in appropriately selected young patients with excellent functional and acceptable short-term oncologic results.
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Affiliation(s)
- Yaw A Nyame
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| | - Homayoun Zargar
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel Ramirez
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Vishnu Ganesan
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Paurush Babbar
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Georges-Pascal Haber
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH
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Gill BC, Ericson KJ, Hemal S, Babbar P, A. Shoskes D. The Digital Footprint of Academic Urologists: Where Do we Stand? Urology 2016; 90:27-31. [DOI: 10.1016/j.urology.2015.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/16/2015] [Accepted: 12/07/2015] [Indexed: 11/17/2022]
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Nyame YA, Babbar P, Almassi N, Polackwich AS, Sabanegh E. Comparative Cost-Effectiveness Analysis of Modified 1-Layer versus Formal 2-Layer Vasovasostomy Technique. J Urol 2016; 195:434-8. [DOI: 10.1016/j.juro.2015.08.102] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Yaw A. Nyame
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paurush Babbar
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nima Almassi
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alan S. Polackwich
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Edmund Sabanegh
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Nyame YA, De S, Sarkissian C, Brown R, Kartha G, Babbar P, Monga M. Kidney Stone Models for In Vitro Lithotripsy Research: A Comprehensive Review. J Endourol 2015; 29:1106-9. [DOI: 10.1089/end.2014.0850] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yaw A. Nyame
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Shubha De
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carl Sarkissian
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert Brown
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ganesh Kartha
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paurush Babbar
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Manoj Monga
- Department of Urology, Glickman Urologic and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Abstract
We are presenting a rare case of bilateral adrenal non-Hodgkin's lymphoma (NHL) that presented as a primary malignancy. An 83-year-old man presented with newly discovered bilateral adrenal incidentalomas, fatigue, and 30 pound weight loss. Of the 116 cases of primary adrenal NHL reported, over half have presented bilaterally and occur with adrenal insufficiency. Therefore, the finding of bilateral adrenal masses requires an urgent work-up of the functional status of the adrenal gland as well as a thorough analysis of the imaging characteristics seen on noncontrast computed tomography (CT) in order to maximize patient survival. Adrenal function testing was normal. Repeat CT imaging revealed rapidly growing lesions with high attenuations; both masses >10 HU. Histological examination of core biopsies discovered malignant lymphoma with no known past history of lymphoma. Our case coincides with the literature, which states that a mass with attenuation >10 HU in the adrenal glands has a high risk of malignancy.
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Affiliation(s)
| | - Paurush Babbar
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Cleveland, OH 44195, USA
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21
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Simpson WG, Lopez A, Babbar P, Payne LF. Primary bladder lymphoma, diffuse large B-cell type: Case report and literature review of 26 cases. Urol Ann 2015; 7:268-72. [PMID: 25837971 PMCID: PMC4374275 DOI: 10.4103/0974-7796.152947] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/24/2014] [Indexed: 02/06/2023] Open
Abstract
Primary lymphoma of the urinary bladder is exceedingly rare, representing 0.2% of all extranodal non-Hodgkin's lymphoma. Although Matsuno et al. and others state the most common type is mucosa-associated lymphoid tissue (MALT) lymphoma, 20% of all the primary lymphomas of the urinary bladder are considered to be high grade neoplasms; the majority being diffuse large B-cell lymphoma (DLBCL). This is a case report of a 48-year-old man that presented with hematuria, frequency, nocturia, and flank pain that was found to have high grade DLBCL. Twenty-six other cases of both low and high grade primary bladder lymphomas were selected in order to provide a thorough comparison of different treatment modalities. Of the cases reviewed, bladder lymphoma was more common in females (2:1). The average age at diagnosis was 63.9 years old (low grade: 68.7 years old, high grade: 58.8 years old). The most common low-grade neoplasm was MALT lymphoma (85.7%). For the low-grade malignancies, the most successful treatments were simple therapies (2 transurethral resection of a bladder tumour [TURBT], 1 antibiotics), solitary chemotherapy, and combination TURBT/chemo; all 3 of which achieved 100% clinical remission (CR) in the cases reviewed. The most common high grade neoplasm was DLBCL (76.9%). The most successful therapies used to treat high grade lesions were solitary chemotherapy (cyclophosphamide, duanorubacin, vincristine, prednisolone [CHOP] or ritoximab, CHOP [R-CHOP]) and combination therapies (2 radiation/CHOP, 2 surgery/CHOP). In the agreement with the current literature, this review has shown that simple therapies (TURBT) are equally as effective as aggressive treatments (chemotherapy, radiation) and should therefore be used as first line treatment in low grade tumors. For high grade malignancies, chemotherapy (R-CHOP or CHOP) alone or combination therapy (CHOP/surgery or CHOP/radiation) is recommended.
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Affiliation(s)
- W Greg Simpson
- Department of Urology, West Virginia School of Osteopathic Medicine, Lewisburg, WV 24901, USA
| | - Armando Lopez
- Department of Urology, Raleigh General Hospital, Beckley, WV 28051, USA
| | - Paurush Babbar
- Department of Urology, Glickman Urological and Kidney Institute Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Nyame Y, Babbar P, Greene D, Zargar Shoshtari H, Krishnamurthi V, Haber GP. V8-10 ROBOTIC ANTERIOR PELVIC EXENTERATION WITH INTRACORPOREAL ILEAL CONDUIT IN A PATIENT WITH HISTORY OF KIDNEY PANCREAS TRANSPLANTATION. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.2134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pareta R, Sanders B, Babbar P, Soker T, Booth C, McQuilling J, Sivanandane S, Stratta RJ, Orlando G, Opara EC. Immunoisolation: where regenerative medicine meets solid organ transplantation. Expert Rev Clin Immunol 2013; 8:685-92. [PMID: 23078065 DOI: 10.1586/eci.12.64] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Immunoisolation refers to an immunological strategy in which nonself antigens present on an allograft or xenograft are not allowed to come in contact with the host immune system, and it is implemented to prevent allorecognition and avoid immunosuppression. In this setting, the two most promising technologies, encapsulation of pancreatic islets (EPI) and immunocloaking (IC), are used. In the case of EPI, islets are inserted in capsules that, allow exchange of oxygen, nutrients and other molecules. In the case of IC, a natural nanofilm is injected prior to renal transplantation within the vasculature of the graft with the intent to pave the inner surface of the vascular lumen and camouflage the antigens located on the membrane of endothelia cells. Significant progress achieved in experimental models is leading EPI and IC to clinical translation.
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Affiliation(s)
- Rajesh Pareta
- Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA
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Ross CL, Booth C, Sanders B, Babbar P, Bergman C, Soker T, Sittadjody S, Salvatori M, Al-Shraideh Y, Stratta RJ, Orlando G. Regeneration and bioengineering of transplantable abdominal organs: current status and future challenges. Expert Opin Biol Ther 2012; 13:103-13. [PMID: 23110384 DOI: 10.1517/14712598.2013.732063] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The most critical issue to organ transplantation is the identification of new sources of organs. The present manuscript illustrates the state-of-the-art regenerative medicine (RM) investigations aiming to manufacturing abdominal organs for transplant purposes. AREAS COVERED This manuscript focuses on research in the bioengineering and regeneration of kidneys, insulin-producing cells, livers and small bowel. The main technology currently under development exploits the seeding of cells on supporting scaffolding material. Despite favorable preliminary results obtained with relatively simple, hollow organs, when more complex organs are considered, the scenario changes dramatically. Investigations are still in early stages, and clinical translation is not yet foreseeable based on current knowledge and information. Obstacles are numerous but we believe the critical factor hampering success is lack of in-depth understanding of the extracellular matrix (ECM) and cell-ECM interactions, as well as the mechanisms with which organs develop in utero. EXPERT OPINION The success of RM to generate transplantable abdominal organs relies heavily on progress in (stem) cell therapies, developmental and ECM biology, and in the thorough understanding of the intricate relationship and interplay between cells and the ECM. This will require enormous investments in financial and medical resources, which ideally should be embarked upon by governments, the private sector and academia.
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Affiliation(s)
- Christina L Ross
- Wake Forest University School of Medicine, Wake Forest Institute for Regenerative Medicine, Winston Salem, NC, USA
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Sanders BP, Babbar P. The need for further evaluation of objective parameters of swallowing function after transoral robotic surgery. Arch Otolaryngol Head Neck Surg 2012; 138:432-433. [PMID: 22508633 DOI: 10.1001/archoto.2012.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Hemal AK, Stansel I, Babbar P, Patel M. Robotic-assisted Nephroureterectomy and Bladder Cuff Excision Without Intraoperative Repositioning. Urology 2011; 78:357-64. [DOI: 10.1016/j.urology.2010.12.075] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 12/16/2010] [Accepted: 12/25/2010] [Indexed: 11/25/2022]
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Abstract
Robotic surgery is a cutting edge and minimally invasive procedure, which has generated a great deal of excitement in the urologic community. While there has been much advancement in this emerging technology, it is safe to say that robotic urologic surgery holds tremendous potential for progress in the near future. Hence, it is paramount that urologists stay up-to-date regarding new developments in the realm of robotics with respect to novel applications, limitations and opportunities for incorporation into their practice. Robot-assisted surgery provides an enhanced 3D view, increased magnification of the surgical field, better manual dexterity, relatively bloodless field, elimination of surgeon's tremor, reduction in a surgeon's fatigue and mitigation of scattered light. All these factors translate into greater precision of surgical dissection, which is imperative in providing better intraoperative and postoperative outcomes. Pioneering work assessing the feasibility of robotic surgery in urology began in the early 2000's with robot-assisted radical prostatectomy and has since expanded to procedures such as robot-assisted radical cystectomy, robot-assisted partial nephrectomy, robot-assisted nephroureterectomy and robot-assisted pyeloplasty. A MEDLINE search was used to identify recent articles (within the last two years) and publications of specific importance, which highlighted the recent developments and future direction of robotics. This review will use the aforementioned urologic surgeries as vehicles to evaluate the current status and future role of robotics in the advancement of the field of urology.
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Affiliation(s)
- Paurush Babbar
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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28
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Hemal AK, Agarwal MM, Babbar P. Impact of newer unidirectional and bidirectional barbed suture on vesicourethral anastomosis during robot-assisted radical prostatectomy and its comparison with polyglecaprone-25 suture: an initial experience. Int Urol Nephrol 2011; 44:125-32. [PMID: 21523325 DOI: 10.1007/s11255-011-9967-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Accepted: 04/06/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate impact of unidirectional barbed suture on vesicourethral anastomosis (VUA) during robot-assisted radical prostatectomy (RARP) and its comparison with Polyglecaprone-25 suture. PATIENTS AND METHODS The study was initiated as pilot study; the participants were grouped into three based on the suture material used for VUA, i.e., monofilament Polyglecaprone-25 (group 1), unidirectional barbed Glycolic acid-trimethylene carbonate (group 2), and bidirectional barbed Polyglycolic acid-polycaprolactone (group 3), respectively. Group 1 was included retrospectively and the latter two prospectively. All cases were operated upon by the same surgeon, proficient in RARP. Patient-demographics, intraoperative and peri-operative data were collected. Our technique of mucosa-to-mucosa VUA is carried out in a choreographed manner using unibarbed suture. RESULTS Fifty-five patients were included; 25 each in group 1 and 2. The group 3 was prematurely closed after 5 cases due to perceived inappropriateness of needle characteristics of the suture material. Therefore, the statistical analysis was performed between group 1 and 2 only. Preoperative characteristics including age, PSA, clinical stage, and biopsy grade were similar between the groups. The anastomosis time was significantly less in group 2 (8.4 ± 1.7 min vs. 14.3 ± 4.8 min; P = 0.0001; t test). Postoperative hospital stay was less in group 2 (2.7 ± 1.1 days vs. 1.9 ± 0.8 days; P = 0.023; Mann-Whitney U). None of the patient had presented with urinary leaks, urinary retention, or anastomotic strictures at follow-up of 6 months. CONCLUSION VUA with unidirectional barbed suture is safe and takes less time compared to monofilament suture as repeated cinching; help of assistance and knot tying are not required by virtue of its self-retaining characteristics.
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Affiliation(s)
- Ashok K Hemal
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Bharani AK, Babbar P, Jain AC, Sepaha GC. Basilar artery migraine. J Assoc Physicians India 1985; 33:239. [PMID: 4044484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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