Zachariah A Allen

Wheeling Jesuit University, Wheeling, West Virginia, United States

Are you Zachariah A Allen?

Claim your profile

Publications (89)207.7 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the relationship between pre-treatment erectile function and all-cause mortality in patients with prostate cancer treated with brachytherapy. In all, 1279 consecutive patients with clinically localized prostate cancer and pre-implant erectile function assessed by the International Index of Erectile Function-6 (IIEF-6) underwent brachytherapy. Potency was defined as an IIEF-6 score of ≥13 without pharmacological or mechanical support. Patients were stratified into IIEF-6-score cohorts (≤12, 13-23 and 24-30). The median follow-up was 5.0 years. The 8-year overall survival (OS) of the study population was 85.1%. The 8-year OS for IIEF-6scores ≤12, 13-23 and 24-30 were 78.0%, 92.8% and 91.4%, respectively (P < 0.001). Cardiovascular events accounted for a significant portion of deaths in each IIEF-6 group. When combined with other risk factors for cardiovascular disease, an IIEF-6 score of ≤12 had an additive effect on all-cause mortality (IIEF-6 score of ≤12 and less than two comorbidities vs two or more comorbidities were 18.2% and 32.1%). A pre-implant IIEF-6score of ≤12 was associated with a higher incidence of all-cause mortality. Pre-treatment erectile dysfunction is a surrogate for underlying vascular pathology, probably explaining the lower OS in this subset of patients. Aggressive treatment of medical co-morbidity is warranted to impactOS.
    BJU International 07/2011; 109(2):220-5. · 3.05 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate temporal changes in testosterone after prostate brachytherapy and investigate the potential impact of these changes on response to treatment. Between January 2008 and March 2009, 221 consecutive patients underwent Pd-103 brachytherapy without androgen deprivation for clinically localized prostate cancer. Prebrachytherapy prostate-specific antigen (PSA) and serum testosterone were obtained for each patient. Repeat levels were obtained 3 months after brachytherapy and at least every 6 months thereafter. Multiple clinical, treatment, and dosimetric parameters were evaluated to determine an association with temporal testosterone changes. In addition, analysis was conducted to determine if there was an association between testosterone changes and treatment outcomes or the occurrence of a PSA spike. There was no significant difference in serum testosterone over time after implant (p = 0.57). 29% of men experienced an increase ≥ 25%, 23% of men experienced a decrease ≥ 25%, and the remaining 48% of men had no notable change in testosterone over time. There was no difference in testosterone trends between men who received external beam radiotherapy and those who did not (p = 0.12). On multivariate analysis, preimplant testosterone was the only variable that consistently predicted for changes in testosterone over time. Men with higher than average testosterone tended to experience drop in testosterone (p < 0.001), whereas men with average or below average baseline testosterone had no significant change. There was no association between men who experienced PSA spike and testosterone temporal trends (p = 0.50) nor between initial PSA response and testosterone trends (p = 0.21). Prostate brachytherapy does not appear to impact serum testosterone over time. Changes in serum testosterone do not appear to be associated with PSA spike phenomena nor with initial PSA response to treatment; therefore, PSA response does not seem related to temporal testosterone changes.
    International journal of radiation oncology, biology, physics 04/2011; 82(1):e33-8. · 4.59 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the effect of prostate brachytherapy case volume on postimplant dosimetric quality in Pro-Qura proctored programs. From August 1999 to December 2008, the computed tomography datasets for 6,600 prostate implants performed by 129 brachytherapists were submitted to Pro-Qura for dosimetric analysis. Brachytherapists were divided into three roughly equal-sized terciles based on total case volume. Postimplant computed tomography scans were obtained at a median of 30 days. Excellent target coverage was defined by a V100≥90% and D90≥100% minimum prescribed peripheral dose. To determine if the number of excellent implants improved with increasing case numbers, each brachytherapist's series of implants was bisected into early and late experience by a moveable critical point. For the entire cohort, the mean V100 and D90 were 89.2% and 102.8%, respectively, with 47.7% of the implants scored as excellent. Brachytherapists in the highest-case tercile had a significantly greater fraction of excellent target coverage (57.9%) than did those in the two lower terciles (39.5% and 45.7%, p=0.015). Twenty-one (25.6%) of the 82 brachytherapists with sufficient case volume for dosimetric improvement analyses demonstrated quality improvement over time. Although there was no significant difference between prostate volume and seed strength, the number of seeds used was significantly greater in adequate implants. The highest-volume brachytherapists were most likely to obtain excellent target coverage. We are encouraged that in general practice, nearly 48% of all implants were scored excellent. It is conceivable that with greater expert third-party involvement, an even greater percentage of cases with excellent target coverage will become reality.
    International journal of radiation oncology, biology, physics 02/2011; 81(5):e727-34. · 4.59 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To report the incidence of transition zone (TZ) cancer in patients undergoing transperineal template-guided mapping biopsy (TTMB) of the prostate gland. Five hundred thirty-nine consecutive patients underwent TTMB by means of an anatomic technique with sampling of 24 defined prostate regions. The position of each biopsy core was recorded in 3 dimensions. For every patient, the location of each positive biopsy core, the number of positive cores, the Gleason score, the percentage involvement of each core, and the presence/absence of perineural invasion was documented. The median volumetric prostate volume was 56.0 cm(3) with an ellipsoid TZ volume of 20.1 cm(3). The median number of TTMB cores was 58 with a median of 11 TZ cores. Two hundred eighty-seven (53.2%) were diagnosed with prostate cancer. TZ cancer was detected in 130 (45.3%) of patients with prostate cancer but only 6 (4.6%) were confined to the TZ. Overall, 38.9% of TZ cores were positive for malignancy. Of the TZ cancers, 37 (28.5%), 64 (49.2%), and 29 (22.3%) were assigned Gleason scores 6, 7, and 8-10. Compared with a standard 12-core biopsy approach, the results of the TZ biopsy upgraded the Gleason score in 24.6% of patients. Only 4 cancers (3.1%) involving the TZ were classified as clinically insignificant. Although only 4.6% of cancers were confined to the TZ, 45.3% of all prostate cancer patients had TZ involvement.
    Urology 02/2011; 77(5):1148-52. · 2.42 Impact Factor
  • Source
    Wayne M. Butler, Robert W. Galbreath, Zachariah A. Allen
    Brachytherapy 01/2011; 10. · 1.22 Impact Factor
  • Brachytherapy 01/2011; 10. · 1.22 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine whether periprostatic treatment margins correlate with biochemical control in prostate brachytherapy patients with optimized intraprostatic dosimetry. Nineteen biochemically failed brachytherapy patients were matched to 74 dosimetric and clinically equivalent nonfailures. The median followup time for the entire study population was 9.4 years. Eligibility requirements included a Day 0 intraprostatic D(90) of 100% or greater and V(100) of 90% or greater, absence of androgen deprivation therapy, and no evidence of distant metastasis in biochemically failed patients. A 5-mm annulus was constructed around the perimeter of each prostate. D(90) and V(100) at the anterior, posterior, superior, inferior, right lateral, and left lateral aspects of the annulus were evaluated for patients with biochemically controlled and failed disease. Biochemical progression-free survival (bPFS) was defined as a prostate-specific antigen level of 0.40ng/mL or less after nadir. D(90) and V(100) parameters were compared between the controlled and failed groups using logistic regression. Predictors of biochemical failure were identified using Cox regression. No statistically significant differences in prostate-specific antigen level, Gleason score, percent positive biopsies, or intraprostatic dosimetry were observed between the controlled and failed patients. The D(90) and V(100) at the anterior, posterior, superior, inferior, right lateral, and left lateral aspects of the annulus were not statistically different between biochemically controlled and failed groups. In this study, there was no relationship observed between annular dosimetry and biochemical control. It is unlikely that further radial dose intensification would have altered treatment outcome in this population of patients with optimized intraprostatic dosimetry.
    Brachytherapy 12/2010; 10(5):409-15. · 1.22 Impact Factor
  • Fuel and Energy Abstracts 04/2010; 78(3).
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To investigate the dosimetry, treatment-related morbidity, and biochemical outcomes for brachytherapy in patients with prostate glands <20 cm(3). From November 1996 to October 2006, 104 patients with prostate glands <20 cm(3) underwent brachytherapy. Multiple prostate, urethral, and rectal dosimetric parameters were evaluated. Treatment-related urinary and rectal morbidity were assessed from patient questionnaires. Cause-specific survival, biochemical progression-free survival, and overall survival were recorded. The median patient age, follow up, and pre-treatment ultrasound volume was 64 years, 5.0 years and 17.6cm(3), respectively. Median day 0 dosimetry was significant for the following: V100 98.5%, D90 126.1% and R100 <0.5% of prescription dose. The mean urethral and maximum urethral doses were 119.6% and 133.8% of prescription. The median time to International Prostate Symptom Score resolution was 4 months. There were no RTOG grade III or IV rectal complications. The cause-specific survival, biochemical progression-free survival, and overall survival rates were 100%, 92.5%, and 77.8% at 9 years. For biochemically disease-free patients, the median most recent postbrachytherapy PSA value was 0.02 ng/mL. Our results demonstrate that brachytherapy for small prostate glands is highly effective, with an acceptable morbidity profile, excellent postimplant dosimetry, acceptable treatment-related morbidity, and favorable biochemical outcomes.
    International journal of radiation oncology, biology, physics 04/2010; 76(5):1450-5. · 4.59 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In this study, the effect of prostate brachytherapy seed activity on postimplant rectal dosimetry was evaluated in Pro-Qura (Prostate Brachytherapy Quality Assurance; Seattle, WA) proctored, community-based programs. Twenty-three hundred patients (1563 iodine-125 [(125)I] and 737 palladium-103 [(103)Pd]) from 78 brachytherapists with postimplant rectal dosimetry were identified. Seed activity was stratified into three tertiles for each isotope (≤0.300, 0.301-0.326, and >0.326 mCi/seed for (125)I and ≤1.330, 1.331-1.547, and >1.547 mCi/seed for (103)Pd). Postimplant dosimetry was performed in a standardized fashion. The rectum was contoured by outlining the outer rectal wall. The volume of the rectum receiving 100% of the prescription dose (R(100)) was calculated in cubic centimeters. The prostate V(100) and D(90) volumes were also calculated. The mean prostate volume was 35.8 and 32.3 cm(3) for (125)I and (103)Pd. The median time to postimplant CT was 30 days. For (125)I, the V(100) increased from 91.0% to 93.7% (p=0.012) and the D(90) increased from 105.9% to 108.7% (p<0.001) for the lowest to the highest (125)I seed activities. In contrast, no significant changes in V(100) (p=0.751) or D(90) (p=0.200) were discerned when stratified by seed activity. For both isotopes, there was no correlation between seed activity and R(100), and R(100) was highest for the intermediate seed activities. Overall, the R(100) was lower for (103)Pd vs. (125)I (0.63 vs. 0.82 cm(3), p<0.001). Within the confines of seed activities used in this study, higher activity seeds did not result in a deleterious effect on rectal dose. Higher activity seeds were associated with improved prostate dosimetry for (125)I, whereas (103)Pd dosimetry was not dependent on seed activity.
    Brachytherapy 02/2010; 10(1):35-43. · 1.22 Impact Factor
  • Medical Physics 01/2010; 37(6). · 2.91 Impact Factor
  • Fuel and Energy Abstracts 01/2010; 78(3).
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the effect of prostate-specific antigen (PSA) velocity (PSAV) on prostate cancer diagnosis, Gleason score, tumor location, and cancer volume in men undergoing transperineal template-guided mapping biopsy (TTMB). PSAV has been associated with greater Gleason scores and greater prostate cancer-specific mortality. From January 2005 through September 2007, 217 patients underwent TTMB. The inclusion criteria included a persistently elevated PSA level and/or diagnosis of atypical small acinar proliferation or high-grade prostatic intraepithelial neoplasia on previous biopsy. The prostate gland was arbitrarily divided into 24 regions, and a median of 58 cores were obtained per patient. The patients were divided into 3 velocity cohorts according to the following changes in PSA level in the year before biopsy: < or =0.0, 0.1-1.9, and > or =2.0 ng/mL. The PSAV was evaluated as a predictor for prostate cancer diagnosis, Gleason score, tumor volume, and cancer location. The mean patient age was 64.2 years, with a mean prebiopsy PSA level of 8.5 ng/mL. Prostate cancer was diagnosed in 97 patients (44.7%). The study population had undergone an average of 1.8 +/- 1.0 biopsies before TTMB. PSAV did not predict for prostate cancer diagnosis (P = .84), Gleason score (P = .78), the percentage of positive cores (P = .37), or tumor location. Among patients with persistently elevated PSA levels despite previously negative biopsy findings, PSAV did not reliably predict for a diagnosis of prostate cancer nor did it correlate with prostate cancer grade, volume, or location using TTMB.
    Urology 03/2009; 74(1):171-6. · 2.42 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the impact of external beam radiation therapy (XRT) on weekly ultrasound determined post-void residual (PVR) urine volumes in patients with prostate cancer. 125 patients received XRT for clinically localized prostate cancer. XRT was delivered to the prostate only (n = 66) or if the risk of lymph node involvement was greater than 10% to the whole pelvis followed by a prostate boost (n = 59). All patients were irradiated in the prone position in a custom hip-fix mobilization device with an empty bladder and rectum. PVR was obtained at baseline and weekly. Multiple clinical and treatment parameters were evaluated as predictors for weekly PVR changes. The mean patient age was 73.9 years with a mean pre-treatment prostate volume of 53.3 cc, a mean IPSS of 11.3 and a mean baseline PVR of 57.6 cc. During treatment, PVR decreased from baseline in both cohorts with the absolute difference within the limits of accuracy of the bladder scanner. Alpha-blockers did not predict for a lower PVR during treatment. There was no significant difference in mean PVR urine volumes or differences from baseline in either the prostate only or pelvic radiation groups (p = 0.664 and p = 0.458, respectively). Patients with a larger baseline PVR (>40 cc) had a greater reduction in PVR, although the greatest reduction was seen between weeks one and three. Patients with a small PVR (<40 cc) had no demonstrable change throughout treatment. Prostate XRT results in clinically insignificant changes in weekly PVR volumes, suggesting that radiation induced bladder irritation does not substantially influence bladder residual urine volumes.
    Radiation Oncology 02/2009; 4:26. · 2.11 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study analyzed rectal dosimetry outcomes of Pro-Qura proctored implants to assess the achievability of proposed rectal dose constraints in the setting of standardized pre- and postimplant dosimetry in community-based brachytherapy programs. From August 2005 to July 2007, 713 postimplant CT scans were evaluated from 26 brachytherapists actively participating in Pro-Qura. Postimplant dosimetry was performed in a standardized fashion. The entirety of the rectal wall was contoured and evaluated for dose. Rectal dose was defined in terms of the volume of the rectum receiving 100% of the prescription dose (R(100)). Criteria for implant adequacy for both (103)Pd and (125)I included a prostate the percentage of the prostate volume covered by the prescription dose (V(100))>80%, a prostate the maximum dose covering 90% of the prostate volume (D(90)) of 90-140%, and an R(100)<1.0cm(3) for early (Day 0-7) dosimetry and <1.3cm(3) for late (Day 20-45) dosimetry. Mean prostatic volume was 35.1cm(3). The mean time from implant to CT scan was 29.9 days (range, 0-45 days). The respective mean overall prostate V(100) and D(90) were 89% and 101%, respectively, and remained consistent for sequence groups 1 through 6. Overall, the mean R(100) was 0.97+/-1.04cm(3). The R(100) was 1.15cm(3) for sequence Group 1 and with each subsequent sequence group decreased with a nadir of 0.83cm(3) in sequence Group 6 (p=0.22). Rectal dosimetry was deemed inadequate in 39% of Group 1 implants but only 22% in Group 6 (p=0.016). The reduced rectal doses did not impact prostate gland coverage. Using standardized dosimetry, R(100) improved with increasing brachytherapist's experience, reaching a plateau after approximately 20 patients.
    Brachytherapy 01/2009; 8(1):34-9. · 1.22 Impact Factor
  • Fuel and Energy Abstracts 01/2009; 75(3).
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the influence of postimplant dosimetric timing on prostate brachytherapy quality in community practice. The Pro-Qura database was stratified by multiple time intervals between the implant and postimplant dosimetric analysis. Postimplant dosimetry was performed in a standardized fashion. Criteria for implant adequacy included V(100) >80%, D(90) >90%, and V(150) <60% for I-125 and <75% for Pd-103. Implants with V(100) <80% and D(90) <90% were deemed "too cool." Implants were considered "too hot" if D(90) >140% of prescription dose and/or V(150) >150% for I-125 and >75% for Pd-103. For I-125, the average V(100) and D(90) increased from 88.6% to 89.8%, and 102.8% to 103.1% for day 0 and day 30 dosimetry. For Pd-103 implants the change was more pronounced, with V(100) and D(90) increasing from 81.6% to 87.8% (P < 0.001) and 88.7% to 100.0% (P < 0.001) for day 0, and day 30, respectively. The percentage of implants considered too cool based on a V(100) and D(90) criteria decreased from 18.8% and 26.9% on day 0 to 11.0% and 19.7% on day 30, respectively. Implants determined to be too hot based on a V(150) >60% (I-125)/>75% (Pd-103) or D(90) >140% were 16.4% and 2.2% on day 0 and 16.0% and 0.7% on day 30, respectively. In community-based brachytherapy programs, postimplant dosimetry performed at day 30 resulted in a statistically and clinically significant improvement in postimplant dosimetry compared with day 0. The influence of timing is substantially greater for Pd-103 than I-125.
    American journal of clinical oncology 01/2009; 31(6):523-31. · 2.21 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Low testosterone has been implicated as a possible adverse prognostic factor in patients with newly diagnosed prostate cancer. We evaluated the impact of pretreatment serum testosterone on survival after prostate brachytherapy. From October 2001 to November 2004, 619 patients underwent brachytherapy and 546 had a pretreatment serum testosterone level measured. Pretreatment serum testosterone levels were assigned by the following criteria: below-normal (n = 105), low normal (n = 246), mid normal (n = 132), high normal (n = 50), and above normal (n = 13). Median follow-up was 5.2 years. Cause of death was determined for each deceased patient. Six-year biochemical progression-free survival (bPFS), cause-specific survival (CSS), and overall survival (OS) were 97.7%, 99.8%, and 89.2%. When comparing patients with low or low normal testosterone with those with average or higher testosterone, there was no significant difference in bPFS (97.6% vs. 98.4%; p = 0.72), CSS (99.8% vs. 100%; p = 0.72), or OS (88.9% vs. 90.8%; p = 0.73). Among patients with average and higher pretreatment testosterone, there was no significant difference in outcomes when comparing patients who did and did not receive androgen deprivation therapy (ADT). For patients with low or low normal testosterone levels, there was no significant difference in bPFS or CSS when comparing patients who did and did not receive ADT. However, there was a trend toward lower OS in patients with baseline lower testosterone levels who also received ADT (83.9% vs. 91.3%, p = 0.075). Low pretreatment testosterone levels alone did not affect disease recurrence or OS. Patients with baseline low testosterone who also were treated with ADT had a trend toward decreased OS.
    International journal of radiation oncology, biology, physics 01/2009; 74(4):1143-9. · 4.59 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Despite favorable long-term prostate brachytherapy outcomes, there remains a bias to recommend radical prostatectomy for young patients. Herein, we report cause-specific survival, biochemical progression-free survival (bPFS), overall survival and functional outcomes in men < or =50 years of age who underwent brachytherapy with or without supplemental therapies. From October 1995 to November 2004, 42 consecutive patients < or =50 years of age underwent permanent interstitial brachytherapy. No patient underwent seminal vesicle biopsy or pathologic lymph node staging. The mean and median follow-up was 5.6 and 5.1 year. bPFS was defined as a prostate-specific antigen < or =0.40 ng/mL after nadir. Functional outcome determinations included urinary, bowel and erectile function evaluations. Multiple clinical, treatment and dosimetric parameters were evaluated for impact on survival. Cause-specific survival, bPFS, and overall survival for the entire cohort were 100%, 97.7%, and 100%, respectively. To date, only one patient has failed biochemically. Median time to International Prostate Symptom Score resolution was 3 months. No patient required a postimplant transurethral resection of the prostate or developed urinary incontinence. Two patients developed bulbomembtranous urethral strictures. The overall potency preservation rate was 75.6% (International Index of Erectile Function-6 >13 without mechanical or pharmacologic support). Bowel habits were reported to be the same or better than prior to treatment in 92.5% patients. No severe rectal complications requiring therapeutic intervention occurred. Men < or =50 years of age have favorable biochemical and functional outcomes following brachytherapy. Depending on risk group assignment, brachytherapy with or without supplemental therapies should be considered a viable option for all healthy men regardless of age.
    American journal of clinical oncology 01/2009; 31(6):539-44. · 2.21 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: PSA Kinetics following High Dose Intensity Modulated External Beam Radiation Therapy with and without Image Guidance J. L. Reed, G. S. Merrick, W. M. Butler, Z. A. Allen, B. S. Kurko, B. C. Murray, and R. W. Galbreath Schiffler Cancer Center, Wheeling, WV Purpose/Objective(s): It has previously been reported that PSA kinetics in the first year following definitive external beam radiation therapy are predictive of biochemical progression-free and overall survival in patients treated with radiation therapy alone. In this study, we evaluated PSA kinetics in the first two years following high-dose intensity modulated external beam radiation therapy (IMRT) with and without image guidance. Materials/Methods: One hundred consecutive patients (the last 50 IMRT patients treated without image-guidance and the first 50 patients treated with image-guidance) were evaluated. All patients received 81 Gy in 1.8 Gy fractions calculated to the 90% isodose line. No patient received androgen deprivation therapy. All patients were irradiated in the prone position in a custom Aquaplast hip-fix immobilization device with an empty bladder and rectum. For image-guided patients, a daily cone-beam CT scan was obtained prior to treatment with positioning readjustments due to internal organ motion corrected for prior to the daily treatment. For non-imaged guidance patients, laser parameters were used on a daily basis to ensure appropriate setup. Weekly portal films were obtained for all 100 patients. Multiple clinical and treatment parameters were evaluated for impact on PSA kinetics. Results: The mean patient age was 72 years with a mean pre-treatment PSA of 7.0 ng/ml, a mean Gleason score of 6.6 and a mean prostate volume of 40.5 cm3. No statistical differences in clinical parameters were identifiable between the two cohorts. At 6, 9, 12, 15, 18 and 24 months no statistically significance differences in post-treatment PSA were discerned between patients with and without image-guidance. At 12 and 24 months post-treatment, the mean PSA was 0.70 and 0.40 without image-guidance and 0.60 and 0.38 with image-guidance, respectively. Possibly because of the homogeneity of the evaluated population, none of the evaluated parameters predicted for short-term PSA kinetics. Conclusions: Within the confines of this study, our results suggest that patients immobilized in the prone position in a custom hip-fix immobilization device have comparable PSA kinetics to patients treated in an identical manner but with the addition of daily cone-beam image guidance. Excellent PSA responses were noted in both cohorts.
    Fuel and Energy Abstracts 01/2009; 75(3).

Publication Stats

800 Citations
207.70 Total Impact Points

Institutions

  • 2003–2011
    • Wheeling Jesuit University
      Wheeling, West Virginia, United States
  • 2005–2010
    • University of Washington Seattle
      • Department of Radiation Oncology
      Seattle, WA, United States
  • 2009
    • United States Army
      Washington, West Virginia, United States
  • 2003–2008
    • Wheeling Hospital
      Wheeling, West Virginia, United States
  • 2007
    • Institute for Urologic Research
      Wheeling, West Virginia, United States
  • 2006
    • University of Michigan
      • Department of Urology
      Ann Arbor, MI, United States