Mihir M Desai

Keck School of Medicine USC, Los Ángeles, California, United States

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Publications (314)1071.86 Total impact

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    ABSTRACT: Clear cell renal cell carcinoma (ccRCC) is the most common subtype of renal cell cancer (RCC), followed by papillary RCC (pRCC). It is important to distinguish these two subtypes because of prognostic differences and possible changes in management, especially in cases undergoing active surveillance. The purpose of our study is to evaluate the use of voxel-based whole-lesion (WL) enhancement parameters on contrast enhanced computed tomography (CECT) to distinguish ccRCC from pRCC. In this institutional review board-approved study, we retrospectively queried the surgical database for post nephrectomy patients who had pathology proven ccRCC or pRCC and who had preoperative multiphase CECT of the abdomen between June 2009 and June 2011. A total of 61 patients (46 with ccRCC and 15 with pRCC) who underwent robotic assisted partial nephrectomy for clinically localized disease were included in the study. Multiphase CT acquisitions were transferred to a dedicated three-dimensional workstation, and WL regions of interest were manually segmented. Voxel-based contrast enhancement values were collected from the lesion segmentation and displayed as a histogram. Mean and median enhancement and histogram distribution parameters skewness, kurtosis, standard deviation, and interquartile range were calculated for each lesion. Comparison between ccRCC and pRCC was made using each imaging parameter. For mean and median enhancement, which had a normal distribution, independent t-test was used. For histogram distribution parameters, which were not normally distributed, Wilcoxon rank sum test was used. ccRCC had significantly higher mean and median whole WL enhancement (p < 0.01) compared to pRCC on arterial, nephrographic, and excretory phases. ccRCC had significantly higher interquartile range and standard deviation (p < 0.01) and significantly lower skewness (p < 0.01) compared to pRCC on arterial and nephrographic phases. ccRCC had significantly lower kurtosis compared to pRCC on only the arterial phase. Our study suggests that voxel-based WL enhancement parameters can be used as a quantitative tool to differentiate ccRCC from pRCC. Differentiating between the two main types of RCC would provide the patient and the treating physicians more information to formulate the initial approach to managing the patient's renal cancer.
    SpringerPlus 12/2015; 4(1). DOI:10.1186/s40064-015-0823-z
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    ABSTRACT: To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). We utilize a four-arm robotic approach and a 5-6 port placement consisting of: 1- 12 mm camera port, 3- 8 mm robotic ports, and 1 to 2 assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. This technique has been utilized since 2010 on over 2,370 robotic urologic cases. To date, no procedure has required patient or robot positioning while maintaining 4th arm functionality with minimal robotic arm clashing. Our approach of port placement and robot docking is reproducible and feasible for pelvic and kidney surgery.
    Journal of endourology / Endourological Society 04/2015; DOI:10.1089/end.2015.0077 · 2.10 Impact Factor
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    ABSTRACT: Level III inferior vena cava (IVC) tumor thrombectomy for renal cancer is one of the most challenging open urologic oncologic surgeries. The initial series of completely intra-corporeal robotic level III IVC tumor thrombectomy is presented. Nine patients underwent robotic level III IVC thrombectomy; additionally, 7 patients underwent level II thrombectomy. The entire operation (high intra-hepatic IVC control, caval exclusion, tumor thrombectomy, IVC repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize chances of intra-operative IVC thrombus embolization, an 'IVC-first, kidney-last' robotic technique was developed. Data were accrued prospectively. All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (n=9), median primary kidney (right=6, left=3) cancer size was 8.5 cm (5.3-10.8) and IVC thrombus length was 5.7 cm (4-7). Median operative time was 4.9 hours (4.5-6.3), estimated blood loss was 375 cc (200-7000) and hospital stay was 4.5 days. All surgical margins were negative. There was no intra- and 1 post-operative complication (Clavien 3b). Over median 7 months follow-up (1-18), all patients are alive. Compared to level II thrombi, the level III cohort trended towards greater IVC thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hrs) and blood loss (290 vs 375 cc). With appropriate patient selection, surgical planning and robotic experience, completely intra-corporeal robotic level III IVC thrombectomy is feasible and can be performed efficiently. Larger experience, longer follow-up and comparison with open surgery are needed to confirm these initial outcomes. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
    The Journal of urology 04/2015; DOI:10.1016/j.juro.2015.03.119 · 3.75 Impact Factor
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    ABSTRACT: To assess survival following radical prostatectomy (RP), intensity modulated radiation therapy (IMRT) or conformal radiation therapy (CRT) versus no local therapy (NLT) for metastatic prostate cancer (MPCa), adjusting for patient comorbidity, androgen deprivation therapy (ADT) and other factors. Men ≥66 with MPCa undergoing treatment by RP, IMRT, CRT or NLT identified from SEER-Medicare linked database (2004-2009). Multivariable Cox proportional hazards models, before and after inverse propensity score weighting, were used to assess all cause and PCa specific mortality. Competing risk regression analysis was used to assess PCa specific mortality. Among 4069 men with MPCa, RP (n=47), IMRT (n=88), CRT (n=107) were selected as local therapy versus NLT (n=3827). RP was associated with a 52% (HR: 0.48, 95% CI: 0.27-0.85) reduction in the risk of PCa specific mortality, after adjusting for socio-demographic, primary tumour characteristics, comorbidity, ADT and bone radiation within 6 months of diagnosis. IMRT was associated with a 62% (HR: 0.38, 95% CI: 0.24-0.61) reduction in the risk of PCa specific mortality, respectively. CRT was not associated with improved survival compared to NLT. Propensity score weighting yielded comparable results. Competing risk analysis revealed a 42% (SHR: 0.58, 95% CI: 0.35-0.95) and 57% (SHR: 0.43, 95% CI: 0.27-0.68) reduction in the risk of PCa specific mortality for RP and IMRT. Local therapy with RP and IMRT, but not CRT, was associated with a survival benefit in MPC and warrants prospective evaluation in clinical trials. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
    The Journal of Urology 02/2015; DOI:10.1016/j.juro.2015.02.084 · 3.75 Impact Factor
  • Mihir M Desai, Inderbir S Gill
    European Urology 01/2015; DOI:10.1016/j.eururo.2015.01.017 · 12.48 Impact Factor
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    ABSTRACT: We demonstrate the construct validity, reliability, and utility of Global Evaluative Assessment of Robotic Skills (GEARS), a clinical assessment tool designed to measure robotic technical skills, in an independent cohort using an in vivo animal training model. Using a cross-sectional observational study design, 47 voluntary participants were categorized as experts (>30 robotic cases completed as primary surgeon) or trainees. The trainee group was further divided into intermediates (≥5 but ≤30 cases) or novices (<5 cases). All participants completed a standardized in vivo robotic task in a porcine model. Task performance was evaluated by two expert robotic surgeons and self-assessed by the participants using the GEARS assessment tool. Kruskal-Wallis test was used to compare the GEARS performance scores to determine construct validity; Spearman's rank correlation measured interobserver reliability; and Cronbach's alpha was used to assess internal consistency. Performance evaluations were completed on nine experts and 38 trainees (14 intermediate, 24 novice). Experts demonstrated superior performance compared to intermediates and novices overall and in all individual domains (p < 0.0001). In comparing intermediates and novices, the overall performance difference trended toward significance (p = 0.0505), while the individual domains of efficiency and autonomy were significantly different between groups (p = 0.0280 and 0.0425, respectively). Interobserver reliability between expert ratings was confirmed with a strong correlation observed (r = 0.857, 95 % CI [0.691, 0.941]). Experts and participant scoring showed less agreement (r = 0.435, 95 % CI [0.121, 0.689] and r = 0.422, 95 % CI [0.081, 0.0672]). Internal consistency was excellent for experts and participants (α = 0.96, 0.98, 0.93). In an independent cohort, GEARS was able to differentiate between different robotic skill levels, demonstrating excellent construct validity. As a standardized assessment tool, GEARS maintained consistency and reliability for an in vivo robotic surgical task and may be applied for skills evaluation in a broad range of robotic procedures.
    Surgical Endoscopy 01/2015; 187(4). DOI:10.1007/s00464-015-4070-8 · 3.31 Impact Factor
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    ABSTRACT: We summarise our experience with RPN emphasising on learning curve, techniques and outcomes. A retrospective chart review of 57 patients was done. The preoperative workup included a triple phase CT angiography. The parameters analyzed were demographics, tumor characteristics, operative details, postoperative outcome, histopathology and follow-up. The data were compared with historical cohort of the laparoscopic partial nephrectomy (LPN). 58 renal units in 57 patients (45 males and 12 females) underwent RPN. The mean age was 53.08 ± 13.6 (30-71) years. The mean tumor size was 4.96 ± 2.33 (2-15.5) cm. Average operative time was 129.4 ± 29.9 (70-200) min.; mean warm ischemia time was 20.9 ± 7.34 (9-39) min. 8 renal units in 7 patients were operated with the zero ischemia technique. The average follow-up was 5.15 months (1-18). There was no recurrence. 15 patients underwent LPN. The mean tumor size was 4.3 ± 1.6 (1.6-8) cm. operative time was 230.7 ± 114.8 (150-300) min.; mean warm ischemia time was 31.8 ± 9 min. The nephromerty score in the LPN group was 7.1 ± 0.89, in the RPN group was 8.75 ± 1.21. Our results suggest that prior experience of LPN shortens the learning curve for RPN as seen by shorter warm ischemia time and operative time in our series. The nephrometry score in RPN were higher suggesting that complex tumour can be managed with robotic approach.
    Journal of Minimal Access Surgery 01/2015; 11(1):78-82. DOI:10.4103/0972-9941.147701 · 1.37 Impact Factor
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    ABSTRACT: To develop two nomograms predicting disease-free survival (DFS) and cancer-specific survival (CSS) and to externally validate them in multiple series. Prospectively collected data from a single-centre series of 818 consecutive patients who underwent RC and PLND were used to build the nomogram. External validation was performed in 3,173 patients from 7 centres worldwide. Time to recurrence and to cancer-specific death were addressed with univariable and multivariable analyses. Nomograms were built to predict 2-, 5- and 8-year DFS and CSS probabilities. Predictive accuracy was quantified using the concordance index. Age, pathologic T stage, lymph-node density and extent of PLND were independent predictors of DFS and CSS (p < 0.05). Discrimination accuracies for DFS and CSS at 2, 5 and 8 years were 0.81, 0.8, 0.79 and 0.82, 0.81, 0.8, respectively, with a slight overestimation at calibration plots beyond 24 months. In the external series, predictive accuracies for DFS and CSS at 2, 5 and 8 years were 0.83, 0.82, 0.82 and 0.85, 0.85, 0.83 for European centres; 0.73, 0.72, 0.71 and 0.80, 0.74, 0.68 for African series; 0.76, 0.74, 0.71 and 0.79, 0.76, 0.73 for American series. These nomograms developed from a contemporary series are simple clinical tools and provide optimal oncologic outcome prediction in all external cohorts.
    World Journal of Urology 12/2014; 191(4). DOI:10.1007/s00345-014-1465-4 · 3.42 Impact Factor
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    ABSTRACT: Objective To prospectively evaluate the feasibility and safety of a novel, second-generation telementoring interface (Connect™; Intuitive Surgical Inc., Sunnyvale, CA, USA) for the da Vinci robot.Materials and Methods Robotic surgery trainees were mentored during portions of robot-assisted prostatectomy and renal surgery cases. Cases were assigned as traditional in-room mentoring or remote mentoring using Connect. While viewing two-dimensional, real-time video of the surgical field, remote mentors delivered verbal and visual counsel, using two-way audio and telestration (drawing) capabilities. Perioperative and technical data were recorded. Trainee robotic performance was rated using a validated assessment tool by both mentors and trainees. The mentoring interface was rated using a multi-factorial Likert-based survey. The Mann-Whitney and t-tests were used to determine statistical differences.ResultsWe enrolled 55 mentored surgical cases (29 in-room, 26 remote). Perioperative variables of operative time and blood loss were similar between in-room and remote mentored cases. Robotic skills assessment showed no significant difference (P > 0.05). Mentors preferred remote over in-room telestration (P = 0.05); otherwise no significant difference existed in evaluation of the interfaces. Remote cases using wired (vs wireless) connections had lower latency and better data transfer (P = 0.005). Three of 18 (17%) wireless sessions were disrupted; one was converted to wired, one continued after restarting Connect, and the third was aborted. A bipolar injury to the colon occurred during one (3%) in-room mentored case; no intraoperative injuries were reported during remote sessions.Conclusion In a tightly controlled environment, the Connect interface allows trainee robotic surgeons to be telementored in a safe and effective manner while performing basic surgical techniques. Significant steps remain prior to widespread use of this technology.
    BJU International 11/2014; DOI:10.1111/bju.12985 · 3.13 Impact Factor
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    ABSTRACT: To assess the feasibility of a novel percutaneous navigation system (Translucent™ Medical) that integrates position-tracking technology with a movable tablet display.
    BJU International 10/2014; 115(4). DOI:10.1111/bju.12948 · 3.13 Impact Factor
  • Mihir M. Desai, Inderbir S. Gill
    European Urology 10/2014; 66(4):722–723. DOI:10.1016/j.eururo.2014.02.045 · 12.48 Impact Factor
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    ABSTRACT: To propose a novel system based on segmental renal anatomy for objectively reporting location of clinical T1 masses for nephron-sparing surgery.
    World Journal of Urology 08/2014; DOI:10.1007/s00345-014-1386-2 · 3.42 Impact Factor
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    ABSTRACT: During enucleative partial nephrectomy (PN), excision is performed adjacent to the tumor edge. To better inform the oncological propriety of enucleative PN, we histologically examined the tumor-parenchyma interface.
    The Journal of Urology 08/2014; 193(2). DOI:10.1016/j.juro.2014.08.010 · 3.75 Impact Factor
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    ABSTRACT: Purpose: We present a 2-institution experience with completely intracorporeal robotic orthotopic ileal neobladder after radical cystectomy in 132 patients. Materials and Methods: Established open surgical techniques were duplicated robotically with all neobladders suture constructed intracorporeally in a globular configuration. Nerve sparing was performed in 56% of males. Lymphadenectomy was extended (up to aortic bifurcation in 51, 44%) and superextended (up to the inferior mesenteric artery in 20, 17%). Ureteroileal anastomoses were Wallacetype (86, 65%) or Bricker-type (46, 35%). The learning curve at each institution was assessed using chronological subgroups and by trends across the entire cohort. Data were prospectively collected and retrospectively queried. Results: Mean operating time was 7.6 hours (range 4.4 to 13), blood loss was 430 cc (range 50 to 2,200) and hospital stay was 11 days (median 8, range 3 to 78). Clavien grade I, II, III, IV and V complications within 30 days were 7%, 25%, 13%, 2% and 0%, respectively, and between 30 and 90 days were 5%, 9%, 11%, 1% and 2%, respectively. Mean nodal yield was 29 (range 7 to 164) and the node positivity rate was 17%. Operative time, blood loss, hospital stay and prevalence of late complications improved with experience. During a mean followup of 2.1 years (range 0.1 to 9.8) cancer recurred in 20 patients (15%). Five-year overall, cancer specific and recurrence-free survival was 72%, 72% and 71%, respectively. Conclusions: We developed a refined technique of robotic intracorporeal orthotopic neobladder diversion, duplicating open principles. Operative efficiency and outcomes improved with experience. Going forward, we propose a prospective randomized comparison between open and robotic intracorporeal neobladder surgery.
    The Journal of Urology 07/2014; 192(6). DOI:10.1016/j.juro.2014.06.087 · 3.75 Impact Factor
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    ABSTRACT: Introduction and Objective: To evaluate the safety and efficacy of a novel robotic tissue ablation system (PROCEPT AquablationTM System, PAS), in performing prostate ablation in a survival canine model. Methods: This novel technology uses a high-velocity saline stream delivered that aims to selectively ablates prostatic glandular tissue while sparing collagenous structures like blood vessels and capsule. Once the ablation is complete a laser beam is captured by a low-pressure water jet to produce surface hemostasis. The extent and depth of ablation is pre-determined by endoscopic and TRUS guidance. The procedure was performed in 8 non-castrated male beagles aged 6 years or older (Acute 2, Chronic 6) through a previously created perineal urethrostomy. Results: Aquablation time ranged from 40 to 84 secs (mean 60.5 secs). There was no active bleeding in any of the dogs during or after Aquablation. Waterjet-guided laser coagulation was used for purposes of monitoring its safety and efficacy. Five of the six dogs the pre-determined 6 week mark. Complications included 2 dogs with infection successfully treated with antibiotics, a false passage created during catheter placement, and 2 bladder neck perforations (from mechanical insertion), one leading to euthanasia. Histological evaluation at 6 weeks revealed a normal cellular architecture and full re-epithelialization of the treatment cavity. Conclusions: We report the initial survival data in the animal model of a novel robotic device developed for treating symptomatic BPH. Aquablation produces ablation of adenomatous elements while preserving collagenous structures and is a promising technology for surgical treatment of symptomatic BPH.
    Journal of endourology / Endourological Society 07/2014; 29(1). DOI:10.1089/end.2014.0304 · 2.10 Impact Factor
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    ABSTRACT: Radical cystectomy is the gold-standard treatment for muscle-invasive and refractory nonmuscle-invasive bladder cancer. We describe our technique for robotic radical cystectomy (RRC) and intracorporeal urinary diversion (ICUD), that replicates open surgical principles, and present our preliminary results.
    Indian Journal of Urology 07/2014; 30(3):300-6. DOI:10.4103/0970-1591.135673
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    ABSTRACT: Objectives: To present time-efficiency data during our initial experience with intracorporeal urinary diversion and technical tips that may shorten operative time early in the learning curve. Patients and methods: Data were analyzed in the initial 37 consecutive patients undergoing robotic radical cystectomy and intracorporeal urinary diversion in whom detailed step-wise operative time data were available. Median age was 65 years and median BMI was 27. Neoadjuvant chemotherapy was administered in 6 patients and 11 patients had clinical evidence of T3 or lymph node-positive disease. Each component of the operation was subdivided into specific steps and operative time for each step was prospectively recorded. Peri-operative and follow-up data upto 90 days and final pathological data were recorded. Results: All procedures were completed intracorporeally and robotically without need for conversion to open surgery or extracorporeal diversion. Median total operative time was 387 vs 386 minutes (p=0.2) and median total console time was 361 vs 295 minutes (p<0.007) for orthotopic neobladder and ileal conduit, respectively. Median time for radical cystectomy was 77 min, extended PLND was 63 min and diversion was 111 min (Ileal conduit 92 min, orthotopic neobladder 124 min). Median estimated blood loss was 250 cc, and median hospital stay was 9 days. High grade (Clavien grade 3-5) complications at 30 and 90 days follow up were recorded in 6 (16%) and 9 (24%) patients, respectively. Over a median follow up of 16 months, 12 (32%) patients experienced disease recurrence and 9 (24%) died from bladder cancer. These correspond to 1-year recurrence-free and overall survival of 64% and 70%, respectively. Conclusions: Intracorporeal urinary diversion following robotic radical cystectomy can be performed safely and reproducibly in a time efficient manner even during the early learning curve.
    Journal of endourology / Endourological Society 06/2014; DOI:10.1089/end.2014.0284 · 2.10 Impact Factor
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Publication Stats

9k Citations
1,071.86 Total Impact Points

Institutions

  • 2011–2015
    • Keck School of Medicine USC
      Los Ángeles, California, United States
    • University of Texas Southwestern Medical Center
      • Department of Urology
      Dallas, Texas, United States
    • The University of Chicago Medical Center
      • Section of Urology
      Chicago, Illinois, United States
  • 2009–2015
    • University of Southern California
      • Keck School of Medicine
      Los Ángeles, California, United States
    • University Hospital Of North Staffordshire NHS Trust
      • Department of Urology
      Stoke-upon-Trent, England, United Kingdom
    • Cleveland Clinic
      • Department of Urology
      Cleveland, Ohio, United States
  • 2002–2015
    • Muljibhai Patel Urological Hospital
      Aimand, Gujarat, India
  • 2014
    • Istituto Regina Elena - Istituti Fisioterapici Ospitalieri
      Roma, Latium, Italy
    • Michigan Institute of Urology
      Detroit, Michigan, United States
  • 2011–2014
    • University of California, Los Angeles
      Los Ángeles, California, United States
  • 2010
    • Children's Hospital Los Angeles
      Los Angeles, California, United States
  • 2008
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 2003
    • American Physical Society
      CGS, Maryland, United States