Jennifer T Anger

Cedars-Sinai Medical Center, Los Ángeles, California, United States

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Publications (110)303.31 Total impact

  • Alexandriah N Alas, Jennifer T Anger
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    ABSTRACT: Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery. • Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10]. • Pessaries should be managed with regular follow-up care to minimize complications [14•]. • Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•]. • Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•]. • Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy. • Obliterative procedures are effective but are considered definitive surgery [24••]. • The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.
    Current Urology Reports 05/2015; 16(5):498. DOI:10.1007/s11934-015-0498-6
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    ABSTRACT: Over 90,000 legal claims for complications related to transvaginal mesh have been filed to date. Safety issues specifically related to the use of transvaginal mesh for pelvic organ prolapse have not been appropriately differentiated from the use of mesh for stress urinary incontinence by either attorneys or the media. This litigious environment and nebulous communication on the safety issues have led to patient and physician concern regarding mesh slings for the treatment of stress urinary incontinence. The ultimate result is likely to be a decrease in use of the gold standard of care for stress urinary incontinence—the mid-urethral synthetic sling.
    Current Bladder Dysfunction Reports 03/2015; 10(1). DOI:10.1007/s11884-014-0278-z
  • Christopher J Dru, Jennifer T Anger
    BMJ Clinical Research 12/2014; 349:g7698. DOI:10.1136/bmj.g7698 · 14.09 Impact Factor
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    ABSTRACT: Introduction and hypothesis Limited data exist on women’s experience with pelvic organ prolapse (POP) symptoms. We aimed to describe factors that prevent disease understanding among Spanish-speaking and English-speaking women. Methods Women with POP were recruited from female urology and urogynecology clinics in Los Angeles, California, and Albuquerque, New Mexico. Eight focus groups were conducted, four in Spanish and four in English. Topics addressed patients’ emotional responses when noticing their prolapse, how they sought support, what verbal and written information was given, and their overall feelings of the process. Additionally, patients were asked about their experience with their treating physician. All interview transcripts were analyzed using grounded theory qualitative methods. Results Qualitative analysis yielded two preliminary themes. First, women had misconceptions about what POP is as well as its causes and treatments. Second, there was a great deal of miscommunication between patient and physician which led to decreased understanding about the diagnosis and treatment options. This included the fact that women were often overwhelmed with information which they did not understand. The concept emerged that there is a strong need for better methods to achieve disease and treatment understanding for women with POP. Conclusions Our findings emphasize that women with POP have considerable misconceptions about their disease. In addition, there is miscommunication during the patient–physician interaction that leads to further confusion among Spanish-speaking and English-speaking women. Spending more time explaining the diagnosis of POP, rather than focusing solely on treatment options, may reduce miscommunication and increase patient understanding.
    International Urogynecology Journal 12/2014; 26(4). DOI:10.1007/s00192-014-2562-z · 2.16 Impact Factor
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    ABSTRACT: Health care providers are increasingly being evaluated by the quality of care they provide. Our aim was to assess the feasibility of recently developed quality indicators (QIs) for pelvic organ prolapse (POP) and identify possible deficits in care. A panel ranked 14 QIs based on the RAND appropriateness method assessing screening and diagnosis, pessary management, and surgery for POP. Retrospective chart abstraction was performed after identifying patients with a diagnosis of POP evaluated within a hospital-based multispecialty group using International Classification of Diseases, ninth edition, diagnosis codes. Of 283 patients identified, 98% of those with a new complaint of vaginal bulge had a pelvic examination. The POP was described but not staged in 6% and not documented at all in 25.1%. Among those managed with pessaries, 98% had vaginal examinations at least every 6 months. Forty-nine percent of the patients who had surgery had complete preoperative POP staging. Only 20% of women undergoing apical surgery had documentation of counseling regarding different surgical options, and of the women who underwent a hysterectomy for POP, only 48% had a concomitant vault suspension. Although 71% had documentation about the risk of postoperative stress incontinence, only 14.5% had documented counseling regarding risks of mesh. Only 37% of patients implanted with mesh for POP had documented follow-up at 1 year. An intraoperative cystoscopy was performed in 86% undergoing cystocele repair or apical surgery. The quality of care for women with POP can be feasibly measured with QIs. Processes of care were deficient in many areas, and our findings can serve as a basis for quality improvement interventions. Copyright © 2015 Elsevier Inc. All rights reserved.
    American Journal of Obstetrics and Gynecology 10/2014; DOI:10.1016/j.ajog.2014.10.1105 · 3.97 Impact Factor
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    ABSTRACT: Interstitial cystitis/painful bladder syndrome (IC) is a chronic syndrome of unknown etiology that presents with bladder pain, urinary frequency, and urgency. The lack of specific biomarkers and a poor understanding of underlying molecular mechanisms presents challenges for disease diagnosis and therapy. The goals of this study were to identify non-invasive biomarker candidates for IC from urine specimens and potentially gain new insight into disease mechanisms using a nuclear magnetic resonance (NMR)-based global metabolomics analysis of urine from female IC patients and controls. Principal component analysis (PCA) suggested that the urinary metabolome of IC and controls was clearly different, with 140 NMR peaks significantly altered in IC patients (FDR<0.05), compared to controls. Based on strong correlation scores, eight metabolite peaks were nominated as the strongest signature of IC. Among those signals that were higher in the IC groups, three peaks were annotated as tyramine, the pain-related neuromodulator. Two peaks were annotated as 2-oxoglutarate. Levels of tyramine and 2-oxoglutarate were significantly elevated in urine specimens of IC subjects. An independent analysis using mass spectrometry also showed the significantly increased levels of tyramine and 2-oxoglutarate in IC patients, compared to controls. Functional studies showed that 2-oxoglutarate, but not tyramine, retarded growth of normal bladder epithelial cells. These preliminary findings suggest that analysis of urine metabolites has promise in biomarker development in the context of IC.
    Journal of Proteome Research 10/2014; 14(1). DOI:10.1021/pr5007729 · 5.00 Impact Factor
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    ABSTRACT: Aims In the last decade, many new surgical treatments have been developed to achieve less invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national dataset to analyze the temporal trends in patterns of care for women with pelvic organ prolapse. Methods Data were obtained from Public Use Files from the Centers for Medicare and Medicaid for a 5% random sample of national beneficiaries with an ICD-9-CM diagnosis of POP from 1999 to 2009. CPT-4 and ICD-9-CM procedure codes were used to evaluate non-surgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed. Results Over the study time period, the number of women with a diagnosis of pelvic organ prolapse in any one year in our 5% sample of Medicare beneficiaries remained relatively stable (range 21,245 and 23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low, however showed a relative increase over time (22% in 1999 to 26% in 2009). Conclusions Patterns and rates of prolapse repairs remained relatively unchanged from 1999 to 2009, with an exception of a rapid rise in mesh use. These data suggests that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the U.S. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP.
    American Journal of Obstetrics and Gynecology 10/2014; DOI:10.1016/j.ajog.2014.10.025 · 3.97 Impact Factor
  • Lauren N Wood, Jennifer T Anger
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    ABSTRACT: Urinary incontinence affects women of all ages. History, physical examination, and certain tests can guide specialists in diagnosing stress urinary incontinence, urgency urinary incontinence, and mixed urinary incontinence. First line management includes lifestyle and behavior modification, as well as pelvic floor strength and bladder training. Drug therapy is helpful in the treatment of urgency incontinence that does not respond to conservative measures. In addition, sacral neuromodulation, intravesical onabotulinumtoxinA injections, and posterior tibial nerve stimulation can be used in select patient populations with drug refractory urgency incontinence. Midurethral synthetic slings, including retropubic and transobturator approaches, are safe and efficacious surgical options for stress urinary incontinence and have replaced more invasive bladder neck slings that use autologous or cadaveric fascia. Despite controversy surrounding vaginal mesh for prolapse, synthetic slings for the treatment of stress urinary incontinence are considered safe and minimally invasive.
    BMJ Clinical Research 09/2014; 349:g4531. DOI:10.1136/bmj.g4531 · 14.09 Impact Factor
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    ABSTRACT: The objectives of this study are to evaluate urinary incontinence and pelvic organ prolapse knowledge among elder southwestern American Indian women and to assess barriers to care for pelvic floor disorders through community-engaged research.
    Journal of Pelvic Medicine and Surgery 09/2014; 21(1). DOI:10.1097/SPV.0000000000000103
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    ABSTRACT: As the aging population in the United States grows, the investigation of urinary incontinence (UI) issues becomes increasingly important, especially among women. Using data from the California Health Interview Survey (CHIS), we sought to determine the prevalence and correlates of UI among an ethnically diverse population of older community-dwelling women.
    The Journal of Urology 09/2014; DOI:10.1097/SPV.0000000000000093 · 3.75 Impact Factor
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    ABSTRACT: The objectives of this study are to better understand women's experience with pelvic organ prolapse (POP) and to compare this experience between English-speaking and Spanish-speaking women.
    Journal of Pelvic Medicine and Surgery 09/2014; DOI:10.1097/SPV.0000000000000077
  • Alexandriah N Alas, Jennifer T Anger
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    ABSTRACT: Purpose of review The aim was to review most recent literature and provide updates in clinical management and surgical treatment of apical pelvic organ prolapse. Recent findings In patients who decline surgical intervention, formal referral to pelvic floor muscle training is beneficial over self-directed Kegel exercises. Systematic reviews revealed that sacrocolpopexy has better long-term outcomes than vaginal approaches. Uterosacral ligament suspension and sacrospinous ligament suspension have equal efficacy at 1 year. These procedures should be considered as acceptable alternatives to sacrocolpopexy. Two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Summary Minimally invasive sacrocolpopexy should be considered the gold standard for apical prolapse, but these techniques are associated with longer operating times and higher complication rates and longer convalescence than nonmesh vaginal surgery. Surgeons must individualize surgical technique for each patient and should consider a vaginal approach in patients who do not desire laparotomy and are not candidates for minimally invasive surgery.
    Current Opinion in Obstetrics and Gynecology 08/2014; 26(5). DOI:10.1097/GCO.0000000000000105 · 2.37 Impact Factor
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    ABSTRACT: Laparoscopic and robotic sacrocolpopexy are widely used for pelvic organ prolapse (POP) treatment. Evidence comparing outcomes and costs is lacking. We compared costs and clinically relevant outcomes in women randomized to laparoscopic sacrocolpopexy compared with robotic sacrocolpopexy. Participants with symptomatic stage POP II or greater, including significant apical support loss, were randomized to either laparoscopic or robotic sacrocolpopexy. We compared surgical costs (including costs for robot, initial hospitalization) and rehospitalization within 6 weeks. Secondary outcomes included postoperative pain, POP quantification, symptom severity and quality of life, and adverse events. We randomized 78 women (mean age 59 years): laparoscopic (n=38) and robotic (n=40). The robotic sacrocolpopexy group had higher initial hospital costs ($19,616 compared with $11,573, P<.001) and over 6 weeks, hospital costs remained higher for robotic sacrocolpopexy ($20,898 compared with $12,170, P<.001). When we excluded costs of robot purchase and maintenance, we did not detect a statistical difference in initial day of surgery costs of robotic compared with laparoscopic ($12,586 compared with $11,573; P=.160) or hospital costs over 6 weeks ($13,867 compared with $12,170; P=.060). The robotic group had longer operating room times (202.8 minutes compared with 178.4 minutes, P=.030) and higher pain scores 1 week after surgery (3.5±2.1 compared with 2.6±2.2; P=.044). There were no group differences in symptom bother by Pelvic Floor Distress Inventory, POP stage, or rate of adverse events. Costs of robotic sacrocolpopexy are higher than laparoscopic, whereas short-term outcomes and complications are similar. Primary cost differences resulted from robot maintenance and purchase costs.,, NCT01124916. : I.
    Obstetrics and Gynecology 07/2014; 123(1):5-12. DOI:10.1097/AOG.0000000000000006 · 4.37 Impact Factor
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    ABSTRACT: Objective To compare short-term outcomes between prolapse repairs with and without mesh using a national data set. Mesh use in surgical treatment of pelvic organ prolapse has gained wide popularity. However, mesh complications have increased concomitantly with its use. Methods Public Use File data were obtained for a 5% random national sample of female Medicare beneficiaries aged 65 years and older. Women who underwent prolapse surgery were identified using Current Procedural Terminology Coding System, Fourth Edition (CPT-4) codes. Because the code for mesh placement was effected in 2005, we separated patients into 3 cohorts as follows: those who underwent prolapse repairs from 1999 to 2000 (presumably without mesh), those who underwent repairs from 2007 to 2008 (presumably without mesh), and those with mesh (based on CPT-4 code 57267) from 2007 to 2008. One-year outcomes were identified using International Classification of Diseases, Ninth Revision diagnosis and procedure codes and CPT-4 procedure codes. Results A total of 9180 prolapse repairs without mesh were performed from 1999 to 2000, 7729 without mesh from 2007 to 2008, and 1804 prolapse repairs with mesh from 2007 to 2008. Prolapse reoperation within 1 year of surgery was higher in nonmesh vs mesh cohorts (6%-7% vs 4%, P <.02). Mesh removal rates were higher in mesh vs nonmesh group (4% vs 0%-1%, P <.001). Mesh use was associated with more dyspareunia, mesh-related complications, and urinary retention, even when controlling for concomitant sling. Conclusion Mesh to treat pelvic organ prolapse and stress urinary incontinence was associated with a small decrease in early reoperation for prolapse. This decrease came at the expense of increased rates of pelvic pain, retention, mesh-related complications, and mesh removal.
    Urology 04/2014; 83(4):768–773. DOI:10.1016/j.urology.2013.10.072 · 2.13 Impact Factor
  • The Journal of Urology 04/2014; 191(4):e780-e781. DOI:10.1016/j.juro.2014.02.2139 · 3.75 Impact Factor
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    ABSTRACT: Objectives Sacral neuromodulation is Food and Drug Administration approved for many types of voiding dysfunction. Goals of treatment often include cessation of anticholinergic therapy. With the goal of understanding the impact of sacral neuromodulation on anticholinergic use, we analyzed patterns of care using a national claims-based dataset. Materials and Methods The Ingenix (i3) data base contains insurance claims, including utilization and cost data, for 75 large employers. De-identified patients who underwent sacral neuromodulation between 2002 and 2007 were identified by the unique current procedural terminology-4 procedure code for pulse generator implantation, code 64590. The number and costs of anticholinergic prescriptions were compared before and after treatment. ResultsThere were 266 percutaneous and 794 two-staged procedures performed from 2002 to 2007 in the i3 dataset. A total of 484 pulse generator implantations were performed, representing 46% of the test procedures. During the year prior to pulse generator placement, each patient purchased an average of 2.1 prescriptions for an anticholinergic agent (SD 3.5). During the year after neuromodulation, each patient purchased an average of 1.0 prescription (SD 2.3, p < 0.0001 by t-test). Prescription charges were $241.31 per patient before and $103.52 after neuromodulation, a statistically significant cost difference (p < 0.0001 by t-test). During the year before the procedure, 50% of patients filled anticholinergic prescriptions. This decreased to 23% after the procedure (p < 0.0001 by chi-square test). Conclusions Sacral neuromodulation was associated with a significant decrease in the use of anticholinergic medication. Cost-effectiveness analyses that take into account patient quality-adjusted life years are needed to determine the true cost-benefit ratio of sacral neuromodulation.
    Neuromodulation 01/2014; 17(1). DOI:10.1111/ner.12062 · 1.79 Impact Factor
  • Journal of Minimally Invasive Gynecology 11/2013; 20(6):S88. DOI:10.1016/j.jmig.2013.08.289 · 1.58 Impact Factor
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    ABSTRACT: To develop a means to measure the quality of care provided to women treated for urinary incontinence (UI) through the development of quality-of-care indicators (QIs). We performed an extensive literature review to develop a set of potential quality indicators for the management of UI. QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. Nine experts ranked the indicators on a nine-point scale for both validity and feasibility. We analyzed preliminary rankings of each indicator using the RAND Appropriateness Method. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which the indicators were rated a second time individually using the same nine-point scale. QIs were developed that addressed screening, diagnosis, work-up, and both non-surgical and surgical management. Areas of controversy included whether routine screening for incontinence should be performed, whether urodynamics should be performed before non-surgical management is initiated, and whether cystoscopy should be part of the pre-operative work-up of uncomplicated stress incontinence. Following the expert panel discussion, 27 of 40 potential indicators were determined to be valid for UI with a median score of at least seven on a nine-point scale. We identified 27 quality indicators for the care of women with UI. Once these QIs are pilot-tested for feasibility, they will be applied on a larger scale to measure the quality of care provided to women with UI in the United States. Neurourol. Urodynam. © 2013 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 11/2013; 32(8). DOI:10.1002/nau.22353 · 2.46 Impact Factor
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    ABSTRACT: Recurrent pelvic organ prolapse (POP) has been attributed to many factors, one of which is lack of vaginal apical support. To assess the role of vaginal apical support and POP, we analyzed a national dataset to compare long-term reoperation rates after prolapse surgery performed with and without apical support. Public use file data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with POP who underwent surgery during 1999 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification, and Current Procedural Terminology, Fourth Edition codes. Individual patients were followed-up through 2009. Prolapse repair was categorized as anterior, posterior, or anterior-posterior with or without a concomitant apical suspension procedure. The primary outcome was the rate of retreatment for POP. In 1999, 21,245 women had a diagnosis of POP. Of these, 3,244 (15.3%) underwent prolapse surgery that year. There were 2,756 women who underwent an anterior colporrhaphy, posterior colporrhaphy, or both with or without apical suspension. After 10 years, cumulative reoperation rates were highest among women who had an isolated anterior repair (20.2%) and significantly exceeded reoperation rates among women who had a concomitant apical support procedure (11.6%; P<.01). Ten years after surgery for POP, the reoperation rate was significantly reduced when a concomitant apical suspension procedure was performed. This analysis of a national cohort suggests that the appropriate use of a vaginal apical support procedure at the time of surgical treatment of POP might reduce the long-term risk of prolapse recurrence. LEVEL OF EVIDENCE:: II.
    Obstetrics and Gynecology 10/2013; 187(4). DOI:10.1097/AOG.0b013e3182a8a5e4 · 4.37 Impact Factor
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    ABSTRACT: Numerous studies have documented a relationship between provider variables, including surgeon volume and specialty, and outcomes for surgical procedures. In this study we analyzed claims data from a Medicare database to analyze outcomes of sacral neuromodulation (SNM) with respect to both provider and patient factors. A 5% random sample of Medicare beneficiaries from 1997 to 2007 was the data source. Data retrieved included demographic information, ICD-9 diagnosis codes, and CPT procedure codes. Multivariate analysis was performed to identify predictors of progression to implantable pulse generator (IPG) implantation. After stage I testing, urologists were more likely than gynecologists to proceed to IPG placement (Center for Medicare and Medicaid Services: 49% vs. 43%, p < 0.0001). After percutaneous testing, gynecologists were more likely than urologists to proceed to battery placement (63% vs.44%, p = 0.005). Among the patient variables analyzed, women were more likely than men to progress to battery placement. Patients treated by high-volume providers had higher rates of IPG placement after formal stage I trials (71% vs. 33%, p < 0.0001). The rate of IPG implantation after SNM was greater among high-volume providers. Women had better outcomes than men. Further research may better define the relationship between outcomes of sacral neuromodulation and specific etiology of voiding dysfunction.
    Neuromodulation 09/2013; 17(4). DOI:10.1111/ner.12109 · 1.79 Impact Factor

Publication Stats

892 Citations
303.31 Total Impact Points


  • 2011–2015
    • Cedars-Sinai Medical Center
      • • Cedars Sinai Medical Center
      • • Department of Surgery
      Los Ángeles, California, United States
  • 2014
    • Loyola University Chicago
      • Department of Obstetrics and Gynecology
      Chicago, Illinois, United States
  • 2004–2014
    • University of California, Los Angeles
      • • Department of Urology
      • • Department of Medicine
      Los Ángeles, California, United States
  • 2013
    • University of New Mexico
      • Division of Urology
      Albuquerque, New Mexico, United States
    • United BioSource Corporation
      Maryland, United States
  • 2009
    • CSU Mentor
      Long Beach, California, United States
  • 2008
    • Detroit Medical Center
      • Division of Urology
      Detroit, Michigan, United States
  • 2006
    • Duke University Medical Center
      • Division of Urology
      Durham, North Carolina, United States
  • 2003–2004
    • Weill Cornell Medical College
      • Center for Male Reproductive Medicine and Microsurgery
      New York City, New York, United States