S Duke Herrell

Vanderbilt University, Nashville, Michigan, United States

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Publications (113)267.1 Total impact

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    ABSTRACT: To determine whether statin use at time of surgery is associated with survival following nephrectomy or partial nephrectomy for renal cell carcinoma (RCC). Statins are thought to exhibit a protective effect on cancer incidence and possibly cancer survival in a number of malignancies; to date, no studies have shown an independent association between statin use and mortality in RCC.
    Urologic Oncology: Seminars and Original Investigations. 10/2014;
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    ABSTRACT: Objectives To examine racial differences in the distribution of histologic subtypes of renal cell carcinoma (RCC) and associations with established RCC risk factors by subtype.Materials and methodsTumors from 1,532 consecutive RCC patients who underwent nephrectomy at Vanderbilt University Medical Center (1998-2012) were classified as clear cell, papillary, chromophobe, and other subtypes. In pairwise comparisons, we used multivariate logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for the associations between race, sex, age, ESRD and body mass index at diagnosis (BMI, kg/m2) according to histologic subtype.ResultsThe RCC subtype distribution was significantly different among blacks compared with whites (p<0.0001), with a substantially higher proportion of patients with papillary RCC among blacks than whites (35.7% vs. 13.8%). In multivariate analyses, compared to clear cell RCC, papillary cases were significantly more likely to be black (OR=4.15; 95% CI 2.64-6.52) and less likely to be female (OR=0.60; 95% CI 0.43-0.83). Chromophobe cases were significantly more likely to be female (OR=2.32; 95% CI 1.44-3.74). Both papillary (OR=6.26; 95% CI 2.75-14.24) and chromophobe (OR=7.07; 95% CI 2.13-23.46) cases were strongly and significantly more likely to have ESRD, compared to clear cell cases.Conclusion We observed marked racial differences in the proportional subtype distribution of RCCs diagnosed at a large tertiary care academic center. To our knowledge, no previous study has examined racial differences in the distribution of RCC histologies while adjusting for ESRD, which was the factor most strongly associated with papillary and chromophobe RCC compared to clear cell.
    BJU International 10/2014; · 3.05 Impact Factor
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    ABSTRACT: To compare biochemical recurrence (BCR)-free survival and predictors of BCR in intermediate-risk (IR) and high-risk (HR) patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) vs open radical prostatectomy (ORP). We conducted a retrospective study on 1336 men with D'Amico IR or HR prostate cancer who underwent RALP or ORP between 2003 and 2009. Exclusion criteria were use of neoadjuvant therapy, <6 months of follow-up, and insufficient clinicopathologic data. We compared demographic, clinical, and pathologic variables between groups. Kaplan-Meier analysis was performed to compare the 5-year BCR-free survival between groups. Multivariate models were developed to determine whether surgical approach influences BCR. A total of 979 IR and HR patients (237 ORP and 742 RALP patients) met inclusion criteria. Median follow-up was shorter for RALP (43 vs 63 months; P <.001). ORP patients had a higher median prostate-specific antigen level (7.9 vs 6.7 ng/mL; P <.002), significantly more Gleason sum 8-10 tumors, and more adverse pathologic features overall. There was no difference in positive surgical margins between groups. Pathologic features including extraprostatic extension, seminal vesicle involvement, lymph node involvement, pathologic Gleason sum, and positive surgical margin were significant independent predictors of BCR in multivariate analysis. Surgical approach (RALP vs ORP) did not predict BCR when controlling for other known predictors of BCR. Among IR and HR prostate cancer patients, the oncologic outcomes are similar between RALP and ORP. Not surprisingly, adverse pathologic features are harbingers of BCR.
    Urology 04/2014; · 2.42 Impact Factor
  • S Duke Herrell
    Urology 02/2014; 83(2):506-7. · 2.42 Impact Factor
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    ABSTRACT: Objective To compare biochemical recurrence (BCR)–free survival and predictors of BCR in intermediate-risk (IR) and high-risk (HR) patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) vs open radical prostatectomy (ORP). Materials and Methods We conducted a retrospective study on 1336 men with D'Amico IR or HR prostate cancer who underwent RALP or ORP between 2003 and 2009. Exclusion criteria were use of neoadjuvant therapy, <6 months of follow-up, and insufficient clinicopathologic data. We compared demographic, clinical, and pathologic variables between groups. Kaplan-Meier analysis was performed to compare the 5-year BCR-free survival between groups. Multivariate models were developed to determine whether surgical approach influences BCR. Results A total of 979 IR and HR patients (237 ORP and 742 RALP patients) met inclusion criteria. Median follow-up was shorter for RALP (43 vs 63 months; P <.001). ORP patients had a higher median prostate-specific antigen level (7.9 vs 6.7 ng/mL; P <.002), significantly more Gleason sum 8-10 tumors, and more adverse pathologic features overall. There was no difference in positive surgical margins between groups. Pathologic features including extraprostatic extension, seminal vesicle involvement, lymph node involvement, pathologic Gleason sum, and positive surgical margin were significant independent predictors of BCR in multivariate analysis. Surgical approach (RALP vs ORP) did not predict BCR when controlling for other known predictors of BCR. Conclusion Among IR and HR prostate cancer patients, the oncologic outcomes are similar between RALP and ORP. Not surprisingly, adverse pathologic features are harbingers of BCR.
    Urology 01/2014; · 2.42 Impact Factor
  • S Duke Herrell, Robert Webster, Nabil Simaan
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    ABSTRACT: To review recent developments at Vanderbilt University of new robotic technologies and platforms designed for minimally invasive urologic surgery and their design rationale and potential roles in advancing current urologic surgical practice. Emerging robotic platforms are being developed to improve performance of a wider variety of urologic interventions beyond the standard minimally invasive robotic urologic surgeries conducted currently with the da Vinci platform. These newer platforms are designed to incorporate significant advantages of robotics to improve the safety and outcomes of transurethral bladder surgery and surveillance, further decrease the invasiveness of interventions by advancing LESS surgery, and to allow for previously impossible needle access and ablation delivery. Three new robotic surgical technologies that have been developed at Vanderbilt University are reviewed, including a robotic transurethral system to enhance bladder surveillance and transurethral bladder tumor, a purpose-specific robotic system for LESS, and a needle-sized robot that can be used as either a steerable needle or small surgeon-controlled micro-laparoscopic manipulator.
    Current opinion in urology 11/2013; · 2.50 Impact Factor
  • S Duke Herrell
    Current opinion in urology 11/2013; · 2.50 Impact Factor
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    ABSTRACT: Increased urinary volume decreases recurrence rates of nephrolithiasis. Current recommendations for goal volumes are not adjusted to reflect individual risk factors, such as obesity. Our intent was to develop and evaluate a goal urine volume for stone prevention based on predictive calcium modeling. Stone formers with a 24-h urine study (6/2001-9/2010) were identified. Patients with inadequate collections or non-calcium stones were excluded. Multivariate and univariate predictive models for daily calcium were evaluated and a univariate (weight) model was selected. A target calcium concentration constant (2.5 mM) was determined from current recommendations. Individualized weight-based goal urine volumes (WGUV) were calculated. Measured calcium concentration and expected calcium concentrations using a 2-L goal volume and WGUV were compared. 185 of 399 patients met inclusion criteria. Body weight was a strong predictor of calcium excretion in each model (p < 0.0001). While a 2-L goal urine volume would be expected to improve mean calcium concentrations for the cohort from 3.53 to 2.96 mM, the benefit is unequal between subsets with nearly twofold expected concentration for the highest weight quartile (3.98 vs. 2.10 mM) and higher expected concentration for males (3.35 vs. 2.59 mM). By contrast, a WGUV model improves expected concentrations for all subsets to <2.9 mM and the overall cohort to 2.50 mM. This study demonstrates a strong relationship between body weight and urinary calcium excretion in stone formers. We introduce the novel concept of individualized goal urine output using statistical modeling, which may be preferable to current recommendations.
    Urolithiasis. 07/2013;
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    ABSTRACT: PURPOSE: The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy. MATERIALS AND METHODS: A systematic literature review identified published articles in the English literature between January 1999 and 2011 relevant to key questions specified by the Panel related to kidney neoplasms and their follow-up (imaging, renal function, markers, biopsy, prognosis). Study designs consisting of clinical trials (randomized or not), observational studies (cohort, case-control, case series) and systematic reviews were included. RESULTS: Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of post-operative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathologic tumor stage. CONCLUSIONS: Evaluation for patients on active surveillance and following definitive therapy for renal neoplasms should include physical exam, renal function, serum studies and imaging and should be tailored according to recurrence risk, comorbidities and monitoring for treatment sequelae. Expert opinion determined a judicious course of monitoring/surveillance that may change in intensity as surgical/ablative therapies evolve, renal biopsy accuracy improves and more long term follow-up data is collected. The beneficial impact of careful follow-up will also need critical evaluation as further study is completed.
    The Journal of urology 05/2013; · 3.75 Impact Factor
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    ABSTRACT: Image guided surgery (IGS) has led to significant advances in surgical procedures and outcomes. Endoscopic IGS is hindered, however, by the lack of suitable intraoperative scanning technology for registration with preoperative tomographic image data. This paper describes implementation of an endoscopic laser range scanner (eLRS) system for accurate, intraoperative mapping of the kidney surface, registration of the measured kidney surface with preoperative tomographic images, and interactive image-based surgical guidance for subsurface lesion targeting. The eLRS comprises a standard stereo endoscope coupled to a steerable laser, which scans a laser fan beam across the kidney surface, and a high-speed color camera, which records the laser-illuminated pixel locations on the kidney. Through calibrated triangulation, a dense set of 3-D surface coordinates are determined. At maximum resolution, the eLRS acquires over 300,000 surface points in less than 15 seconds. Lower resolution scans of 27,500 points are acquired in one second. Measurement accuracy of the eLRS, determined through scanning of reference planar and spherical phantoms, is estimated to be 0.38 +/- 0.27 mm at a range of 2 to 6 cm. Registration of the scanned kidney surface with preoperative image data is achieved using a modified iterative closest point algorithm. Surgical guidance is provided through graphical overlay of the boundaries of subsurface lesions, vasculature, ducts, and other renal structures labeled in the CT or MR images, onto the eLRS camera image. Depth to these subsurface targets is also displayed. Proof of clinical feasibility has been established in an explanted perfused porcine kidney experiment.
    Proc SPIE 03/2013;
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    ABSTRACT: PURPOSE: Salvage robotic-assisted laparoscopic prostatectomy (sRALP) is a treatment option for certain patients with recurrent prostate cancer (CaP) after primary therapy. Data regarding patient selection, complication rates, and cancer outcomes are scarce. Here, we report the largest, single-institution series to date of sRALP. METHODS: We reviewed our database of 4,234 patients who have undergone robotic-assisted laparoscopic prostatectomy at Vanderbilt University and identified 34 men who had surgery after failure of prior definitive ablative therapy. Each patient had biopsy-proven recurrent CaP and no evidence of metastases. The primary outcome measure was biochemical failure (BCF). RESULTS: The median time from primary therapy to sRALP was 48.5 months with a median PSA prior to sRALP of 3.86 ng/mL. Most patients had Gleason scores ≤ 7 on pre-sRALP biopsy, although 12 patients (35%) had ≥ Gleason 8 disease. After a median follow-up of 16 months, 18% had BCF. The positive margin rate was 26%, of which 33% had BCF following surgery. On univariable analysis, there was a significant association between PSA doubling time and BCF (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.60-0.99; p=0.049) as well as between Gleason score at original diagnosis and BCF (HR 3.49, 95% CI 1.18-10.3; p=0.023). There were two Clavien II-III complications: a pulmonary embolism and a rectal laceration. Post-operatively, 39% had excellent continence. CONCLUSIONS: sRALP is safe, with many outcomes favorable to open, salvage radical prostatectomy series. Advantages include superior visualization of the posterior prostatic plane, modest blood loss, low complication rates, and short length of stay.
    The Journal of urology 02/2013; 189(2):507-513. · 3.75 Impact Factor
  • A. Bajo, R.B. Pickens, S.D. Herrell, N. Simaan
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    ABSTRACT: Constrained motion control of robotic end-effectors is essential for safe operation in confined spaces such as the urinary bladder. This paper presents the clinical motivation for the development of new control algorithms for robotic-assisted transurethral bladder resection and surveillance using multisegment continuum robots. The anatomy, workspace, and access constraints for this procedure are identified and used as a guideline for the design of the telesurgical system and its control architecture. Constraints are mapped into the configuration space of the robot rather than in task space simplifying the modeling and the enforcement of virtual fixtures. The redundancy resolution is autonomously modified in order to exploit the remaining degrees of freedom using task priority. These methods are validated on a glass model of urinary bladder.
    Robotics and Automation (ICRA), 2013 IEEE International Conference on; 01/2013
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    ABSTRACT: Bladder cancer, a significant cause of morbidity and mortality worldwide, presents a unique opportunity for aggressive treatment due to the ease of transurethral accessibility. While the location affords advantages, transurethral resection of bladder tumors can pose a difficult challenge for surgeons encumbered by current instrumentation or difficult anatomic tumor locations. This paper presents the design and evaluation of a telerobotic system for transurethral surveillance and surgical intervention. The implementation seeks to improve current procedures and enable development of new surgical techniques by providing a platform for intravesicular dexterity and integration of novel imaging and interventional instrumentation. The system includes a dexterous continuum robot with access channels for the parallel deployment of multiple visualization and surgical instruments. The paper first presents the clinical conditions imposed by transurethral access and the limitations of the current stateof- the-art instrumentation. Motivated by the clinical requirements, the design considerations for this system are discussed and the prototype system is presented. Telemanipulation evaluation demonstrates submillimetric RMS positioning accuracy and intravesicular dexterity suitable for improving transurethral surveillance and intervention.
    IEEE transactions on bio-medical engineering 10/2012; · 2.15 Impact Factor
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    ABSTRACT: Study Type - Prognosis (cohort series) Level of Evidence 3a What's known on the subject? and What does the study add? Some evidence suggests that ABO blood type may be a risk factor for cancer incidence and prognosis. For example, a large study recently discovered an increased incidence of pancreatic cancer in patients with non-O blood type; however, it is not known whether blood group correlates with outcomes in patients with RCC. We found a significant and independent association between ABO blood group and overall survival in patients undergoing surgery for locoregional RCC. Specifically, we identified non-O blood type as a predictor of mortality. OBJECTIVE: •  To determine whether ABO blood group is associated with survival after nephrectomy or partial nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS: •  We conducted a retrospective cohort study of 900 patients who underwent surgery for locoregional RCC between 1997 and 2008 at a single institution. •  Covariates included age, gender, race, American Society of Anesthesiology Physical Status, preoperative anaemia and hypoalbuminemia, tumour characteristics, lymph node status, procedure performed, transfusion status and ABO blood group. •  Primary outcomes were overall (OS) and disease-specific survival (DSS). •  Univariable survival analyses were performed using the Kaplan-Meier and log-rank methods. Multivariable analysis was performed using a Cox proportional hazards model. RESULTS: •  The 3-year OS estimate was 75% (95%CI 70-79%) for O blood group and 68% (95% CI 63-73%) for non-O blood group (P= 0.072). The 3-year DSS was 81% (95% CI 76-85%) for O blood group and 76% (95%CI 71-80%) for non-O blood group (P= 0.053). •  In the multivariable analysis for OS, non-O blood type was significantly associated with decreased OS (HR 1.68, 95%CI 1.18-2.39; P= 0.004) but not DSS (HR 1.53, 95%CI 0.97-2.41; P= 0.065). CONCLUSION: •  These data suggest that ABO blood group is independently associated with OS in patients undergoing surgery for locoregional RCC. ABO blood group has not been previously recognized as a predictor of survival in RCC.
    BJU International 09/2012; · 3.05 Impact Factor
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    ABSTRACT: Soft-tissue image-guided interventions often require the digitization of organ surfaces for providing correspondence from medical images to the physical patient in the operating room. In this paper, the effect of several inexpensive surface acquisition techniques on target registration error (TRE) and surface registration error (SRE) for soft tissue is investigated. A systematic approach is provided to compare image-to-physical registrations using three different methods of organ spatial digitization: (1) a tracked laser range scanner (LRS), (2) a tracked pointer, and (3) a tracked conoscopic holography sensor (called a conoprobe). For each digitization method, surfaces of phantoms and biological tissues were acquired and registered to CT image volume counterparts. A comparison among these alignments demonstrated that registration errors were statistically smaller with the conoprobe than the tracked pointer and LRS (p < 0.01). In all acquisitions, the conoprobe outperformed the LRS and tracked pointer: for example, the arithmetic means of the SRE over all data acquisitions with a porcine liver were 1.73 ± 0.77 mm, 3.25 ± 0.78 mm, and 4.44 ± 1.19 mm for the conoprobe, LRS, and tracked pointer, respectively. In a cadaveric kidney specimen, the arithmetic means of the SRE over all trials of the conoprobe and tracked pointer were 1.50 ± 0.50 mm and 3.51 ± 0.82 mm, respectively. Our results suggest that displacement due to contact force and attempts to maintain contact with tissue, compromise registrations that are dependent on data acquired from a tracked surgical instrument and we provide an alternative method (tracked conoscopic holography) of digitizing surfaces for clinical usage. The tracked conoscopic holography device outperforms LRS acquisitions with respect to registration accuracy.
    IEEE transactions on bio-medical engineering 08/2012; · 2.15 Impact Factor
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    ABSTRACT: BACKGROUND: Registered medical images can assist with surgical navigation and enable image-guided therapy delivery. In soft tissues, surface-based registration is often used and can be facilitated by laser surface scanning. Tracked conoscopic holography (which provides distance measurements) has been recently proposed as a minimally invasive way to obtain surface scans. Moving this technique from concept to clinical use requires a rigorous accuracy evaluation, which is the purpose of our paper. METHODS: We adapt recent non-homogeneous and anisotropic point-based registration results to provide a theoretical framework for predicting the accuracy of tracked distance measurement systems. Experiments are conducted a complex objects of defined geometry, an anthropomorphic kidney phantom and a human cadaver kidney. RESULTS: Experiments agree with model predictions, producing point RMS errors consistently < 1 mm, surface-based registration with mean closest point error < 1 mm in the phantom and a RMS target registration error of 0.8 mm in the human cadaver kidney. CONCLUSIONS: Tracked conoscopic holography is clinically viable; it enables minimally invasive surface scan accuracy comparable to current clinical methods that require open surgery. Copyright © 2012 John Wiley & Sons, Ltd.
    International Journal of Medical Robotics and Computer Assisted Surgery 07/2012; · 1.49 Impact Factor
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    ABSTRACT: Image-Guided Surgery has become the standard of care in intracranial neurosurgery providing more exact resections while minimizing damage to healthy tissue. Moving that process to abdominal organs presents additional challenges in the form of image segmentation, image to physical space registration, organ motion and deformation. In this paper, we present methodologies and results for addressing these challenges in two specific organs: the liver and the kidney.
    Journal of healthcare engineering. 06/2012; 3(2):203-228.
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    ABSTRACT: Treatment of organ confined renal masses with partial nephrectomy has durable oncologic outcomes comparable to radical nephrectomy. Partial nephrectomy is associated with lower risk of chronic kidney disease and in some series with better overall survival. We report a contemporary analysis on national trends of partial nephrectomy use to determine partial nephrectomy use over time, and whether nontumor related factors such as structural attributes of the treating institution or patient characteristics are associated with the underuse of partial nephrectomy. We performed an analysis of the NIS (National Inpatient Sample), which contains 20% of all United States inpatient hospitalizations. We included patients who underwent radical or partial nephrectomy for a renal mass between 2002 and 2008. Survey weights were applied to obtain national estimates of nephrectomy use and to evaluate nonclinical predictors of partial nephrectomy. A total of 46,396 patients were included in the study for a weighted sample of 226,493. There was an increase in partial nephrectomy use from 15.3% in 2002 to 24.7% in 2008 (p <0.001). On multivariate analysis hospital attributes (urban teaching status, nephrectomy volume, geographic region) and patient socioeconomic status (higher income ZIP code and private/HMO payer) were independent predictors of partial nephrectomy use. Since 2002 the national use of partial nephrectomy for the management of renal masses has increased. However, the adoption of partial nephrectomy at smaller, rural and nonacademic hospitals lags behind that of larger hospitals, urban/teaching hospitals and higher volume centers. A lower rate of partial nephrectomy use among patients without private insurance and those living in lower income ZIP code areas highlights the underuse of partial nephrectomy as a quality of care concern.
    The Journal of urology 03/2012; 187(3):816-21. · 3.75 Impact Factor
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    ABSTRACT: Cumulative radiation exposure from imaging studies is hazardous. In chronic diseases such as urolithiasis, efforts are made to limit radiation exposure, particularly for routine surveillance. We sought to determine the correlation of ultrasonography (US) compared with noncontrast CT (NCCT) in detecting and determining size of stones. Findings were evaluated in patients who underwent both imaging modalities within a 90-day period between July 2008 and June 2010. Urinary calculi were noted on NCCT in 72 patients. The sensitivity of US to determine the number, size, and location of the stones as described on official radiology reports were compared in reference to NCCT. There were 203 urinary calculi in 90 urinary tracts identified on NCCT imaging. The sensitivity, specificity, and accuracy of detecting specific stones on US were 40%, 84%, and 53%. Correlation between US and NCCT findings decreased with smaller stone size and ureteral location and increased with right-sided laterality. For identified stones, larger stone size discrepancies were noted in up to one-third of stones on US. Despite concern for excessive radiation exposure, urologists should recognize limitations of US in the evaluation of urolithiasis. As the ideal study to image stones, particularly for routine surveillance, remains unclear, tese data also supports the need for low-dose NCCT protocols and/or selective use of alternative modalities, such as magnetic resonance urography.
    Journal of endourology / Endourological Society 03/2012; 26(3):209-13. · 1.75 Impact Factor
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    ABSTRACT: Post-prostatectomy urinary incontinence can impact health related quality of life in men treated with radical prostatectomy for prostate cancer. Currently no consensus exists on which patients are at risk for impaired health related quality of life secondary to post-prostatectomy urinary incontinence. Using trajectory clustering analysis we identified predictors of post-prostatectomy urinary incontinence recovery in unique patient groups. In a 5-year period health related quality of life was evaluated in patients treated with radical prostatectomy using UCLA-PCI preoperatively, and 3, 6 and 12 months postoperatively. We used a novel cluster modeling technique to identify unique group trajectories of urinary function recovery with time. Group based modeling of UCLA-PCI urinary function scores identified 3 distinct post-prostatectomy urinary incontinence recovery patterns. The 73 group 1 patients had a significant postoperative decrease with only 33.4% of optimum function at 12 months. The 258 group 2 patients had moderately decreased urinary function at 3 months with improvement to 76.8% of optimum function at 12 months. The 89 group 3 patients had high scores throughout. Group 1 patients tended to be older (p=0.001), have major depression (p=0.008) and lower extremity circulatory disease (p=0.004), be a past or a current smoker (p=0.004) and have more comorbidities (p<0.001) than those in groups 2 and 3. On multivariate analysis age and the number of comorbidities significantly predicted inclusion in the poor function group. A novel modeling approach identified 3 distinct post-prostatectomy urinary incontinence recovery patterns. Patient age and the number of comorbidities predicted worse outcome. These findings have implications for preoperative patient counseling and early intervention for post-prostatectomy urinary incontinence.
    The Journal of urology 02/2012; 187(4):1346-51. · 3.75 Impact Factor

Publication Stats

1k Citations
267.10 Total Impact Points

Institutions

  • 2003–2014
    • Vanderbilt University
      • • Division of Urologic Surgery
      • • Department of Neurology
      Nashville, Michigan, United States
  • 2011
    • Hackensack University Medical Center
      Hackensack, New Jersey, United States
  • 2010
    • University of Iowa
      • Department of Urology
      Iowa City, IA, United States
    • Uniformed Services University of the Health Sciences
      • Department of Surgery
      Bethesda, MD, United States
  • 2007
    • Ramathibodi Hospital
      Krung Thep, Bangkok, Thailand
  • 2005
    • Loma Linda University
      Loma Linda, California, United States
  • 2002
    • Kansas City VA Medical Center
      Kansas City, Missouri, United States