Michael A Gorin

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States

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Publications (76)227.28 Total impact

  • The Canadian Journal of Urology 01/2015; · 0.74 Impact Factor
  • Clinical Genitourinary Cancer 12/2014; · 1.43 Impact Factor
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    ABSTRACT: Purpose To determine preoperative predictors associated with renal cell carcinoma (RCC) and unfavorable pathology in small renal masses treated with partial nephrectomy (PN). Materials and methods PN records from 5 centers were retrospectively queried for patients with a clinically localized single tumor <4 cm on imaging (clinical T1a). Between 2007 and 2013, 1,009 patients met the inclusion criteria. Unfavorable pathology was defined as any grade III or IV RCC or tumors upstaged to pathologic T3a disease. Logistic regression models were used to determine preoperative characteristics associated with RCC and with unfavorable pathology. Results A total of 771 (76.4%) patients were found to have RCC and 198 (19.6%) had unfavorable pathology. On multivariate, bootstrap-adjusted logistic regression analysis, factors associated with the presence of malignancy were imaging tumor size≥3 cm (odds ratio [OR] = 1.46; P = 0.040), male sex (OR = 1.88; P<0.0001), and nephrometry score≥8 (OR = 1.64; P = 0.005). These same factors were independently associated with risk of unfavorable pathology: size≥3 cm (OR = 1.46; P = 0.021), male sex (OR = 2.35; P<0.0001), and nephrometry score≥8 (OR = 1.49; P = 0.015). The c statistic was 0.62 for the predicting malignancy and 0.63 for unfavorable pathology. Conclusions In this multi-institutional cohort, male sex, imaging tumor size≥3 cm, and nephrometry score≥8 were predictors of RCC and adverse pathology following PN. These factors may assist in risk stratification and selective renal mass biopsy before decision making. Further studies are necessary to validate these findings.
    Urologic Oncology 11/2014; · 3.65 Impact Factor
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    ABSTRACT: Objective To investigate the clinical utility of frozen section (FS) analysis performed during partial nephrectomy (PN) and its influence on intraoperative management.Patients and Methods We performed a retrospective analysis of consecutive PN cases from 2010-2013. We evaluated the concordance between the intraoperative FS diagnosis and the FS control diagnosis, a postoperative quality assurance measure performed on all FS diagnoses after formalin fixation of the tissue. We also evaluated the concordance between the intraoperative FS diagnosis and the final specimen margin. Operative reports were reviewed for change in intraoperative management for cases with a positive or “atypia” FS diagnosis, or if the mass was sent for FS.Results576 intraoperative FS were performed in 351 cases to assess the PN tumor bed margin, 19 (5.4%) of which also had a mass sent for FS to assess the tumor type. The concordance rate between the FS diagnosis and the FS control diagnosis was 98.3%. There were 30 (8.5%) final positive specimen margins, of which 4 (13.3%) were called “atypia”, 17 (56.7%) negative, and 9 (30%) positive on FS diagnosis. Intraoperative management was influenced in 6 of 9 cases with a positive FS diagnosis and in 1 of 9 cases with a FS diagnosis of “atypia.”Conclusions The relatively high false negative rate, controversy over the prognosis of a positive margin, and inconsistency in influencing intraoperative management, argues against the routine use of FS in PN cases.
    BJU International 11/2014; · 3.05 Impact Factor
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    ABSTRACT: Introduction: We sought to evaluate the financial impact of robotic technology for partial nephrectomy (PN) and radical nephrectomy (RN) in the state of Maryland. Methods: The Maryland Health Services Cost Review Commission (HSCRC) documents all acute care hospital charges data. This database was queried for patients who underwent laparoscopic or robotic RN and PN from 2008-2012. Total hospital charge, sub-charge and length of stay (LOS) were analyzed separately for RN and PN. Results: Overall, 2,834 patients were identified. Of those, 282 were laparoscopic PN (LPN), 1,078 robotic PN (RPN), 1,098 laparoscopic RN (LRN) and 376 robotic RN (RRN). For PN, the total hospital charge was $19,062 for LPN and $18,255 for RPN (p = 0.138), with a charge savings of $807 per case in favor of robotics. For RN, total hospital charge was $23,391 for RRN and $18,280 for LPN (p = 0.004), with a charge premium of $5,111 for robotic casesLOS was shorter for RPN compared to LPN (2.51 vs 2.99 days, p < 0.0001) and for RRN compared to LRN (3.52 vs 3.98, p= 0.0498). Conclusions: RPN is associated with less hospital charges than LPN, while RRN is associated with higher hospital charges than LRN. Savings for RPN are driven by decreased room and board charge, while the premium for RRN is driven by higher operating room and supply charges. As RRN utilization is increasing, the financial implications of RRN use for routine cases warrants further study.
    Journal of Endourology 08/2014; · 2.07 Impact Factor
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    ABSTRACT: Objective To assess the utility of an extensive restaging examination performed after the completion of neoadjuvant chemotherapy (NAC) but before radical cystectomy (RC) in the management of patients with advanced bladder cancer. Methods We studied 62 patients who underwent NAC with the intent of proceeding to consolidative RC. A restaging examination, including endoscopic and bimanual examination, as well as cross-sectional imaging of the abdomen and pelvis, was performed after chemotherapy. The impact of restaging on clinical management was determined. In patients proceeding to RC, the degree of correlation between clinical stage (at diagnosis vs on restaging) and pathologic stage was determined. Results Restaging altered the treatment course in 6 patients (9.7%) in whom RC was not performed because of restaging findings. An additional 56 patients (90.3%) proceeded to RC. In these patients, compared with clinical stage at diagnosis, the postchemotherapy clinical stage correlated more strongly with pathologic stage (κ = 0.02 vs 0.17). On multivariate analysis, diagnostic clinical stage was not associated with pathologic stage (P = .85), whereas postchemotherapy clinical stage was strongly predictive of pathologic stage (P <.01). Conclusion An extensive restaging examination altered treatment strategy in a small, but clinically significant subset of patients treated with NAC for bladder cancer. Furthermore, restaging allowed for more accurate prediction of pathologic stage after RC, thereby improving assessment of patient prognosis. Consideration should be given to incorporating a restaging evaluation into the standard management paradigm for bladder cancer.
    Urology 08/2014; 84(2):358–364. · 2.42 Impact Factor
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    ABSTRACT: Introduction Intrarenal tumors pose a unique challenge to surgeons due to the lack of visual cues on the kidney surface. Intraoperative ultrasonography has facilitated the management of these tumors during minimally invasive partial nephrectomy. We sought to evaluate the safety, feasibility, and comparative effectiveness of robotic-assisted partial nephrectomy (RPN) in the management of completely intrarenal tumors. Methods Our institutional database was queried for patients undergoing RPN between 2007 and 2013. Patient demographics, tumor characteristics and perioperative outcomes were compared for patients with intrarenal tumors and tumors with any exophytic component. Patients without available preoperative imaging were excluded from the study. Results A total of 297 patients were identified with 30 having completely intrarenal tumors and 267 having some exophytic component. Patient demographics were similar between the two groups. Median tumor size was smaller for the intrarenal group than the exophytic group (2.3 vs. 2.7cm, p=0.015) and nephrometry score was higher for the intrarenal group (9 vs. 6, p<0.0001). Tumor characteristics were otherwise similar. Perioperative outcomes were similar between the intrarenal and exophytic groups: estimated blood loss (100 vs. 100 mL, p=0.56), operative time (165 vs. 162 min, p=0.86), warm ischemia time (17 vs. 17 min, p=0.54), RCC positive surgical margin (0% vs. 2.4%, p=0.74), intraoperative complications (0% vs. 0.76%, p=0.81) and postoperative complications (6.7% vs. 17.6% p=0.76). Conclusions RPN is feasible, safe, and effective in the treatment of select intrarenal kidney tumors with outcomes similar to those of partially exophytic tumors. This is likely facilitated by intraoperative ultrasonography. Completely intrarenal kidney tumors should not be automatically relegated to radical nephrectomy or open surgery.
    Journal of Endourology 07/2014; · 2.07 Impact Factor
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    ABSTRACT: Objective The present study is designed to assess the long-term renal function of children who underwent radical nephrectomy for unifocal Wilms tumor. Methods A single institution retrospective cohort study of non-syndromic children treated with radical nephrectomy for unifocal Wilms tumor between 1995 and 2011 was performed to identify risk factors for decreased glomerular filtration rate (GFR). The primary endpoint was decrease in age-adjusted GFR below normal published ranges. The secondary endpoint was progression to chronic renal insufficiency (CRI). Results A total of 55 patients were identified in the cohort. Eight (15%) patients exhibited decreased age-adjusted GFR during the follow-up period, with 2 (4%) progressing to CRI. Increasing time between surgery and the last known GFR follow-up was associated with decreased GFR, with the normal GFR group having median follow-up of 7.32 years versus 11.47 years (p = 0.019) in the decreased GFR group. Conclusions A trend toward decline in GFR was detected with longer follow-up. Longer follow-up may reveal that clinically significant decline in renal function occurs years following nephrectomy among a subset of Wilms tumor survivors, even among those who do not progress to end stage renal disease.
    Journal of Pediatric Urology 07/2014; · 1.37 Impact Factor
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    ABSTRACT: Understanding the degree of phenotypic heterogeneity within a small renal mass (SRM) may have implications for interpreting renal mass biopsy (RMB) data. In this study we sought to quantify the nuclear grade heterogeneity within SRMs.
    The Journal of urology 06/2014; · 3.75 Impact Factor
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    ABSTRACT: The objectives of the present study were analyze specific comorbidities associated with survival and actual causes of death for patients with small renal masses, and to suggest a simplified measure associated with decreased overall survival specific to this population.
    International Journal of Urology 06/2014; · 1.73 Impact Factor
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    ABSTRACT: Purpose No consensus exists regarding the most effective procedure for neovagina formation. We describe our experience with modified single Monti tube colovaginoplasty in pediatric patients with disorders of sexual differentiation. Materials and Methods Six patients were retrospectively identified who underwent primary sigmoid vaginoplasty with a modified single Monti tube between 2009 and 2012. Data were collected from patient charts. The procedure is performed by isolating an 8 to 10 cm segment of distal sigmoid colon or proximal rectum, which is detubularized along the anterior mesentery, folded and retubularized longitudinally, leaving the mesentery in a cephalad position. A channel is dissected in the pelvis to accommodate the neovagina. Results Mean patient age was 12.7 years (range 6 to 17). The primary diagnosis was androgen insensitivity in 3 cases (50%), and Mayer-Rokitansky syndrome, partial androgen insensitivity and persistent cloaca in 1 each (16.7%). Chromosomal analysis revealed 46XY in 4 patients (66.7%). Median followup was 7.9 months (range 3 to 41). One patient who engages in vaginal intercourse reported satisfactory vaginal length without discomfort. In 1 patient an anastomotic stricture developed, which was managed by buccal mucosal grafting. Conclusions Modified single Monti tube sigmoid vaginoplasty is a safe, effective technique for neovagina formation in pediatric patients with disorders of sexual differentiation. Compared to other existing methods, our technique allows for the use of shorter bowel segments with decreased tension of the vascular pedicle.
    The Journal of urology 05/2014; · 3.75 Impact Factor
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    ABSTRACT: The objective of this study was to evaluate the impact of hospital case volume on perioperative outcomes and costs of radical cystectomy (RC) after controlling for differences in patient case mix. The Maryland Health Services Cost Review Commission database was queried for patients who underwent an open RC between 2000 and 2011. Patients were divided into tertiles based on hospital case volume. Groups were compared for differences in length of intensive care unit (ICU) stay, length of total hospital stay, rate of in-hospital deaths and procedure-related costs. In total, 1620 patients underwent a RC during the study period. Of these patients, 457 (28.2%) underwent surgery at 37 low volume centers, 465 (28.7%) at six mid volume centers and 698 (43.1%) at a single high volume center. The mean case volume of each group was 1.1, 7.0 and 63.5 RC/center/year, respectively. After controlling for marked differences in patient case mix, having surgery at the single high-volume center was independently associated with a decrease in length of ICU stay (coefficient = -0.41 days, 95% CI -0.78--0.05, p = 0.03), in-hospital mortality (OR 0.18, 95% CI 0.04-0.80, p = 0.02) and total medical costs (coefficient = -2.91k USD, 95% CI -4.15--1.67, p < 0.001). Decreased total costs were driven by reductions in charges associated with the operating room, drugs, radiology tests, labs, supplies and physical/occupational therapy (all p < 0.001). Undergoing RC at a high volume medical center was associated with improved outcomes and reduced costs. These data support the centralization of RC to high volume centers.
    The Canadian Journal of Urology 02/2014; 21(1):7102-7. · 0.74 Impact Factor
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    ABSTRACT: Robotic-assisted partial nephrectomy (RAPN) for posterior renal masses necessitates access to the posterior surface of the kidney either via a transperitoneal (TP) or retroperitoneal (RP) approach. While advocates of an RP approach claim reduced morbidity for posterior tumors, it is a less familiar approach to many urologists. In our institution, a TP approach is used for all patients undergoing robotic partial nephrectomy. We compared demographics and perioperative outcomes of TP RAPN for posterior and anterior/lateral renal masses. Our institutional renal mass database was queried for patients with available pre-operative imaging who underwent TP RAPN from 2007-2013. Posterior masses were accessed by opening Gerota's fascia and rotating the kidney anteromedially. Demographic and perioperative outcomes were compared for patients with posterior masses and anterior/lateral masses. Overall, 260 TP RAPN were identified. Of these, 92 were for posterior tumors and 168 were for anterior and lateral tumors. Renal cell carcinoma (RCC) was found in 77.3% of cases. Patient demographic and tumor characteristics were similar between groups. Among operative characteristics, warm ischemia time (17 minutes v. 16.5, p=0.70), operative time (160 v. 159 minutes, p=0.82), estimated blood loss (100 v. 100 ml, p=0.44), RCC positive surgical margins (1.4 v 1.5%), and post-operative complications (19.6 v. 16.1%, p=1.0) were similar for posterior and anterior/lateral tumors, respectively. TP RAPN is a safe, effective treatment option for posterior renal masses with no additional morbidity compared to anterior/lateral renal masses. Retroperitoneal partial nephrectomy remains an alternative treatment option.
    Journal of Endourology 01/2014; · 2.07 Impact Factor
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    ABSTRACT: Objectives To characterize pathological and cancer-specific outcomes of surgically resected cystic renal tumors and to identify clinical or radiographic features associated with these outcomes. Methods and materials All patients at our institution who underwent radical or partial nephrectomy for complex renal cystic masses between 2004 and 2011 with available computed tomographic imaging were included. The Bosniak score was determined, as were 10 specific radiographic characteristics of renal cysts in patients with preoperative imaging available for review. These characteristics were correlated with cystic mass histopathology. Recurrence-free survival after surgery was determined. Results Overall, 133 patients underwent renal surgery for complex cystic lesions, 89 (67%) of whom had malignant lesions. Malignancy risk increased with Bosniak score (P≤0.01) and presence of mural nodules (P = 0.01). Most (63%) malignancies demonstrated clear cell histology. The papillary renal cell carcinomas (25%) exhibited lower enhancement levels (P = 0.04) and were less often septated (P<0.01). Of the malignancies, 79% were low stage (pT1), and 73% were Fuhrman grade 1 or 2. Large cyst size was associated with advanced tumor stage (P = 0.05). Neither Bosniak score nor any other radiographic parameter was associated with Fuhrman grade. In 70 patients with a median follow-up of 43 months, only 1 (1.4%) developed disease recurrence. Conclusions Most cystic renal malignancies are low-stage, low-grade lesions. Papillary renal cell carcinomas account for nearly a quarter of cystic renal malignancies and have unique radiographic characteristics. Disease recurrence after surgical resection is rare. These findings suggest an indolent behavior for cystic renal tumors, and these lesions may be amenable to active surveillance.
    Urologic Oncology: Seminars and Original Investigations. 01/2014;
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    ABSTRACT: Objective To more precisely define the risk of non–organ-confined (non-OC) prostate cancer among men with perineural invasion (PNI) identified on prostate biopsy. Materials and Methods The Johns Hopkins radical prostatectomy database was queried for men with PNI reported on prostate biopsy. Patients with and without non-OC disease were compared for differences in preoperative clinical and pathologic characteristics, including three biopsy-based measures of tumor volume (number of cores with cancer, percentage of cores with cancer, and maximum percent core involvement with cancer). After evaluating the different preoperative variables in univariate analyses, a multivariable logistic regression model was generated, and bootstrap estimates of the risk of non-OC disease were calculated. Results In total, 556 patients with PNI were analyzed, 279 (50.2%) of whom were found to have non-OC prostate cancer. In univariate analyses, preoperative prostate-specific antigen, clinical T stage, biopsy Gleason sum, and the three biopsy-based measures of tumor volume were significantly associated with non-OC disease. Of the three measures of tumor volume, the best fit to the data and highest degree of model discrimination were obtained using maximum percent core involvement with cancer. Incorporating this variable, preoperative prostate-specific antigen, clinical T stage, and biopsy Gleason sum into a multivariable model, the estimated risk of non-OC disease was found to range from 13.8% to 94.4% (bootstrap corrected c-index = 0.735). Conclusion Men with PNI on prostate biopsy are at a wide range of risk for non-OC disease. Preoperative estimation of this risk is improved by considering readily available biopsy estimates of tumor volume.
    Urology 01/2014; · 2.42 Impact Factor
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    ABSTRACT: Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function. To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD. A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15-60ml/min per 1.73 m(2)) were identified. Perioperative results of 121 patients were compared against propensity score-matched controls without CKD (eGFR ≥60ml/min per 1.73 m(2)). RPN in patients with or without baseline CKD. Descriptive statistics and propensity score-matched operative and functional outcomes. After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (-5.1 vs -10.9), which remained significant at a mean follow-up of 12.6 mo (-2.8 vs -9.1, p<0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p=0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p=0.007). The retrospective analysis was the main limitation of this study. RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay.
    European Urology 12/2013; · 10.48 Impact Factor
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    ABSTRACT: To compare overall and cancer-specific survival (CSS) of patients who undergo nonsurgical management (NSM), partial nephrectomy (PN), and radical nephrectomy (RN). NSM is being increasingly used for older patients with early-stage kidney cancer and competing risks of death. However, survival is poorly characterized for this approach compared with surgery with PN or RN. The Surveillance, Epidemiology and End Results-Medicare database from 1995 to 2007 was used to identify patients aged 65 years or older diagnosed with localized T1a kidney cancer treated with PN, RN, or NSM. We used Cox proportional hazards regression, Fine and Gray competing risks regression, and propensity score matching to adjust for patient and tumor characteristics. Of 7177 Medicare beneficiaries meeting the inclusion criteria, 754 (10.5%) underwent NSM, 1849 (25.8%) PN, and 4574 (63.7%) RN, with 436 (57.8%), 389 (21.0%), and 1598 (34.9%) patients dying from any cause, respectively, at a median follow-up of 56 months. Overall survival favored PN and RN compared with NSM (hazard ratio [95% CI]: 0.40 [0.34-0.46] and 0.50 [0.45-0.56], respectively) as did CSS (hazard ratio [95% CI]: 0.42 [0.27-0.64] and 0.62 [0.46-0.85], respectively). However, there was no difference in CSS between any 2 treatment groups for younger patients (<75 years), whereas there was an excess of kidney cancer deaths for NSM patients aged 75-79 years and an attenuated difference for patients aged 80 years or older. NSM was associated with an increased risk of kidney cancer death among Medicare beneficiaries aged 75-79 years. Evolving active surveillance protocols will need to develop robust selection criteria to maximize cancer survival for older patients with kidney cancer.
    Urology 11/2013; · 2.42 Impact Factor
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    ABSTRACT: Partial cystectomy (PC) is a therapeutic option for select patients with bladder cancer, but its associated perioperative risks and costs are unknown. We estimated annual rates of PC in a nationally representative sample of hospitals, and analyzed whether hospital volume affects postoperative outcomes and costs in patients undergoing PC. From the Nationwide Inpatient Sample, we selected a weighted cohort of patients with bladder cancer who underwent PC between 2002 and 2008. Differences in length of stay, charges, and clinical outcomes were calculated based on operative volume, and univariate and multivariate regression models were fitted to predict in-hospital mortality (IHM) and hospital-acquired conditions. A total of 10,780 patients with bladder cancer who underwent PC were identified with an annual rate between 1457 and 1628 cases. IHM rates were 1.8%, constituting 195 patients (between 9 and 46 annually). A total of 417 patients (3.9%) experienced a "never event" complication, which Medicare no longer reimburses. The mean annual hospital volume of patients who died was 1.7 cases/y compared with 2.4 cases/y among those without fatal complications. No cases of IHM were identified among hospitals performing at least 5 partial cystectomies/y. In a multivariate regression model increased hospital volume was independently associated with decreased mortality (odds ratio = 0.70, 95% confidence interval; 0.60-0.80). Approximately 1 in 25 patients undergoing PC experience a hospital-acquired complication, and nearly 1 in 50 die as a result of the operation. For each additional case a hospital performs annually, the risk of IHM decreases by 30%.
    Urologic Oncology 11/2013; · 3.65 Impact Factor
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    ABSTRACT: We report the 30-year institutional experience of radical prostatectomy (RP) for men with clinically localized prostate cancer (PC) found to have lymph node (LN) metastases at surgery. The Johns Hopkins RP Database (1982-2011) was queried for 505 (2.5%) men with node-positive (N1) PC. Survival analysis was completed using the Kaplan-Meier method and proportional hazard regression models. The proportion of men with N1PC was 8.3%, 3.5%, and 1.4% in the pre- (1982-1990), early- (1991-2000), and contemporary-PSA eras (2001-2011), respectively. A trend toward decreasing PSA, less palpable disease but more advanced Gleason sum was noted in the most contemporary era. Median total and positive nodes were 13.2 (1-41) and 1.7 (1-12), respectively. Of 135 patients with a unilateral tumor, 80 (59.3%), 28 (20.7%), and 15 (11.1%) had ipsilateral, contralateral, and bilateral positive LN. 15-year biochemical-recurrence free, metastases-free and cancer-specific survival was 7.1%, 41.5%, and 57.5%, respectively. Predictors of biochemical-recurrence, metastases and death from PC in multivariate analysis included Gleason sum at RP, the number and percent of positive LN; notably total number of LN dissected did not predict outcome. In this highly-selected RP cohort, men found to have N1PC disease at RP can experience a durable long-term metastases-free and cancer-specific survival. Predictors of survival include Gleason sum, number, and percentage of positive LN. While total number of LN dissected was not predictive, approximately 30% of men with N1PC will have positive LN contralateral to the primary prostatic lesion highlighting the importance of a thorough, bilateral pelvic LN dissection. Prostate © 2013 Wiley Periodicals, Inc.
    The Prostate 09/2013; · 3.84 Impact Factor
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    Urology 09/2013; 82(3):659. · 2.42 Impact Factor

Publication Stats

119 Citations
227.28 Total Impact Points

Institutions

  • 2013
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Biostatistics
      Baltimore, Maryland, United States
    • European University of Madrid
      Madrid, Madrid, Spain
    • Hospital Universitario de Getafe
      Madrid, Madrid, Spain
  • 2012–2013
    • Johns Hopkins Medicine
      • Department of Urology
      Baltimore, MD, United States
    • University of Miami
      • Department of Urology
      Coral Gables, FL, United States
  • 2010–2013
    • University of Miami Miller School of Medicine
      • Department of Urology
      Miami, FL, United States