Michael A Gorin

Johns Hopkins Medicine, Baltimore, Maryland, United States

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Publications (94)313.47 Total impact

  • Lorenzo Marconi, Michael A Gorin, Mohamad E Allaf
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    ABSTRACT: To ensure the early detection of recurrent disease, all patients should undergo routine surveillance following partial nephrectomy for renal cell carcinoma. In order to optimize resource allocation and avoid unnecessary radiation exposure, the frequency and duration of surveillance should be tailored to the individual patient's risk of cancer recurrence. The evidence for surveillance after partial nephrectomy is presented reviewing the current literature on prognostic models and proposed surveillance protocols based on the timing and patterns of renal cell carcinoma recurrence. In addition, we review recent guidelines on post partial nephrectomy surveillance as well as the literature on novel imaging techniques that may aid in early disease discovery.
    Current Urology Reports 04/2015; 16(4):489. DOI:10.1007/s11934-015-0489-7
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    ABSTRACT: Objective To compare the safety and perioperative outcomes of robotic versus laparoscopic retroperitoneal lymph node dissection (RPLND). Patients and Methods Our institutional review board approved retrospective testicular cancer registry was queried for patients who underwent a primary unilateral robotic (R-RPLND) or laparoscopic (L-RPLND) RPLND by a single surgeon for a stage I testicular nonseminomatous germ cell tumor. Groups were compared for differences in baseline and outcomes variables. Results Between July 2006 and July 2014, a total of 16 R-RPLND and 21 L-RPLND cases were performed by a single surgeon. Intra- and perioperative outcomes including operative time, estimated blood loss, lymph node yield, complicate rate and ejaculatory status were similar between groups (all p > 0.1). Conclusions As an early checkpoint, R-RPLND appears comparable to the laparoscopic approach in terms of safety and perioperative outcomes. It remains unclear if R-RPLND offers any tangible benefits over standard laparoscopy.
    BJU International 03/2015; DOI:10.1111/bju.13121 · 3.13 Impact Factor
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    ABSTRACT: A growing body of retrospective literature is emerging regarding active surveillance (AS) for patients with small renal masses (SRMs). There are limited prospective data evaluating the effectiveness of AS compared to primary intervention (PI). To determine the characteristics and clinical outcomes of patients who chose AS for management of their SRM. From 2009 to 2014, the multi-institutional Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry prospectively enrolled 497 patients with solid renal masses ≤4.0cm who chose PI or AS. AS versus PI. The registry was designed and powered as a noninferiority study based on historic recurrence rates for PI. Analyses were performed in an intention-to-treat manner. Primary outcomes were overall survival (OS) and cancer-specific survival (CSS). Of the 497 patients enrolled, 274 (55%) chose PI and 223 (45%) chose AS, of whom 21 (9%) crossed over to delayed intervention. AS patients were older, had worse Eastern Cooperative Oncology Group scores, total comorbidities, and cardiovascular comorbidities, had smaller tumors, and more often had multiple and bilateral lesions. OS for PI and AS was 98% and 96% at 2 yr, and 92% and 75% at 5 yr, respectively (log rank, p=0.06). At 5 yr, CSS was 99% and 100% for PI and AS, respectively (p=0.3). AS was not predictive of OS or CSS in regression modeling with relatively short follow-up. In a well-selected cohort with up to 5 yr of prospective follow-up, AS was not inferior to PI. The current report is among the first prospective analyses of patients electing for active surveillance of a small renal mass. Discussion of active surveillance should become part of the standard discussion for management of small renal masses. Copyright © 2015. Published by Elsevier B.V.
    European Urology 02/2015; DOI:10.1016/j.eururo.2015.02.001 · 10.48 Impact Factor
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    ABSTRACT: To describe our technique for robot-assisted radical nephrectomy (RARN) with inferior vena cava (IVC) tumor thrombectomy and to present initial results for our first two patients. Two patients with renal masses with infrahepatic IVC extension underwent RARN with IVC tumor thrombectomy using a four-arm configuration. Both cases were right-sided tumors. Vascular control was obtained with complete cross-clamping of the vena cava with robotic bulldog clamps. Intraoperative ultrasound was used to delineate extent of tumor extension. Specimens were removed en-bloc, and the IVC was closed with 2-layers of 4-0 Prolene. The specimen is extracted through a lower midline incision. Two robotic IVC thrombectomies were successfully completed. There were no conversions, intraoperative or postoperative complications. Median operative time was 243 minutes with a median estimated blood loss of 150 mL. Both patients were able to ambulate independently free of intravenous opioids on postoperate day 1. Median length of stay was 4.5 (range 3-6) days. Final pathology revealed clear cell RCC in both cases with negative surgical margins. Robotic technology may facilitate RN and IVC thrombectomy in the well selected patient and appears to be a safe and feasible approach.
    The Canadian Journal of Urology 02/2015; 22(1). · 0.91 Impact Factor
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    ABSTRACT: The differentiation of oncocytoma from renal cell carcinoma (RCC) remains a challenge with currently available cross-sectional imaging techniques. As a result, a large number of patients harboring a benign oncocytoma undergo unnecessary surgical resection. In this study, we explored the utility of Tc-MIBI SPECT/CT for the differentiation of these tumors based on the hypothesis that the large number of mitochondria in oncocytomas would lead to increased Tc-MIBI uptake. In total, 6 patients (3 with oncocytoma and 3 with RCC) were imaged with Tc-MIBI SPECT/CT. Relative quantification was performed by measuring tumor-to-normal renal parenchyma background ratios. All 3 oncocytomas demonstrated radiotracer uptake near or above the normal renal parenchymal uptake (range of uptake ratios, 0.85-1.78). In contrast, the 3 RCCs were profoundly photopenic relative to renal background (range of uptake ratios, 0.21-0.31). Tc-MIBI SPECT/CT appears to be of value in scintigraphically distinguishing benign renal oncocytoma from RCC.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
    Clinical Nuclear Medicine 01/2015; DOI:10.1097/RLU.0000000000000670 · 2.86 Impact Factor
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    ABSTRACT: The aim of this study was to evaluate the outcome of patients with translocation renal cell carcinoma (RCC) treated with partial nephrectomy. Our institutional review board-approved renal mass registry was queried for patients who underwent partial nephrectomy for a pathologically confirmed translocation RCC. We describe the demographic, clinical, pathological, and follow-up data for this series of patients. Between 2003 and 2013, 1897 patients with RCC were treated at our institution with a radical or partial nephrectomy. In total, 10 (0.5%) patients were diagnosed with a translocation RCC. Of these patients, 4 (40%) underwent treatment with partial nephrectomy for an incidentally detected small renal mass (mean imaging diameter, 2.6 cm [range, 1.0-4.2 cm]). During a mean follow-up of 37 months (range, 8-81 months), all patients were alive without evidence of disease. At short-term follow-up, partial nephrectomy appears to be an effective treatment option for patients with small translocation RCCs. Larger studies are required to more extensively investigate the optimal treatment of these potentially aggressive tumors. Copyright © 2015 Elsevier Inc. All rights reserved.
    Clinical Genitourinary Cancer 12/2014; DOI:10.1016/j.clgc.2014.12.008 · 1.69 Impact Factor
  • Wesley W Ludwig, Michael A Gorin, Mohamed E Allaf
    European Urology 11/2014; 67(3). DOI:10.1016/j.eururo.2014.11.023 · 12.48 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; DOI:10.1016/j.urolonc.2014.11.003 · 3.36 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; DOI:10.1111/bju.13011 · 3.13 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 10/2014; 32(7). DOI:10.1016/j.urolonc.2014.02.022 · 3.36 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; DOI:10.1089/end.2014.0559 · 2.10 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. DOI:10.1016/j.urology.2014.03.040 · 2.13 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; 10(4). DOI:10.1016/j.jpurol.2014.06.017 · 1.41 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; DOI:10.1089/end.2014.0348 · 2.10 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; DOI:10.1016/j.juro.2014.06.067 · 3.75 Impact Factor
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    ABSTRACT: Objective 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. Methods The Surveillance, Epidemiology and End Results-Medicare database (1995-2007) was queried to identify patients with localized T1a kidney cancer undergoing partial nephrectomy, radical nephrectomy or deferring therapy. We explored independent associations of specific comorbidities with causes of death, and developed a simplified cardiovascular index. Cox proportional hazards, and Fine and Gray competing risks regression were used. ResultsOf 7177 Medicare beneficiaries in the study population, 754 (10.5%) deferred therapy, 1849 (25.8%) underwent partial nephrectomy and 4574 (63.7%) underwent radical nephrectomy with none of the selected comorbidities identified in 3682 (51.3%) patients. Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival. The cardiovascular index provided good survival risk stratification, and reclassified 1427 (41%) patients with a score 1 on the Charlson Comorbidity Index to a 0 on the cardiovascular index with minimal concession of 5-year survival. Conclusions Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival among Medicare beneficiaries with small renal masses. The cardiovascular index could serve as a clinically useful prognostic aid when advising older patients that are borderline candidates for surgery or active surveillance.
    International Journal of Urology 06/2014; DOI:10.1111/iju.12527 · 1.80 Impact Factor
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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 05/2014; DOI:10.1016/j.urology.2013.12.042 · 2.13 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; DOI:10.1016/j.juro.2013.08.073 · 3.75 Impact Factor
  • The Journal of Urology 04/2014; 191(4):e574. DOI:10.1016/j.juro.2014.02.1596 · 3.75 Impact Factor
  • The Journal of Urology 04/2014; 191:e652-e653. DOI:10.1016/j.juro.2014.02.1804 · 3.75 Impact Factor

Publication Stats

287 Citations
313.47 Total Impact Points

Institutions

  • 2012–2015
    • Johns Hopkins Medicine
      • Department of Urology
      Baltimore, Maryland, United States
  • 2014
    • Johns Hopkins University
      • Department of Pathology
      Baltimore, Maryland, United States
  • 2009–2013
    • University of Miami Miller School of Medicine
      • Department of Urology
      Miami, FL, United States
  • 2009–2012
    • University of Miami
      • Department of Microbiology & Immunology
      كورال غيبلز، فلوريدا, Florida, United States
  • 2010
    • University of Michigan
      • Department of Internal Medicine
      Ann Arbor, Michigan, United States