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Studier-Fischer A, Bressan M, Qasim AB, Özdemir B, Sellner J, Seidlitz S, Haney CM, Egen L, Michel M, Dietrich M, Salg GA, Billmann F, Nienhüser H, Hackert T, Müller BP, Maier-Hein L, Nickel F, Kowalewski KF. Spectral characterization of intraoperative renal perfusion using hyperspectral imaging and artificial intelligence. Sci Rep 2024; 14:17262. [PMID: 39068299 PMCID: PMC11283474 DOI: 10.1038/s41598-024-68280-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024] Open
Abstract
Accurate intraoperative assessment of organ perfusion is a pivotal determinant in preserving organ function e.g. during kidney surgery including partial nephrectomy or kidney transplantation. Hyperspectral imaging (HSI) has great potential to objectively describe and quantify this perfusion as opposed to conventional surrogate techniques such as ultrasound flowmeter, indocyanine green or the subjective eye of the surgeon. An established live porcine model under general anesthesia received median laparotomy and renal mobilization. Different scenarios that were measured using HSI were (1) complete, (2) gradual and (3) partial malperfusion. The differences in spectral reflectance as well as HSI oxygenation (StO2) between different perfusion states were compelling and as high as 56.9% with 70.3% (± 11.0%) for "physiological" vs. 13.4% (± 3.1%) for "venous congestion". A machine learning (ML) algorithm was able to distinguish between these perfusion states with a balanced prediction accuracy of 97.8%. Data from this porcine study including 1300 recordings across 57 individuals was compared to a human dataset of 104 recordings across 17 individuals suggesting clinical transferability. Therefore, HSI is a highly promising tool for intraoperative microvascular evaluation of perfusion states with great advantages over existing surrogate techniques. Clinical trials are required to prove patient benefit.
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Affiliation(s)
- A Studier-Fischer
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
- Department of Urology and Urosurgery, Medical Faculty of the University of Heidelberg, University Medical Center Mannheim, Mannheim, Germany.
- Division of Intelligent Systems and Robotics in Urology (ISRU), German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany.
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
| | - M Bressan
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A Bin Qasim
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, Heidelberg, Germany
| | - B Özdemir
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Division of Intelligent Systems and Robotics in Urology (ISRU), German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - J Sellner
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, Heidelberg, Germany
- Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany
| | - S Seidlitz
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, Heidelberg, Germany
- Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany
| | - C M Haney
- Department of Urology and Urosurgery, Medical Faculty of the University of Heidelberg, University Medical Center Mannheim, Mannheim, Germany
- Division of Intelligent Systems and Robotics in Urology (ISRU), German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - L Egen
- Department of Urology and Urosurgery, Medical Faculty of the University of Heidelberg, University Medical Center Mannheim, Mannheim, Germany
- Division of Intelligent Systems and Robotics in Urology (ISRU), German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - M Michel
- Department of Urology and Urosurgery, Medical Faculty of the University of Heidelberg, University Medical Center Mannheim, Mannheim, Germany
- Division of Intelligent Systems and Robotics in Urology (ISRU), German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - M Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - G A Salg
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - F Billmann
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - H Nienhüser
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - B P Müller
- Department of Digestive Surgery, University Digestive Healthcare Center, Basel, Switzerland
| | - L Maier-Hein
- Division of Intelligent Medical Systems, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, Heidelberg, Germany
- Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany
| | - F Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K F Kowalewski
- Department of Urology and Urosurgery, Medical Faculty of the University of Heidelberg, University Medical Center Mannheim, Mannheim, Germany
- Division of Intelligent Systems and Robotics in Urology (ISRU), German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
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Wei L, Wang C, Fu J, Qiangba T, Zhou X, He P, Li X, Lang L, Li C, Wang Y. Holographic 3D renal segments reconstruction protects renal function by promote choice of selective renal artery clamping during robot-assisted partial nephrectomy. World J Urol 2023; 41:2975-2983. [PMID: 37698633 DOI: 10.1007/s00345-023-04599-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVE To investigate the impact of selective artery clamping (SAC) and main artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) on renal function and the influence of holographic three-dimensional (3D) reconstruction of renal segments on the selection between SAC and MAC. METHODS This retrospective observational study included patients who underwent RAPN at First Hospital Affiliated to the Army Medical University between December 2016 and July 2022. According to the clamping methods, the patients were divided into the SAC group and the MAC group. The primary outcome was renal function. RESULTS A total of 422 patients (194 in the SAC group and 228 in the MAC group) were included. The RAPN procedures were all completed successfully. The patients in SAC group had less glomerular filtration rate (GFR) decline in the affected kidney (8.6 ± 7.0 ml/min vs. 18.7 ± 10.9 ml/min, P < 0.001) and minor estimated glomerular filtration rate (eGFR) decrease (4.3 ± 10.5 ml/min vs. 12.6 ± 12.1 ml/min, P < 0.001) than those in MAC group. Among 37 patients with baseline renal insufficiency, the GFR decline of the affected kidney in the SAC subgroup was significantly lower than in the MAC subgroup (5.5 ± 6.5 ml/min vs. 14.3 ± 9.2 ml/min, P = 0.002). The proportion of patients who underwent 3D reconstruction was significant higher in the SAC group than in the MAC group. (65.46% vs. 28.07%, P < 0.001). CONCLUSION The SAC technique during RAPN may serve as a protective measure for renal function, while the implementation of holographic 3D renal segment reconstruction technique may facilitate optimal selection of SAC.
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Affiliation(s)
- Ling Wei
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Cong Wang
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jian Fu
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Tudan Qiangba
- Department of Urology, Tibet CORPS Hospital of Chinese People's Armed Police Forces, Lhasa, 850000, Tibet, China
| | - Xiaozhou Zhou
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Peng He
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xuemei Li
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Lang Lang
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Chunxia Li
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yongquan Wang
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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Amparore D, Piramide F, Checcucci E, Verri P, De Cillis S, Piana A, Volpi G, Busacca G, Colombo M, Fiori C, Porpiglia F. Three-dimensional Virtual Models of the Kidney with Colored Perfusion Regions: A New Algorithm-based Tool for Optimizing the Clamping Strategy During Robot-assisted Partial Nephrectomy. Eur Urol 2023; 84:418-425. [PMID: 37117108 DOI: 10.1016/j.eururo.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/25/2023] [Accepted: 04/04/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND An empirical selective clamping strategy based on the direction of the arterial branches can lead to failures during partial nephrectomy, even when assisted by three-dimensional virtual models (3DVMs). OBJECTIVE To develop and test new 3DVMs that include kidney perfusion regions and evaluate their intraoperative accuracy in guiding selective clamping and their impact on postoperative renal function. DESIGN, SETTING, AND PARTICIPANTS For patients with a kidney suitable for nephron-sparing surgery, 3DVMs were supplemented with a Voronoi diagram, a Euclidean distance-based mathematical tool, to calculate vascular-dominant regions the kidney. SURGICAL PROCEDURE Robot-assisted partial nephrectomy guided by perfusion-region (PR)-3DVMs. MEASUREMENTS All anatomic information given by the PR-3DVMs was collected. Selective or superselective clamping was planned and performed intraoperatively when feasible under 3DVM assistance. Changes in split renal function (SRF) and estimated renal plasmatic flow (ERPF) were evaluated for 51 patients who underwent baseline and 3-mo postoperative renal scintigraphy. RESULTS AND LIMITATIONS A total of 103 patients were prospectively enrolled. The median number of kidney and tumor perfusion regions were 8 (interquartile range [IQR] 7-10) and 3 (IQR 2-3), respectively. A clampless, selective clamping, and global clamping strategy was applied in eight (7.8%), 79 (76.6%), and 16 (15.5%) cases, respectively, with no differences between planning and surgery in terms of the number or order of arteries clamped or the perfusion regions that underwent ischemia. Among the 51 patients who underwent renal scintigraphy, the mean SRF decreased by 11.3%, 7.7%, and 1.7% after global, selective, and superselective clamping, respectively (p = 0.004). Similar results were obtained for ERPF (18.9%, 9.9%, and 6.0%; p = 0.02). The main limitation is the need for a bioengineer to manually refine the 3DVMs. CONCLUSIONS Use of mathematical algorithms for 3DVMs allows precise estimation of kidney perfusion regions to maximize the efficacy of selective clamping and minimize renal function impairment. PATIENT SUMMARY Three-dimensional models that include regions of blood flow to the kidney can be used to guide clamping of blood vessels when part of the kidney is being surgically removed. More limited clamping can reduce damage to the remaining portion of the kidney and result in better recovery of kidney function after surgery.
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Affiliation(s)
- Daniele Amparore
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy.
| | - Federico Piramide
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Enrico Checcucci
- Department of Surgery, Candiolo Cancer Institute FPO-IRCCS, Candiolo, Italy
| | - Paolo Verri
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Sabrina De Cillis
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Alberto Piana
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Gabriele Volpi
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Giovanni Busacca
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Marco Colombo
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Cristian Fiori
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Italy
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Functional Outcomes after Selective Clamping in Robot-Assisted Partial Nephrectomy. J Clin Med 2022; 11:jcm11195648. [PMID: 36233518 PMCID: PMC9572118 DOI: 10.3390/jcm11195648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/22/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
This study aimed to assess the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN). We retrospectively analyzed 372 patients who had undergone RAPN at our hospital between July 2010 and March 2021. After propensity score matching between the full and selective clamping groups, perioperative outcomes and postoperative preservation ratio of the estimated glomerular filtration rate (eGFR) were compared at 6 and 12 months of follow-up. After propensity score matching, we evaluated 47 patients from each group. While no significant differences were observed in surgical time, warm ischemia time, or incidence rates of all grades of complications between the two cohorts, the estimated blood loss (EBL) was significantly lower in the full clamping group than in the selective clamping group (30 vs. 60, p = 0.046). However, no significant intergroup differences were observed in the postoperative preservation ratio of eGFR at 6 or 12 months of follow-up (full clamping 94.0% vs. selective clamping 92.7%, p = 0.509, and full clamping 92.0% vs. selective clamping 91.6%, p = 0.476, respectively). Selective clamping resulted in higher EBL rates than did full clamping in RAPN. However, selective clamping provided no renal functional advantage over full clamping in our propensity-score-matched cohort.
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Giulioni C, Scarcella S, Di Biase M, Marconi A, Sortino G, Diambrini M, Giannubilo W, Castellani D, Ferrara V. The Role of Intraoperative Ultrasonography Associated with Clampless Technique in Three-Dimensional Retroperitoneoscopic Laparoscopic Enucleation of Completely Endophytic Renal Tumors. J Laparoendosc Adv Surg Tech A 2022; 32:987-991. [PMID: 35442780 DOI: 10.1089/lap.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: To evaluate perioperative and functional outcomes of clampless laparoscopic tumor enucleation for completely endophytic renal tumors with the guide of intraoperative ultrasonography. Methods: We analyzed patients with clinically completely endophytic tumors, renal tumors, who underwent clampless three-dimensional (3D) retroperitoneoscopic laparoscopic tumor enucleation between January 2012 and January 2021. Patients with exophytic tumors were excluded. Intraoperative ultrasonography was used to map out the mass in all surgeries. Results: Overall, 57 patients underwent clampless 3D retroperitoneoscopic laparoscopic tumor enucleation. Mean surgical time was 131 minutes, and mean estimated blood loss was 202 mL. Mean hospital stay was 4.7 days. Major and minor postoperative complications occurred, respectively, in 3 and 10 cases. Only a patient had a positive surgical margin. One-year renal function did not differ from baseline. Conclusion: Our study showed that clampless laparoscopic enucleation guided by laparoscopic ultrasonography ensured satisfactory outcomes for completely intrarenal tumors, with excellent renal function preservation 1 year after surgery.
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Affiliation(s)
- Carlo Giulioni
- Department of Urology, "Ospedali Riuniti" University Hospital, Ancona, Italy
| | - Simone Scarcella
- Department of Urology, "Ospedali Riuniti" University Hospital, Ancona, Italy
| | | | - Andrea Marconi
- Department of Urology, Hospital "Carlo Urbani," Jesi, Italy
| | | | | | | | - Daniele Castellani
- Department of Urology, "Ospedali Riuniti" University Hospital, Ancona, Italy
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Bertolo R, Bove P, Minervini A, Antonelli A. Randomized trials to determine the ideal management of the renal artery during partial nephrectomy: Life's under no obligation to give us what we expect. Int J Urol 2021; 29:92-93. [PMID: 34622492 DOI: 10.1111/iju.14707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - Pierluigi Bove
- Urology Department, "San Carlo di Nancy" Hospital, Rome, Italy.,Urology Unit, Department of Surgery, Tor Vergata University of Rome, Rome, Italy
| | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Alessandro Antonelli
- Department of Urology, Azienda Ospedaliera Universitaria Integrata of Verona, University of Verona, Verona, Italy
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Abstract
Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.
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Affiliation(s)
- Ellen O'Connor
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Brennan Timm
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.,North Eastern Urology, Heidelberg, Australia
| | - Nathan Lawrentschuk
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Urology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph Ischia
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia
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8
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Badani KK, Kothari PD, Okhawere KE, Eun D, Hemal A, Abaza R, Porter J, Lovallo G, Ahmed M, Munver R, Stifelman MD. Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help? BJU Int 2020; 125:893-897. [PMID: 32125072 DOI: 10.1111/bju.15043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. PATIENTS AND METHODS Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. RESULTS Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. CONCLUSION In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.
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Affiliation(s)
- Ketan K Badani
- Department of Urology, Mount Sinai Medical School, New York, NY, USA
| | - Pankti D Kothari
- Department of Urology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Daniel Eun
- Department of Urology, Lewis Katz School of Medicine Temple University, Philadelphia, PA, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ronney Abaza
- Department of Urology, OhioHealth Dublin Methodist Hospital, Dublin, OH, USA
| | - James Porter
- Department of Urology, Swedish Urology, Seattle, WA, USA
| | - Gregory Lovallo
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mutahar Ahmed
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ravi Munver
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Michael D Stifelman
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
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