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Lazarovich A, Drori T, Guttman Y, Rosenzweig B, Ben-Yaaqov A, Korach J, Nissan A, Dotan Z. Urological outcomes following pelvic exenteration for non-urological malignancies. Heliyon 2024; 10:e29640. [PMID: 38644885 PMCID: PMC11031810 DOI: 10.1016/j.heliyon.2024.e29640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/17/2023] [Accepted: 04/11/2024] [Indexed: 04/23/2024] Open
Abstract
Background Pelvic exenteration (PE) is a major surgical procedure used as a salvage therapy for patients with locally advanced or recurrent pelvic malignancies. Urinary reconstruction is a major part of PE and is often associated with high rates of post-operative complications. In the current study we evaluate the short and long-term urological outcomes following PE for Colo-Rectal (CR) and gyneco-oncological (GO) malignancies. Methods Study included 22 patients who underwent PE for recurrent or locally advanced CR and GO malignancies in our institution between the years 2010-2018. The endpoint was post-operative freedom from urological complications. Results Of 22 patients included, 13 (59 %) and 9 (41 %) underwent PE for CR and GO malignancies respectively. The mean age of the patients was 54 years. The median follow-up was 19 months. Seven (78 %) patients with GO malignancy and 11 (85 %) with CR malignancy underwent PE for local recurrence. Hydronephrosis prior to surgery existed in 8 (36.3 %) patients, of which, 5 patients required kidney drainage via nephrostomy tube. Two patients underwent posterior pelvic exenteration (PPE) with bladder preservation whereas the remaining 20 underwent cystectomy with urinary diversion by ileal conduit. Hydronephrosis post PE developed in 13 patients (59 %). eight (36 %) patients needed kidney drainage by nephrostomy tubes post PE, of these, 6 (75 %) had disease recurrence. The 2 years freedom from kidney drainage was 68 %, however the median time for kidney drainage was 0.5 months. The median overall survival was 12.5 months. Conclusion The rate of urological complications following PE is relatively high and associated with disease recurrence.
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Affiliation(s)
- A. Lazarovich
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - T. Drori
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y. Guttman
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B. Rosenzweig
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Ben-Yaaqov
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J. Korach
- Department of Gynecological Oncology (GO), Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A. Nissan
- Department of Surgical Oncology C, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Z.A. Dotan
- Department of Urology, Chaim Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Kim JH, Lee DE, Ha HI, Jung JY, Kim SH, Lee HH, Seo HK, Seo SS, Kang S, Park SY, Lim MC. Surgical outcomes of ureteral reconstruction during cytoreductive surgery for ovarian cancer: a retrospective cohort study. BMC Cancer 2022; 22:1163. [PMID: 36357914 PMCID: PMC9650832 DOI: 10.1186/s12885-022-10288-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/20/2022] [Indexed: 11/12/2022] Open
Abstract
Background Ureteral reconstruction is required after surgical resection of the tumor invading the urinary tract in ovarian cancer with low incidence. There are no currently reported surgical outcomes of ureteral reconstruction during cytoreductive surgery. The aim of the study is to investigate the clinical features and surgical outcomes of ureteral reconstruction during primary, interval and secondary cytoreductive surgery for ovarian cancer. Methods A total of 3226 patients who underwent primary, interval or secondary cytoreductive surgery for ovarian cancer between January 2000 and May 2021 were reviewed. Fifty-six patients who underwent ureteral reconstruction during cytoreductive surgery were included in the analysis. Results Ureteral reconstruction was required in 1.7% (56/3226) of ovarian cancer patients. Of the 56 patients who underwent ureteral reconstruction during cytoreductive surgery, 35 (62.5%) had primary ovarian cancer, and 21 (37.5%) had recurrent ovarian cancer. The median tumor size invading the lower urinary tract was 2.0 cm (range, 0.4–9.5 cm). Ureteroneocystostomy with direct implantation (51.8%) and psoas hitch (8.9%), transureteroureterostomy (7.1%), and ureteroureterostomy (32.1%) were required as part of cytoreductive surgery. Complete cytoreduction with ureteral reconstruction was achieved in 83.9% (47/56) and the rest of the patient population (16.1%) achieved a gross residual tumor size of less than 1 cm. All complications, including hydronephrosis (33.9%), were managed, none resulting in long-term sequelae. In primary ovarian cancer, the 5-year disease-free survival and overall survival were 50.0% and 89.5%, respectively. In patients with recurrent ovarian cancer, the 5-year disease-free survival and overall survival were 23.6% and 64.0%, respectively. Conclusions Ureteral reconstruction as a part of cytoreductive surgery for ovarian cancer could be performed with acceptable morbidities. Complete cytoreduction by a multidisciplinary surgical team, including urologic oncologists, should be pursued for the surgical management of ovarian cancer. Trial registration Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10288-x.
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Stearns GL, Tin AL, Benfante NE, Sjoberg DD, Sandhu JS. Outcomes of Ureteroneocystostomy in Patients With Cancer. Urology 2021; 158:131-134. [PMID: 34499968 DOI: 10.1016/j.urology.2021.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the durability of ureteroneocystostomy as well as pre- or post-operative factors that may be associated with failure to provide appropriate renal drainage. METHODS A total of 290 patients who underwent ureteral reimplantation to native bladder between 2003 and 2015 were identified. After excluding pediatric patients and those without any follow-up, 255 patients, 3 of whom had a subsequent contralateral reimplantation were included, for 258 observations. Kaplan-Meier method and univariate Cox models were used to assess whether factors such as radiation, prior abdominal surgery, age at re-implantation, gender and BMI are associated with re-implantation failure. RESULTS Among 258 observations, there were 27 failures. Median follow-up time was 1.1 years from re-implantation surgery among patients without a failure.1 and 5-year ureteral re-implantation failure is 7% (95% CI 4%, 12%) and 22% (95% CI 15%, 33%), respectively. On univariate analysis, post-operative radiation was found to be strongly associated with poorer ureteral re-implantation survival (HR: 6.62; CI 2.40, 18.29; P = .0003) No significant association between re-implantation failure-free survival and age at reimplantation, gender, BMI, previous abdominal surgery, preoperative radiation and adjuvant radiation was noted (all P > .4). CONCLUSIONS Ureteroneocystotomy in the malignant setting has reasonable success rates through five years. No preoperative factors were associated with re-implantation failure. While all patients need to be followed due to increasing rates of failure with time, patients receiving palliative or salvage radiation therapy appear to be more prone to failure requiring further intervention.
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Affiliation(s)
| | - Amy L Tin
- Memorial Sloan Kettering Cancer, New York, NY
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Hagemans J, Voogt E, Rothbarth J, Nieuwenhuijzen G, Kirkels W, Boormans J, Koldewijn E, Richardson R, Verhoef C, Rutten H, Burger J. Outcomes of urinary diversion after surgery for locally advanced or locally recurrent rectal cancer with complete cystectomy; ileal and colon conduit. Eur J Surg Oncol 2020; 46:1160-1166. [DOI: 10.1016/j.ejso.2020.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022] Open
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Federico A, Gallotta V, Foschi N, Costantini B, Conte C, Pinto F, Ercoli A, Ferrandina G, Dal Moro F, Bassi P, Zattoni F, Scambia G, Vizzielli G. Surgical outcomes of segmental ureteral resection with ureteroneocystostomy after major gynecologic surgery. Eur J Surg Oncol 2020; 46:1366-1372. [PMID: 32278519 DOI: 10.1016/j.ejso.2020.03.216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/09/2020] [Accepted: 03/21/2020] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Describing the surgical and oncological outcome of bladder-preserving ureter reconstruction (BPUR) with segmental ureteral resection after major gynecologic surgery. MATHERIALS AND METHODS Patients with BPUR admitted at a single institution between March 2012 and July 2018 were retrospectively analyzed. Surgical and oncological data were assessed. RESULTS Forty-six women with gynecologic tumors involving the ureter were treated with BPUR. R0 resection was achieved in 40/46 patients (86.9%), while pathologic margins were microscopically positive in 6 women (13.1%). Overall, 12 women (26.0%) received radiotherapy before surgery: among them, 8 patients received neoadjuvant chemoradiotherapy. Twenty-six women underwent BPUR during primary surgery, whereas 20 (43.4%) required BPUR upon recurrence. Twenty-six patients (56.2%) were found to have hydronephrosis at pre-operative workup. The psoas bladder hitch was the most common procedure performed for urinary reconstruction (63%) with respect to direct reimplantation (37%). Fourteen patients (14/46 = 30.4%) experienced urological complications. Urinary leakage occurred in 9 patients (19.5%), specifically: 5 uretero-vaginal fistula, 3 uroperitoneum, 1 uretero-enteral fistula. There were 3 cases (6.5%) of hydronephrosis at the side of ureteroneocystostomy and 2 cases (4.3%) of unilateral renal impairment requiring nephrectomy. At multivariate analysis only pre-operative radiotherapy (p = 0.047) and a history of pelvic irradiation (p = 0.025) were independently associated with an increased risk of developing severe urinary complications. CONCLUSIONS BPUR is feasible in gynecologic cancer with invasion of the urinary tract. However, since a slight increase of post-operative urological complications was observed in the previously irradiated fields, a personalized surgical planning is recommended for these women in the next future.
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Affiliation(s)
- Alex Federico
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Nazario Foschi
- Division of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Carmine Conte
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Francesco Pinto
- Division of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Alfredo Ercoli
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
| | - Gabriella Ferrandina
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Department of Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabrizio Dal Moro
- Department of Surgery, Oncology and Gastroenterology-Urology, University of Padua, Padua, Italy
| | - Pierfrancesco Bassi
- Division of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Filiberto Zattoni
- Department of Surgery, Oncology and Gastroenterology-Urology, University of Padua, Padua, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Department of Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Vizzielli
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Department of Surgery, Oncology and Gastroenterology-Urology, University of Padua, Padua, Italy.
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Complications and 5-year survival after radical resections which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases. Tech Coloproctol 2020; 24:181-190. [DOI: 10.1007/s10151-019-02141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
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Bolmstrand B, Nilsson PJ, Holm T, Buchli C, Palmer G. Patterns of complications following urinary tract reconstruction after multivisceral surgery in colorectal and anal cancer. Eur J Surg Oncol 2018; 44:1513-1517. [PMID: 30017328 DOI: 10.1016/j.ejso.2018.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/14/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Multi-visceral resection, including parts of the urinary tract, is sometimes warranted to achieve cancer clear resection margins and optimize survival in patients with locally advanced colorectal and anal cancer. The aim of this study was to assess morbidity after urinary tract reconstruction dictated by colorectal and anal malignancy and to identify potential predictors of urological complications. METHODS All patients undergoing surgery for colorectal or anal malignancy, including urinary tract resection and synchronous reconstruction, performed at the Karolinska University Hospital during 2004-2015 were included in this retrospective cohort study. Data was collected from medical records with follow-up until at least one year after the index surgery. Complications were graded according to the Clavien-Dindo classification system of surgical complications. RESULTS The study included 189 patients; 121 underwent cystectomy and 68 partial ureter resection. The rate of high grade urological complications was 22%. The risk of major urological complications was significantly higher in patients subjected to ureter resection compared to after cystectomy (OR 2.60, 95% CI 1.23-5.49). Also, preoperative radiotherapy and intestinal anastomotic dehiscence significantly increased the risk of high grade urological complications. CONCLUSION To achieve potentially curative resections with uninvolved margins in patients with locally advanced colorectal and anal cancer, multi-visceral resection including urinary tract reconstruction can be performed with reasonable morbidity.
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Affiliation(s)
- Björn Bolmstrand
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden.
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - Torbjörn Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - Christian Buchli
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - Gabriella Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
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van den Heijkant F, Vermeer T, Vrijhof E, Nieuwenhuijzen G, Koldewijn E, Rutten H. Psoas hitch ureteral reimplantation after surgery for locally advanced and locally recurrent colorectal cancer: Complications and oncological outcome. Eur J Surg Oncol 2017; 43:1869-1875. [DOI: 10.1016/j.ejso.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022] Open
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Pelvic Exenteration Surgery: The Evolution of Radical Surgical Techniques for Advanced and Recurrent Pelvic Malignancy. Dis Colon Rectum 2017; 60:745-754. [PMID: 28594725 DOI: 10.1097/dcr.0000000000000839] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.
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Brown KG, Solomon MJ, Latif ER, Koh CE, Vasilaras A, Eisinger D, Sved P. Urological complications after cystectomy as part of pelvic exenteration are higher than that after cystectomy for primary bladder malignancy. J Surg Oncol 2016; 115:307-311. [DOI: 10.1002/jso.24511] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Kilian G.M. Brown
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District; Sydney Australia
- The Institute of Academic Surgery at RPA; Sydney Australia
| | - Michael J. Solomon
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District; Sydney Australia
- The Institute of Academic Surgery at RPA; Sydney Australia
- Department of Colorectal Surgery; Royal Prince Alfred Hospital; Sydney Australia
- University of Sydney; New South Wales; Australia
| | - Edward R. Latif
- Department of Urology; Royal Prince Alfred Hospital; Sydney Australia
| | - Cherry E. Koh
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District; Sydney Australia
- The Institute of Academic Surgery at RPA; Sydney Australia
- Department of Colorectal Surgery; Royal Prince Alfred Hospital; Sydney Australia
| | - Arthur Vasilaras
- Department of Urology; Royal Prince Alfred Hospital; Sydney Australia
| | - David Eisinger
- Department of Urology; Royal Prince Alfred Hospital; Sydney Australia
| | - Paul Sved
- University of Sydney; New South Wales; Australia
- Department of Urology; Royal Prince Alfred Hospital; Sydney Australia
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Brown K, Koh C, Vasilaras A, Eisinger D, Solomon M. Clinical algorithms for the diagnosis and management of urological leaks following pelvic exenteration. Eur J Surg Oncol 2014; 40:775-81. [DOI: 10.1016/j.ejso.2013.09.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/09/2013] [Accepted: 09/22/2013] [Indexed: 11/29/2022] Open
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Göktaş C, Horuz R, Yıldırım M, Faydacı G, Sahin C, Albayrak S. [Major urologic surgical procedures in locally advanced colorectal cancers]. Actas Urol Esp 2012; 36:361-6. [PMID: 22266254 DOI: 10.1016/j.acuro.2011.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 09/13/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the outcomes of major urological procedures performed in patients with locally advanced colorectal cancer. MATERIAL AND METHODS Data of 37 patients with locally advanced colorectal cancer who underwent major urological surgical procedures along with simultaneous cancer surgery between the years of 2005 and 2010 were retrospectively evaluated. RESULTS The mean age was 58.3 years. Male/Female ratio was 2.7. 59% of the patients were primary, and 41% were recurrent cases of colorectal cancer. Bladder, ureters, urethra, kidneys and prostate were found as invaded in 19, 9, 5, 2 and 2 cases, respectively. The following single or combined procedures were performed; partial (n=11) or total (n=8; 2 combined with urethrocutaneostomy, 6 with ileal-conduit) cystectomy, urethroplasty (n=5), nephroureterectomy (n=2), radical nephrectomy (n=1), partial nephrectomy (n=1), ureteroneocystostomy (n=7), Boari's flap (n=4), transureteroureterostomy (n=3). Prolonged drainage was the most common surgical complication (27%). Urethrocutaneous fistula and total urinary incontinence were encountered in 1 and 1 patient, respectively. The incidence of hydronephrosis and elevated creatinine were 38% (preoperative 27%; postoperative 11%) and 24% (11% preoperative; 13% postoperative), respectively. Two deaths occurred in the first month of operations. Mean duration of follow up was 18(6-28) months for surviving 13 patients. Overall survival in 24 cases resulting in death was 21(1-42) months. CONCLUSIONS Since the most important eventual effects of locally advanced colorectal cancer are on the kidneys from the urological point of view; the aim of an urologist, as a member of surgical team, should be preserving renal function in addition to helping complete removal of the tumor.
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Affiliation(s)
- C Göktaş
- Clínica de Urología, Hospital de Formación Kartal, Estambul, Turquía
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Teixeira S, Ferenschild F, Solomon M, Rodwell L, Harrison J, Young J, Vasilaras A, Eisinger D, Lee P, Byrne C. Urological leaks after pelvic exenterations comparing formation of colonic and ileal conduits. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012; 38:361-6. [DOI: 10.1016/j.ejso.2011.12.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/22/2011] [Accepted: 12/06/2011] [Indexed: 11/30/2022]
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