Publications by authors named "Chirag Doshi"

25 Publications

  • Page 1 of 1

Concomitant pulmonary valve replacement with intracardiac repair for adult tetralogy of Fallot.

Ann Pediatr Cardiol 2021 Jul-Sep;14(3):323-330. Epub 2021 Aug 12.

Department of Cardio Vascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India.

Objectives: Adult patients undergoing tetralogy of Fallot (TOF) repair have a higher risk of mortality compared to pediatric patients. Pulmonary regurgitation (PR) further predisposes these patients to heart failure, arrhythmias, and sudden death. Pulmonary valve replacement (PVR) may improve the symptoms in these patients but, fails to reverse the other deleterious effects. Aim of our study was to evaluate the effect of concomitant PVR with TOF repair on right ventricular (RV) parameters, cardiopulmonary exercise capacity, and bioprosthetic valve durability at mid-term.

Materials And Methods: Between January 2013 and August 2018, 37 adolescents and adults with TOF who had hypoplastic pulmonary annulus underwent concomitant TOF repair with PVR at our institute. We retrospectively collected the data from the hospital records including follow-up.

Results: Mean age of the patients was 18.48 ± 7.53 years. Bioprosthetic valve size ranged from 19 mm to 25 mm. There was no early or late mortality. No patient had developed significant perioperative complications. At a mean follow-up of 53.3 ± 16.4 months, there was no significant change in mean QRS duration, RV function, RV end-systolic and end-diastolic dimensions, RV myocardial performance index, and functional status (including NYHA class and 6-min walk test) compared to at-discharge values. Four patients developed prosthetic valve degeneration with mild PR and without significant increase in gradient.

Conclusion: Concomitant PVR with TOF repair in adult provides excellent mid-term outcome, with a minimal rate of pulmonary valve degeneration. It not only eases the early postoperative course but also preserves the RV function as well as functional status at mid-term.
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http://dx.doi.org/10.4103/apc.APC_125_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457283PMC
August 2021

Mini-Bentall Surgery: The Right Thoracotomy Approach.

J Chest Surg 2021 Dec;54(6):554-557

Department of Cardio Vascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, B. J. Medical College, Ahmedabad, India.

Surgeons are increasingly using the right mini-thoracotomy approach to perform aortic valve surgery. This approach has shown better results in terms of blood loss and length of hospital stay than the sternotomy approach. For selected patients requiring aortic root and ascending aorta surgery, a right mini-thoracotomy approach may prove beneficial. In our technique, we placed a 5-cm horizontal skin incision in the right second intercostal space. Femoro-femoral cardiopulmonary bypass was established. A valved aortic conduit was used for aortic root replacement. The patient's postoperative course was uneventful, with a short hospital stay. This technique offers a minimally invasive approach to aortic root and ascending aorta surgery with easy adaptability and reduced costs.
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http://dx.doi.org/10.5090/jcs.21.036DOI Listing
December 2021

Four versus 3 Cycles of Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: Implications for Pathological Response and Survival.

J Urol 2021 Aug 27:101097JU0000000000002189. Epub 2021 Aug 27.

Department of Urology, Loyola University Medical Center, Maywood, Illinois.

Purpose: The ideal number of neoadjuvant chemotherapy (NAC) cycles for muscle-invasive bladder cancer is uncertain with 3 to 4 representing the standard of care (SOC). We compared ypT0 rates and survival between patients receiving 4 versus 3 cycles of NAC with evaluation of chemotherapy-related toxicity for correlation with tumor chemosensitivity and pathological response.

Materials And Methods: Patients receiving NAC followed by radical cystectomy for cT2-4N0M0 urothelial carcinoma from 2 institutions were included. Primary study groups included 4 cisplatin-based NAC cycles, 3 cisplatin-based NAC cycles, and nonSOC NAC (1-2 cycles or noncisplatin-based) to compare ypT0/≤ypT1 rates and survival. A cohort of patients not receiving NAC was included for pathological reference.

Results: Of 693 total patients, 318 (45.9%) received NAC. ypT0 and ≤ypT1 rates were 42/157 (26.8%) and 86/157 (54.8%) for 4 cycles, 38/114 (33.3%) and 71/114 (62.3%) for 3 cycles, and 6/47 (12.8%) and 13/47 (27.7%) for nonSOC (p=0.03 and p <0.01, respectively). Pathological response appeared higher among patients receiving 3 cycles due to toxicity (ypT0: 29/77 [37.7%]; ≤ypT1: 51/77 [66.2%]) but did not reach statistical significance. Toxicities leading to treatment modifications were thrombocytopenia (32.1%), neutropenia (27.2%), renal insufficiency (22.2%), and constitutional symptoms (18.5%). NonSOC patients had lower Kaplan-Meier survival (cT2-cT4N0M0: log-rank p=0.07; cT2N0M0: log-rank p=0.02). There were no statistically significant differences in survival between 4 and 3 cycles (HR 1.00 [95% CI 0.57-1.74], p=0.99).

Conclusions: Patients completing 3 cycles of cisplatin-based NAC have similar pathologic response and short-term survival compared to 4 cycles. Further evaluation of patients experiencing toxicity as a potential marker of tumor chemosensitivity is needed.
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http://dx.doi.org/10.1097/JU.0000000000002189DOI Listing
August 2021

Case of rheumatic mitral stenosis with bilateral coronary artery fistula to pulmonary artery: A rare entity.

J Cardiovasc Thorac Res 2021 30;13(2):176-178. Epub 2021 Jan 30.

Department of Cardiovascular and Thoracic Surgery, Gujarat, India.

Coronary to pulmonary artery fistula is a rare form of congenital coronary artery anomaly. Majority of coronary arteriovenous fistula detected incidentally on coronary angiography. Although, most of these patients are asymptomatic, larger fistulae can produce symptoms of heart failure. Here we present a rare case of 61-year-old female who presented primarily for mitral valve replacement for severe mitral stenosis. On screening angiography, there were two fistula arising from both right and left coronary artery and draining in to the main pulmonary artery. The patient was operated and mitral valve replacement with closure of the fistula. Patient had an uneventful post-operative period and was discharged on 7 the post-operative day.
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http://dx.doi.org/10.34172/jcvtr.2021.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302896PMC
January 2021

African American Men have Increased Risk of Prostate Cancer Detection Despite Similar Rates of Anterior Prostatic Lesions and PI-RADS Grade on Multiparametric Magnetic Resonance Imaging.

Urology 2021 Jul 21. Epub 2021 Jul 21.

Department of Urology, Loyola University Medical Center, Maywood, Illinois; Department of Surgery, Loyola University Medical Center, Maywood, Illinois; Department of Radiology, Loyola University Medical Center, Maywood, Illinois.

Objective: To determine whether the frequency of anterior prostate lesions (APL) on multiparametric magnetic resonance imaging (mpMRI) prior to biopsy differed between African American (AA) and non-AA men and evaluate implications of race and tumor location for prostate cancer (PCa) detection.

Methods: Patients from the Prospective Loyola University mpMRI (PLUM) Prostate Biopsy Cohort (January 2015-December 2020) without prior diagnosis of PCa were evaluated for APLs by race. Multivariable logistic regression models evaluated predictors of APLs and associations of APLs and race with detection of any PCa (grade group 1+) and clinically significant PCa (csPCa; grade group 2+). Additional stratified and propensity score matched analyses were conducted.

Results: Of 1,239 men included, 190 (15.3%) were AA and 302 (24.4%) had at least one APL with no differences by race on multivariable analysis. While men with APLs were twice as likely to harbor PCa or csPCa, the unadjusted proportion of targeted biopsy-confirmed APL PCa (12.6% vs 12.0%) or csPCa (8.4% vs 8.9%) were similar for AA and non-AA men. AA men had higher risk of prostate cancer on targeted cores (OR 1.66 (95%CI 1.06 - 2.61), P = 0.026) which was independent of lesion location or PI-RADS.

Conclusion: AA men were found to have similar rates of APLs on mpMRI to non-AA men indicating access to mpMRI may mitigate some of the historical racial disparity based on lesion location. AA men have increased risk of PCa detection compared to non-AA men independent of anterior location or lesion grade on mpMRI reinforcing the importance of identifying genetic, biologic, and socioeconomic drivers.
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http://dx.doi.org/10.1016/j.urology.2021.07.005DOI Listing
July 2021

Bridging the Telemedicine Gap Among Seniors During the COVID-19 Pandemic.

J Patient Exp 2021 4;8:23743735211014036. Epub 2021 May 4.

Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

At the onset of the COVID-19 pandemic, many senior patients in the USC-Keck Family Medicine clinics were limited or lacking in telemedicine participation. Three factors contributed: lack of video-enabled devices, technological literacy, and/or absence of Wi-Fi connectivity. We addressed the first 2 of these factors. Via phone contact, 9 patients agreed to receive donated Android or Apple devices and to trial instruction manuals for use. Donated equipment and instructions were prepared and delivered in accordance with pandemic guidelines. Follow-up calls indicated that 4 participants were able to set up their devices and 3 of whom had connected with their providers. The remaining 5 participants had not set up their devices by the end of the follow-up period, had difficulty with device setup, accessing applications necessary for telemedicine, or had limited access to Wi-Fi. This project highlights some telemedicine barriers that senior patients may overcome with the additional support of care providers.
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http://dx.doi.org/10.1177/23743735211014036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205366PMC
May 2021

Midterm outcome of off-pump CABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

J Card Surg 2021 Mar 27;36(3):1000-1009. Epub 2021 Jan 27.

Department of CVTS, U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India.

Background: The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce.

Materials And Methods: A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed.

Results: The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676).

Conclusion: OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.
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http://dx.doi.org/10.1111/jocs.15362DOI Listing
March 2021

Contemporary Trends in Presentation and Management of Spermatocytic Seminoma.

Urology 2020 Dec 10;146:177-182. Epub 2020 Oct 10.

Department of Urology, Loyola University Medical Center, Maywood, IL.

Objective: To characterize the presentation and management of spermatocytic seminoma (SS) compared to classic seminoma in adults utilizing a large cancer registry.

Methods: Patients >18 years of age in the National Cancer Database from 2006 to 2016 who underwent orchiectomy for testicular tumors were identified. Demographics, oncologic characteristics, and treatment patterns were compared between patients with SS and classic seminoma.

Results: Of 53,481 adults receiving orchiectomy, 29,208 were diagnosed with classic seminoma and 299 (1%) with SS. Compared to patients with classic seminoma, SS patients were older (57 vs 39 years) and more likely to be African-American (odds ratio (OR) 1.8) and insured by Medicare (OR 2.0; all P <.05). SS patients had larger tumors on presentation (3-6 cm: OR 1.8; >6 cm: OR 1.8), but were less likely to have ≥pT2 stage (OR 0.5), regional nodal involvement (Clinical Stage II: OR 0.3), or distant metastatic disease (Clinical Stage III: OR 0.1; all P <.01). For postorchiectomy management, 73.6% of SS patients underwent surveillance while 24.5% had active treatment (retroperitoneal lymph node dissection, chemotherapy, radiation, or a combination). When stratified by year, there was an increasing trend toward surveillance compared to active treatment.

Conclusion: SS is a rare germ cell tumor that typically presents as a larger tumor in older patients. Although these tumors are less likely to be characterized by advanced disease compared to classic seminoma, many patients have undergone aggressive postorchiectomy treatment in the past. Importantly, treatment trends have shifted toward surveillance in recent years with adjuvant therapy limited primarily to higher stage tumors.
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http://dx.doi.org/10.1016/j.urology.2020.10.002DOI Listing
December 2020

Re-exploration after off-pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing.

J Card Surg 2020 Nov 16;35(11):3062-3069. Epub 2020 Sep 16.

Department of Research, U. N. Mehta Institute of Cardiology and Research Center, Ahmedabad, India.

Objective: Re-exploration after cardiac surgery still remains a troublesome complication. There is still a scarcity of data about the effect of re-exploration after off-pump coronary artery bypass grafting (OPCABG). We here represent our experience on re-exploration following OPCABG.

Method: A total of 5990 OPCABG were performed at our center, out of these patients, 132 (2.2%) were re-explored in the operation room and were included in this study. The medical records of these patients were retrospectively reviewed.

Results: The most common cause of re-exploration was bleeding (83.3%) and the most common site of bleeding was from graft/anastomosis (53.8%). The mean time to re-exploration was 9.75 ± 8.65 hours. The thirty-day mortality was 1.41%. On univariate and multiple regression analysis, emergency surgery, preoperative low platelet count, and the number of grafts were found to be independent risk factors for re-exploration. On multiple regression, emergency surgery, Euroscore II, low platelet count, low ejection fraction, re-exploration, time to re-exploration, blood products used, and high postoperative serum creatinine and bilirubin were found to be independent factors (P < .001) for mortality. On receiver-operating characteristic analysis, the optimum cutoff for time to re-exploration was 14 hours with a sensitivity of 81.3%, specificity of 80%, and area under the curve of 0.798. Patients who re-explored late (>14 hours) had significantly high mortality (30.55% vs 7.3%) and morbidity.

Conclusion: Delaying re-exploration is associated with a three fold increase in mortality and morbidity. So, a strategy of minimizing the incidence of re-exploration, like the use of minimally invasive surgery and early re-exploration with the judicial use of products, should be used to improve outcomes after re-exploration following OPCABG.
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http://dx.doi.org/10.1111/jocs.14986DOI Listing
November 2020

Near-infrared Fluorescence Imaging of Ureters With Intravenous Indocyanine Green During Radical Cystectomy to Prevent Ureteroenteric Anastomotic Strictures.

Urology 2020 Oct 30;144:220-224. Epub 2020 Jun 30.

Department of Urology, Loyola University Medical Center, Maywood, IL. Electronic address:

Objective: To determine whether intraoperative near-infrared fluorescence imaging of the distal ureter using intravenous indocyanine green (ICG) could provide assessment of vascular adequacy and potentially decrease the risk of ureteroenteric anastomotic stricture (UAS).

Methods: A retrospective chart review was performed of all patients undergoing open radical cystectomy by a single surgeon over a 2-year period. Patients were divided into ICG and non-ICG cohorts based on utilization of ICG. For the ICG group, adequacy of ureteral perfusion was based on visual inspection and the ureter was cut back proximally accordingly prior to anastomosis. Follow-up encounters were reviewed to determine development of benign UAS.

Results: A total of 30 and 31 patients were in the non-ICG and ICG cohorts, respectively. There were no differences in baseline demographic and operative data including operative time. Median follow-up was 23.2 months (interquartile range [IQR] 7-29.3) in the non-ICG group compared to 15.8 months (IQR 12.2-18.1) in the ICG group. In the non-ICG cohort, 5 of 30 (16.7%) patients were diagnosed with UAS compared to 1 of 31 (3.2%) in the ICG cohort. The median time to stricture formation for non-ICG cohort was 5.7 months (IQR 3.6-6.6) compared to 7.5 months in the ICG cohort.

Conclusion: The use of near-infrared fluorescence imaging with intravenous ICG to assess ureteral vascularity prior to ureteroenteric anastomosis may reduce the risk of UAS.
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http://dx.doi.org/10.1016/j.urology.2020.06.026DOI Listing
October 2020

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

Gen Thorac Cardiovasc Surg 2021 Jan 25;69(1):8-13. Epub 2020 Jun 25.

Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India.

Background: Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization.

Methods: We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge.

Results: Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent.

Conclusions: Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.
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http://dx.doi.org/10.1007/s11748-020-01412-4DOI Listing
January 2021

Optimal Cystectomy Outcome: A Composite Measurement Evaluating Quality of Care and Mortality Benefit.

Urology 2020 Sep 3;143:117-122. Epub 2020 Jun 3.

Department of Urology, Loyola University Medical Center, Maywood, IL.

Objectives: To evaluate the incidence and impact of an "optimal cystectomy outcome" (OCO), a simplified performance metric that encompasses multiple patient-centered outcomes.

Methods: We identified patients in the National Cancer Center Database undergoing radical cystectomy for stage cT2-cT3 urothelial carcinoma (2006-2014). OCO was defined as negative resection margin, adequate lymphadenectomy (>10 nodes), no prolonged length-of-stay (<75th percentile), no 30-day-readmission, and no 30-day-mortality. We used multivariable logistic regression and Cox proportional-hazards models to identify factors associated with OCO and overall survival (OS).

Results: Among 12,997 patients who fit the inclusion criteria, individual OCO components were attained at a relatively high rate; however, only 37.6% of patients met all 5 OCO criteria. Patients who underwent surgery at a high-volume (OR 2.45) academic facility (OR 1.60) using a minimally-invasive approach (OR 1.32) were more likely to receive an OCO. Patients were less likely to receive an OCO if they were older (OR 0.98), African American (OR 0.71), had Medicaid insurance (OR 0.66), or more comorbidities (OR 0.48) (all P <0.05). Patients who received an OCO were found to have a significantly lower risk of overall mortality (HR 0.69, P <0.05).

Conclusion: Various patient- and hospital-specific factors affect a system's ability to achieve OCO in patients undergoing radical cystectomy. OCO is directly associated with improved OS and has the potential to function as a composite performance metric for the quality of care in bladder cancer.
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http://dx.doi.org/10.1016/j.urology.2020.05.042DOI Listing
September 2020

"Sterile" Epididymal Abscess With Contralateral Intratesticular Recurrence.

Urology 2020 Feb 29;136:e20-e23. Epub 2019 Nov 29.

Department of Urology, Loyola University Stritch School of Medicine, Maywood, IL; Department of Microbiology and Immunology, Loyola University Chicago, Maywood, IL; Division of Urology, Rush University Medical Center, Chicago, IL. Electronic address:

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http://dx.doi.org/10.1016/j.urology.2019.11.021DOI Listing
February 2020

Early and late mortality and morbidity after post-MI ventricular septal rupture repair: predictors, strategies, and results.

Indian J Thorac Cardiovasc Surg 2019 Jul 6;35(3):437-444. Epub 2019 Apr 6.

Department of Cardiac Anaesthesia, U. N. Mehta Institute of Cardiology and Research Center, BJ Medical College, Ahmedabad, India.

Purpose: There has been a shift in the paradigm of management of post-myocardial infarction ventricular septal rupture (MI VSR), with many authors reporting improved prognosis if the surgery can be "optimally delayed." Timing of the procedure is of critical importance and our management (UPMS), and prognosis scores (UPPS) have proven to be relevant. However, long-term outcomes and their correlation with our scores had not been analyzed. In this study, we present our long-term results of post-MI-VSR repair and their correlation with our prognosis score (UPPS).

Methods: Seventy-one patients with post-MI VSR repair (2009-2017) were retrospectively studied. Patients were managed using standard institute protocols.

Results: The 30-day mortality was 56% ( = 40). During a mean follow-up of 4.91 ± 2.43 years, there were eight late deaths. Actuarial survival of 30-day survivors was 87% at 1 year, 74% at 5 years, and 69% at 10 years. Actuarial freedom from major adverse cardiovascular events (MACE) was 82% at 1 year, 72% at 2 years, and 72% at 8 years. The UPPS score predicts late mortality with sensitivity of 75% and negative predictive value of 84%.

Conclusion: Our prognostic score (UPPS) helps not only in predicting early mortality but also in identifying the patients who are likely to live longer. The management score (UPMS) also provides best timing for the procedure, which is helpful in optimal utilization of resources in the developing world. The accuracy of these scores is reasonable and may be helpful in the decision-making in this difficult subset.
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http://dx.doi.org/10.1007/s12055-019-00792-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525703PMC
July 2019

Implications of the Genitourinary Microbiota in Prostatic Disease.

Curr Urol Rep 2019 May 18;20(7):34. Epub 2019 May 18.

Department of Urology, Loyola University Chicago Stritch School of Medicine, 2160 South First Ave. Building 54, Room 23A, Maywood, IL, 60153, USA.

Purpose Of Review: To summarize recent investigation into associations between the genitourinary microbiota and prostatic disease.

Recent Findings: The genitourinary tract is not sterile. There are microbial communities (microbiota) in each niche of the genitourinary tract including the bladder, prostate, and urethra, which have been the subject of increasing scientific interest. Investigators have utilized several unique methods to study them, resulting in a highly heterogeneous body of literature. To characterize these genitourinary microbiota, diverse clinical specimens have been analyzed, including urine obtained by various techniques, seminal fluid, expressed prostatic secretions, and prostatic tissue. Recent studies have attempted to associate the microbiota detected from these samples with urologic disease and have implicated the genitourinary microbiota in many common conditions, including benign prostatic hyperplasia (BPH), prostate cancer, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). In this review, we summarize the recent literature pertaining to the genitourinary microbiota and its relationship to the pathophysiology and management of three common prostatic conditions: BPH, prostate cancer, and CP/CPPS.
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http://dx.doi.org/10.1007/s11934-019-0904-6DOI Listing
May 2019

Urothelial Carcinoma Recurrence in an Orthotopic Neobladder without Urethral or Upper Urinary Tract Involvement.

Case Rep Urol 2019 5;2019:8458706. Epub 2019 Mar 5.

Department of Urology, Loyola University Medical Center, Maywood, IL, USA.

We describe a case of a 71-year-old male with an isolated recurrence of urothelial carcinoma in an ileal neobladder without involvement of the upper urinary tract or urethra. He was diagnosed with high grade urothelial carcinoma involving a bladder diverticulum with associated carcinoma in situ. He underwent a radical cystectomy and orthotopic Studer ileal neobladder. On routine follow-up, 11 years following cystectomy, voided urine cytology was positive for high grade urothelial carcinoma. Further workup revealed normal upper urinary tracts, normal urethra, and a solitary lesion at the left anteroinferior wall of the neobladder. He subsequently underwent resection of the neobladder and conversion to an ileal conduit with pathology confirming the diagnosis of high grade urothelial carcinoma. Isolated recurrence of urothelial carcinoma within a neobladder without involvement of the upper urinary tract or urethra is rare. No guidelines exist regarding its management. Herein we present our management as well as the current literature published on this topic.
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http://dx.doi.org/10.1155/2019/8458706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425315PMC
March 2019

Socioeconomic Disparities in the Acute Management of Stone Disease in the United States.

J Endourol 2019 02 31;33(2):167-172. Epub 2019 Jan 31.

1 Loyola University Medical Center, Department of Urology, Maywood, Illinois.

Introduction: Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality.

Materials And Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared.

Results: We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients.

Conclusion: Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.
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http://dx.doi.org/10.1089/end.2018.0760DOI Listing
February 2019

Concomitant Left Atrial Reduction in Rheumatic Mitral Valve Disease With Giant Left Atrium: Our Technique With Midterm Results.

Innovations (Phila) 2018 Sep/Oct;13(5):349-355

Medical Research, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Civil Hospital Campus, Asarwa, Ahmedabad, India.

Objective: The giant left atrium is a frequent finding with rheumatic heart disease. The enlarged left atrium was found to be a risk factor for early mortality and postoperative higher thromboembolic events, but its management remains controversial. Most of the surgeons just do the mitral valve procedure without any intervention for enlarged left atrium. We present our center's experience of patients with giant left atrium who underwent a newer technique of left atrium reduction concomitant with mitral valve procedure.

Methods: Between January 2012 and February 2015, 25 patients, who underwent surgery for concomitant left atrium reduction with mitral valve disease, were included in the study after institute's ethics committee clearance. Patients having combined aortic and mitral valve disease were excluded. Preoperative, intraoperative, and postoperative data were collected. All the patients were also followed up clinically and echocardiographically in postoperative period.

Results: There were 15 (60%) females. The mean ± SD age of the patients was 36.92 ± 5.4 years. Preoperatively, all patients were in long-standing persistent atrial fibrillation. The mean ± SD bypass and aortic cross-clamp time were 74.56 ± 3.85 and 51.72 ± 4.32 minutes, respectively. There was a significant reduction of left atrium diameter and volume from 94.48 ± 11.0 mm to 40.08 ± 1.35 mm and 348.3 ± 121.1 to 26.57 ± 2.9 mL/m, respectively. There was no early or late mortality. At a mean ± SD follow-up of 42.28 ± 12.1 months, all patients were in New York Heart Association I or II class and 24 (96%) patients were in normal sinus rhythm.

Conclusions: Concurrent left atrium reduction with mitral valve procedure is a feasible and effective technique for event-free survival of the patients having giant left atrium with mitral disease.
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http://dx.doi.org/10.1097/IMI.0000000000000559DOI Listing
March 2019

Direct Femoral Cannulation in Minimal Invasive Pediatric Cardiac Surgery: Our Experience With Midterm Result.

Innovations (Phila) 2018 Jul/Aug;13(4):300-304

Nuclear Medicine, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India.

Objective: One of the major challenges faced in minimally invasive pediatric cardiac surgery is cannulation strategy for cardiopulmonary bypass. Central aortic cannulation through the same incision has been the usual strategy, but it has the disadvantage of cluttering of the operative field. We hereby present the results of femoral cannulation in minimally invasive pediatric cardiac surgery in terms of adequacy and safety.

Methods: From January 2013 to June 2016, 200 children (122 males) with mean ± SD age of 9.2 ± 4.51 years (median = 6 years, range = 3-18 years) and weight of 19.22 ± 8.49 kg (median = 15 kg, range = 8-45 kg) were operated for congenital cardiac defects through anterolateral thoracotomy. The most common diagnosis was atrial septal defect (144 patients). In all the patients, femoral artery and femoral vein were cannulated along with direct superior vena cava cannulation for institution of cardiopulmonary bypass.

Results: There were no deaths or any major complications related to femoral cannulation. Femoral artery cannulation provided adequate arterial inflow, whereas femoral vein with direct superior vena cava cannulation provided adequate venous return in all the patients. No patient required vacuum-assisted venous drainage. No patient required conversion to sternotomy or developed vascular, neurological complications. At discharge and at 1-year follow-up, both femoral artery and vein were patent without a significant stenosis on color Doppler ultrasonography in all the patients. At mean ± SD follow-up period of 30.63 ± 10.09 months, all the patients were doing well without any wound-related, neurological, or vascular complications.

Conclusions: Femoral arterial and venous cannulation is a feasible, reliable, and efficient method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.
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http://dx.doi.org/10.1097/IMI.0000000000000540DOI Listing
December 2018

Surgical overview of cardiac echinococcosis: a rare entity.

Interact Cardiovasc Thorac Surg 2018 08;27(2):191-197

Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated with B.J. Medical College), Ahmedabad, Gujarat, India.

Objectives: The purpose of this study was to describe our experience with the presentation and management of cardiac echinococcosis and the outcomes.

Methods: We performed a retrospective study from January 2012 to September 2017 in 10 patients operated on for cardiac echinococcosis. There were 6 men and 4 women; the age range was 17-55 years (mean age, 35.9 ± 12.04 years). Among the 10 patients, 3 had multiple cysts and of the 7 patients with a solitary cyst, 5 cysts were in the left ventricle, 1 was in the right ventricle and 1 was in the interventricular septum. All patients were evaluated with electrocardiography, transthoracic echocardiography, computed tomography/magnetic resonance imaging of the thorax, ultrasound examinations of the abdominal organs, haemagglutination tests and histopathological examination of the cyst.

Results: Nine operations were performed using cardiopulmonary bypass. One patient with a pericardial cyst was operated on with a beating heart with cystectomy and partial pericardiectomy. Preoperatively, all patients received albendazole for 2 weeks except for 1 patient who had an emergency operation. Albendazole was continued postoperatively in all patients for 12 weeks. There were no postoperative complications. No recurrences have been observed so far.

Conclusions: Cardiac echinococcosis is an infrequently encountered entity, but with clinical suspicion and early diagnosis it can be successfully managed with good outcomes.
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http://dx.doi.org/10.1093/icvts/ivy053DOI Listing
August 2018

Anterior Minithoracotomy: a Safe Approach for Surgical ASD Closure & ASD Device Retrieval.

Braz J Cardiovasc Surg 2017 Jul-Aug;32(4):270-275

Department of Research of the U. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad), Gujarat, India.

Objective: Midline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect.

Methods: Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy.

Results: Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication.

Conclusion: Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.
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http://dx.doi.org/10.21470/1678-9741-2017-0024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613724PMC
October 2017

Safe and easy method with little modification in technique is useful for successful internal jugular vein cannulation on the same side even after intra-arterial puncture without using ultrasound guidance in adult cardiac patients.

Ann Card Anaesth 2016 Apr-Jun;19(2):277-80

Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Ahmedabad, Gujarat, India.

Background: The modification in technique is useful for successful right-sided internal jugular vein (IJV) cannulation on the same side even after intra-arterial puncture without using ultrasound guidance in adult patients.

Materials And Methods: This study was carried out in total 160 adult patient from American Society of Anesthesiologists Grade II to III patients male (n = 95) and female (n = 65) who underwent cardiac surgery where cannulation was done on right sided by triple lumen catheter (7 French) using Seldinger technique.

Results: Majority of patients were cannulated successfully by Seldinger technique with single or double attempt except for five patients in which arterial puncture occurred. All five patients were cannulated successfully on the same side with this modified technique without any significant major complications. They were managed by application of blocker at the end of arterial needle puncture without removing it. In our routine practice, we were used to removing this needle and applying compression for few minutes to prevent hematoma formation after an arterial puncture. In this study, cannula was used as a marker or guideline for the relocation of IJV on the same side and recannulation was performed by changing the direction of needle on same side lateral to the previous one and without going towards the same direction to prevent the arterial puncture again.

Conclusion: Most simple and useful modified technique for institutes where the complications are most common with trainee doctors and in hospitals where there is no advanced facility like ultrasound-guided cannulation available. By this modification, it will be time saving, very comfortable, and user-friendly technique with high success rate.
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http://dx.doi.org/10.4103/0971-9784.179622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900335PMC
January 2017

Clinical significance of prospectively assigned Gleason tertiary pattern 4 in contemporary Gleason score 3+3=6 prostate cancer.

Prostate 2016 Jun 16;76(8):715-21. Epub 2016 Feb 16.

Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.

Objective: To determine the oncologic impact of prospectively assigned tertiary pattern 4 in contemporary Gleason score (GS) 3 + 3 = 6 radical prostatectomy (RP) specimens.

Patients And Methods: Oncologic outcomes were retrospectively reviewed for 720 consecutive patients from a single National Comprehensive Cancer Network (NCCN) center with at least 6 months follow-up after RP for GS3 + 3 = 6 (GS6, N = 222), GS6 with tertiary pattern 4 (GS6t4, N = 62), or GS3 + 4 = 7 (N = 436) prostate cancer, as prospectively graded since 2006 using the 2005 International Society of Urologic Pathologists criteria. Preoperative NCCN risk category, RP pathology, progression-free survival (PFS) and metastasis-free survival (MFS) were compared among the GS6, GS6t4, and GS3 + 4 = 7 groups using χ(2) , Kaplan-Meier, and log-rank analyses.

Results: The incidence of low NCCN preoperative risk classification for GS6t4 patients (63%) was less than that for GS6 patients (77%) while greater than that for GS3 + 4 = 7 patients (30%, P < 0.001). GS6t4 patients had RP pathologic features which were intermediate in risk between that of GS6 and GS3 + 4 = 7 based on extraprostatic extension (27% vs. 6% vs. 31%, respectively, P < 0.001) and mean percentage of prostate gland involvement (13% vs. 10% vs. 16%, respectively, P < 0.001). With a mean overall follow-up of 42 months, PFS for GS6t4 patients (5-year 85%) was intermediate between that of GS6 (5-year 93%) and GS3 + 4 = 7 (5-year 76%) patients (P < 0.001). The 5-year MFS rate was 100% for GS6 and GS6t4 patients compared to 97% for GS3 + 4 = 7 patients (P = 0.07).

Conclusions: This study provides the longest follow-up to date for RP patients with prospectively assigned GS6t4 and supports a risk for adverse RP pathology and postoperative disease progression that is intermediate between GS6 and GS3 + 4 = 7. Whether a tertiary pattern 4 in GS6 disease increases the risk of metastasis is uncertain and requires longer term study. Given favorable oncologic outcomes, less stringent postoperative surveillance for both GS6 and GS6t4 patients may be warranted.
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http://dx.doi.org/10.1002/pros.23166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5437842PMC
June 2016

Obesity and seatbelt use: a fatal relationship.

Am J Emerg Med 2014 Jul 20;32(7):756-60. Epub 2014 Jan 20.

Department of Emergency Medicine, Erie County Medical Center, Buffalo, NY.

Background: Seatbelts significantly reduce the risk of death in motor vehicle accidents, but a certain number of individuals from some subgroups tend not to wear their seatbelts.

Objectives: In this study, we hypothesized that obese drivers (in fatal crashes) were less likely to wear seatbelts than their normal-weight counterparts.

Methods: A retrospective study was conducted on the drivers in motor vehicle crashes entered into the Fatality Analysis Reporting System database between 2003 and 2009. A number of precrash variables were found to be significantly associated with seatbelt use. These were entered into a multivariate logistic regression model using stepwise selection. Drivers were grouped into weight categories based on the World Health Organization definitions of obesity by body mass index. Seatbelt use was then examined by body mass index, adjusted for precrash variables that were significantly associated with seatbelt use.

Results: The odds of seatbelt use for normal-weight individuals were found to be 67% higher than the odds of seatbelt use in the morbidly obese. The relationship of seatbelt use between the different weight groups and the morbidly obese is as follows (odds ratios [ORs] for each comparison are listed with 95% confidence limits [CL]): underweight vs morbidly obese (OR, 1.62; CL, 1.47-1.79), normal weight vs morbidly obese (OR, 1.67; CL, 1.54-1.81), overweight vs morbidly obese (OR, 1.60; CL, 1.48-1.74), slightly obese vs morbidly obese (OR, 1.40; CL, 1.29-1.52), and moderately obese vs morbidly obese (OR, 1.24; CL, 1.13-1.36).

Conclusion: Seatbelt use is significantly less likely in obese individuals compared with their normal-weight counterparts.
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http://dx.doi.org/10.1016/j.ajem.2014.01.010DOI Listing
July 2014

Minimally invasive combined aortic and mitral valve replacement.

Heart Lung Circ 2011 Apr 10;20(4):231-3. Epub 2010 Dec 10.

Dept. of Minimally Invasive Cardiac Surgery, CARE Hospital - The Heart Institute, Athwagate, Surat 395001, Gujarat, India. pragnesh

A technique is described here to carry out combined aortic and mitral valve replacement (DVR) in a patient with rheumatic valve disease utilising a minimally invasive approach without major modification in the conventional technique. An incision of approximately 5 cm is made on the upper sternum followed by partial sternal split with 'J' extension in the right third inter costal space (ICS). The mitral and aortic valves can be replaced with ease and excellent outcome. The technique is reproducible and does not require any special instrumentation. We carried out DVR with this approach in 17 patients.
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http://dx.doi.org/10.1016/j.hlc.2010.10.072DOI Listing
April 2011
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