Ahmer Farooq

Online Reviews of 500 Urologists

PURPOSE Patient demand for easily accessible information about physician quality has led to the development of physician review websites. These sites concern some physicians who argue that ratings can be misleading. In this study we describe the landscape of online reviews of urologists by looking at a sample of ratings and written reviews from popular physician review websites. MATERIALS AND METHODS A total of 500 urologists were randomly selected from a database of 9,940. Numerical ratings from 10 popular physician review websites were collected for each physician and analyzed. Written reviews from a single physician review website were also collected and then categorized as extremely negative/positive, negative/positive or neutral. RESULTS Our sample consisted of 471 male and 29 female urologists from 39 states including small and large cities and 4 census regions. There were 398 (79.6%) urologists who had at least 1 rating on any of the 10 physician review websites (range 0 to 64). On average the composite rating was based on scores from only 2.4 submitted ratings. Most physicians had positive ratings (86%), with 36% having highly positive ratings. No difference was seen in the median number of reviews when gender (p = 0.72), region (p = 0.87) and city size (p = 0.87) were compared. Written reviews were mostly positive or extremely positive (53%). CONCLUSIONS We advise physicians and patients to be aware that most urologists are rated on at least 1 physician review website, and while most ratings and reviews are favorable, composite scores are typically based on a small number of reviews and, therefore, can be volatile.

Size Does Matter: Donor Renal Volume Predicts Recipient Function Following Live Donor Renal Transplantation

PURPOSE With the now routine use of computerized tomography angiography with 3-dimensional reconstruction in the donor evaluation, renal volume can be easily determined using volume calculating software. We evaluated whether donor renal volume could predict recipient renal function. MATERIALS AND METHODS Clinical data of all donor and recipient pairs undergoing live donor kidney transplantation at our institution between January 2006 and October 2009 were reviewed. The volume of the kidney selected for transplant was determined using volume calculating software, and correlated to transplant recipient nadir and 1-year serum creatinine. Multivariate regression analysis was performed to adjust for demographic and clinical variables. RESULTS During the study period 114 patients underwent live donor renal transplantation. Recipient nadir and 1-year serum creatinine levels were significantly correlated with the volume of donated kidney even after adjusting for age, body mass index, body surface area and donor creatinine clearance. Kidney volume also retained significance after excluding recipients from analysis who experienced acute rejection episodes. CONCLUSIONS Larger kidney volumes calculated using 3-dimensional computerized tomography with volume calculating software are correlated with lower recipient nadir and 1-year serum creatinine levels.

Sciatic nerve injury induces functional pro-nociceptive chemokine receptors in bladder-associated primary afferent neurons in the rat.

Visceral sensory afferents during disease or following injury often produce vague, diffuse body sensations, and pain referred to somatic targets. Alternatively, injury due to trauma or disease of somatic nerve targets can also lead to referred pain in visceral targets via a somatovisceral reflex. Both phenomenons are thought to be due to convergence of visceral and somatic afferents within the spinal cord. To investigate a potential peripheral influence for referred pain in visceral targets following somatic nerve injury, we examined whether a sciatic nerve injury known to produce hindpaw tactile hyperalgesia alters the frequency of micturition and the sensitivity of bladder-associated sensory neurons to pro-nociceptive chemokines. Adult female Sprague-Dawley rats received injections of cholera toxin B subunit conjugated to 555 into urinary bladder wall to retrogradely label visceral primary afferent neurons. After 7 days, the right sciatic nerve of these animals was subjected to a lysophosphatidylcholine (LPC)-induced focal demyelination injury. Pre- and post-injury tactile sensitivity in the hind paw and micturition frequency were assayed. Animals were allowed to survive for 14-28 days. Lumbosacral and lumbar dorsal root ganglia (DRG) ipsilateral to the nerve injury were acutely dissociated from sham and nerve injured animals. Bladder wall-associated sensory neurons identified via the retrograde marker were assayed for fluxes in intracellular calcium following administration of pro-nociceptive chemokines. The assayed chemokines included monocyte chemoattractant protein-1 (MCP1/CCL2) and stromal cell derived factor-1 alpha (SDF1/CXCL12). LPC nerve injured animals exhibited tactile hyperalgesia and increased micturition frequency for at least 28 days. Focal demyelination of the sciatic nerve also increased the number of injured L₄L₅ and non-injured L₆-S₂ bladder-associated sensory neurons that responded to MCP1 and SDF1 when compared with sensory neurons derived from uninjured naïve and sham-injured control animals. Taken together, these data suggest that some visceral hypersensitivity states may have a somatic origin. More importantly, nociceptive somatovisceral sensation may be mediated by upregulation of chemokine signaling in visceral sensory neurons.

Technological Improvements in Three-Piece Inflatable Penile Prosthesis Design over the Past 40 Years

INTRODUCTION The advent of the penile prosthesis revolutionized the treatment of erectile dysfunction (ED), resulting in near-complete treatment efficacy and high patient satisfaction rates. While several types of penile prosthesis are available, the inflatable penile prosthesis (IPP) is the most commonly used device in the United States. AIMS To describe the key modifications to IPPs from the two major manufacturers-American Medical Systems (AMS) and Coloplast-since the invention of the IPP, and to relate these changes to improvements in prosthesis function and patient outcomes based on available literature. METHODS Review and evaluation of the literature between 1973 and present describing modifications in IPP design and the influence of these modifications on IPP durability and patient-related factors. MAIN OUTCOME MEASURES Data describing the impact of iterative improvements in three-piece IPP design on device function, durability, and patient outcomes. RESULTS There were progressive improvements in IPP technology from both major manufacturers not only on the durability of the prosthesis but also on patient outcomes, with fewer device failures and lower infection rates. Notable improvements include incorporation of kink-resistant tubing, changes in the weave or addition of shear- and infection-resistant coatings to cylinder layers, pump and tubing connection modifications, the addition of rear tip extenders, and the incorporation of lockout valves to prevent autoinflation. CONCLUSIONS Numerous incremental modifications to the IPP from both major manufacturers since its invention have increased its durability and improved patient outcomes.

Transplant tourism - a dangerous journey?

Polcari AJ, Hugen CM, Farooq AV, Holt DR, Hou SH, Milner JE. Transplant tourism – a dangerous journey?
Clin Transplant 2011: 25: 633–637.

Effect of the Phosphodiesterase-5 Inhibitor Zaprinast on Ischemia-Reperfusion Injury in Rats

PURPOSE The cardiac and renal protective effects of phosphodiesterase-5 (PDE-5) inhibitors against ischemia-reperfusion injury have recently been demonstrated in animal studies. We evaluated the effect of pretreatment with the PDE-5 inhibitor zaprinast on warm renal ischemia in a rat model. METHODS Female Sprague-Dawley rats underwent concomitant right nephrectomy and left renal hilar occlusion for 30 minutes. Twelve animals were equally divided into three groups: Group 1 received no pharmacologic pretreatment, group 2 was pretreated with zaprinast 10 mg/kg, and group 3 was pretreated with zaprinast 20 mg/kg. Zaprinast was dissolved in 25% dimethyl sulfoxide and given as a single intraperitoneal injection 30 minutes before surgery. Serum blood urea nitrogen (BUN) and creatinine levels, histopathology, and TUNEL staining for apoptosis were assessed 24 hours postoperatively. RESULTS The mean creatinine level for groups 1, 2, and 3 was 0.73 mg/dL, 0.55 mg/dL, and 0.38 mg/dL, respectively. These values were not statistically different (P=0.099). The mean BUN levels of 35.8 mg/dL for group 1, 27.3 mg/dL for group 2, and 23.3 mg/dL for group 3 were also statistically similar (P=0.278). There were no objective differences in histopathologic evaluation or TUNEL staining between the groups. CONCLUSION This study did not demonstrate a beneficial effect of zaprinast pretreatment on renal parameters after warm ischemic injury.

A novel technique for the removal of minimally encrusted ureteral stents.

The removal of encrusted ureteral stents typically necessitates secondary treatment modalities, such as ureteroscopy, extracorporeal shock wave lithotripsy, or antegrade nephroscopy. We present a novel technique for the removal of minimally encrusted stents using a suture and a ureteral access sheath.

Male Bladder Microbiome Relates to Lower Urinary Tract Symptoms

BACKGROUND In women, compelling evidence associates lower urinary tract microbiota (LUTM) with lower urinary tract symptoms (LUTS); a similar association in men with benign prostate enlargement (BPE) is not established. OBJECTIVE To determine whether associations exist between LUTM and LUTS. DESIGN, SETTING, AND PARTICIPANTS Forty-nine male volunteers, aged 40-85 yr, were recruited from one academic tertiary care center. Twenty-eight patients undergoing BPE/LUTS surgery and 21 undergoing non-BPE/LUTS surgery were stratified by International Prostate Symptom Score (IPSS), and paired voided/catheterized urine specimens were collected for expanded quantitative urine culture (EQUC) and 16S ribosomal RNA gene sequencing. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary and secondary outcomes were presence of detectable LUTM and specific bacterial members of the LUTM, respectively. Baseline data were compared. Univariable logistic regression models were used to calculate odds ratios (ORs) for IPSS category associated with the presence of bladder microbiota. Relative LUTM proportions were compared with IPSS using chi-square tests. RESULTS AND LIMITATIONS Thirty-nine percent of catheterized and 98% of voided specimens contained LUTM. Catheterized and voided LUTM differed significantly. LUTM was detected in catheterized urine of 22.2% of men with mild LUTS, 30.0% with moderate LUTS, and 57.1% with severe LUTS (p=0.024). Increased IPSS category was associated with significantly higher odds of detectable bacteria (OR: 2.21, 95% confidence interval: 1.09-4.49). Small sample size limited this study, making it unable to identify significant differences in specific bacterial taxa based on IPSS. CONCLUSIONS Voided urine does not adequately characterize the male bladder microbiome. In males with and without BPE, IPSS severity was associated with detectable bacteria in catheterized urine, which samples the bladder. Additional studies are needed to identify specific bladder bacteria associated with LUTS. PATIENT SUMMARY To study bladder bacteria, urine should be collected with a catheter. Men with severe urinary symptoms are more likely to have detectable bladder bacteria than those with less severe symptoms.

Impact of Post-hospital Syndrome on Penile Prosthesis Outcomes: A Period of Global Health Risk

Purpose: Post-hospital syndrome is an acquired transient period of health vulnerability following inpatient admission. We assessed the impact of a preoperative hospitalization on outcomes following penile prosthesis surgery and sought to optimize surgical timing after inpatient admission. Materials and Methods: We used the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery Database for California from 2007 to 2011 and for Florida from 2009 to 2014. Patients were identified as having undergone prosthesis placement by ICD-9 and CPT codes. The primary exposure was post-hospital syndrome, defined as any inpatient admission 90 days or less before prosthesis placement. Patients were further categorized by how recently the inpatient hospitalization occurred. The primary study outcome was 30-day hospital readmission. Secondary outcomes were length of stay, and device and postoperative complications. Results: We identified 16,923 patients who received a penile prosthesis, of whom 477 (3%) had post-hospital syndrome exposure 90 days or less before prosthesis placement. After risk adjustment patients with post-hospital syndrome had higher odds of 30-day readmission (OR 3.0, 95% CI 2.2–4.1), length of stay 2 days or longer (OR 1.7, 95% CI 1.3–2.3) and device complications (OR 1.7, 95% CI 1.2–2.5). When categorizing patients by 30-day intervals, we found a linear decrease in the risk of 30-day readmission as the interval increased between post-hospital syndrome exposure and prosthesis surgery. Conclusions: Post-hospital syndrome exposure is a risk adjusted predictor of 30-day readmissions, prolonged length of stay and device complications. Medical optimization and delayed surgery can help combat the adverse effects associated with post-hospital syndrome exposure and may improve surgical outcomes.

Transitioning from a Low Dose Rate to a High Dose Rate Prostate Brachytherapy Program: Comparing Initial Dosimetry and Improving Workflow Efficiency through Targeted Interventions

Purpose We transitioned from a low-dose-rate (LDR) to a high-dose-rate (HDR) prostate brachytherapy program. The objective of this study was to describe our experience developing a prostate HDR program, compare the LDR and HDR dosimetry, and identify the impact of several targeted interventions in the HDR workflow to improve efficiency. Methods and Materials We performed a retrospective cohort study of patients treated with LDR or HDR prostate brachytherapy. We used iodine-125 seeds (145 Gy as monotherapy, and 110 Gy as a boost) and preoperative planning for LDR. For HDR, we used iridium-192 (13.5 Gy × 2 as monotherapy and 15 Gy × 1 as a boost) and computed tomography–based planning. Over the first 18 months, we implemented several targeted interventions into our HDR workflow to improve efficiency. To evaluate the progress of the HDR program, we used linear mixed-effects models to compare LDR and HDR dosimetry and identify changes in the implant procedure and treatment planning durations over time. Results The study cohort consisted of 122 patients (51 who received LDR and 71 HDR). The mean D90 was similar between patients who received LDR and HDR (P = .28). HDR mean V100 and V95 were higher (P < .0001), but mean V200 and V150 were lower (P < .0001). HDR rectum V100 and D1cc were lower (P < .0001). The HDR mean for the implant procedure duration was shorter (54 vs 60 minutes; P = .02). The HDR mean for the treatment planning duration dramatically improved with the implementation of targeted workflow interventions (3.7 hours for the first quartile to 2.0 hours for the final quartile; P < .0001). Conclusions We successfully developed a prostate HDR brachytherapy program at our institution with comparable dosimetry to our historic LDR patients. We identified several targeted interventions that improved the efficiency of treatment planning. Our experience and workflow interventions may help other institutions develop similar HDR programs.