Alexandra Bor, MD

All Publications

• The Future Global Classroom: Augmented Reality for Anesthesia Crisis Response Simulation with Tanzanian Nurse Anesthetists Hong, T., Mganga, S., Umeh, N., Bor, A., Canady, F., Caruso, T., Khoo, C. LIPPINCOTT WILLIAMS & WILKINS. 2024

  View details for Web of Science ID 001367242802040

• The Hemodynamic Effects of Protamine in Pediatric Patients Undergoing Pulmonary Artery Reconstruction and Unifocalization Surgery: A Pilot StudyHemodynamic Effects of Protamine in Children. Journal of cardiothoracic and vascular anesthesia Li, X., Fang, Z. A., Lennig, M. M., Klein, A., Char, D., Giustini, A. J., Boltz, M. G., Quiñónez, Z. A. 2024

  Abstract

  To determine protamine administration increases pulmonary artery pressures (PAPs) in patients undergoing unifocalization or pulmonary artery reconstruction surgeries.Retrospective database study.A large pediatric heart center within an academic quaternary care facility.All patients undergoing pulmonary artery reconstruction or a unifocalization procedure identifiable within the data warehouse.We collected data from Stanford University's data repository, formatted it, and analyzed it using RStudio (v 2023.06.1+524).Our primary outcome is the change in PAP after the administration of protamine. Secondary outcomes include changes in the mean arterial pressure, the ratio of systolic pulmonary artery to systemic artery pressure, right-sided filling pressure, and left atrial pressure. After a protamine bolus, we found a difference in PAP (Friedman χ2 = 49.46; p < 0.001). When compared with 2 minutes before its administration, the PAP was higher at 2 minutes (29.00 mmHg versus 25.00 mmHg; p < 0.001), 5 minutes (30.00 mmHg versus 25.00 mmHg; p < 0.001) and 10 minutes (31 mmHg versus 25 mmHg; p < 0.001). When coadministered with calcium, there was also a significant increase in PAP (Friedman χ2 = 28.11; p < 0.001), with a higher PAP 10 minutes after calcium administration when compared with 2 minutes before (32 mmHg versus 26 mmHg; p < 0.001).Protamine administration led to a small increase in PAP after separation from cardiopulmonary bypass in patients undergoing pulmonary artery reconstruction or unifocalization surgeries. Calcium coadministration did not lead to a greater increase in PAP.

  View details for DOI 10.1053/j.jvca.2024.11.001

  View details for PubMedID 39592272

• The Hemodynamic Effects of Bolus Dose Calcium in Patients Undergoing Pulmonary Artery Reconstruction and Unifocalization Surgery: A Pilot Study. Journal of cardiothoracic and vascular anesthesia Quiñónez, Z. A., Klein, A., Li, X., Lennig, M. A., Giustini, A. J., Boltz, M. G., Char, D. 2024

  Abstract

  To determine if bolus administration of calcium increases pulmonary artery pressures after unifocalization procedures or pulmonary artery reconstruction surgery.Retrospective cohort study using Stanford University's data warehouse.A large pediatric heart center within an academic quaternary care facility.All patients undergoing pulmonary artery reconstruction or unifocalization procedures identifiable in the data warehouse.Data were collected from Stanford University's data repository and formatted and analyzed using RStudio (v 2023.06.1+524).The primary outcome was the change in pulmonary artery systolic pressure (PASP) after a bolus administration of calcium. Secondary endpoints include changes in pulmonary arterial-to-systemic arterial pressure ratio, mean arterial pressure, right-sided filling pressure, and left atrial pressure. The Friedman test was used to assess differences and the Durbin-Conover rank-sum for pairwise comparisons. A difference in PASP after a bolus dose of calcium was found (Friedman X2 = 13.67, p = 0.003), with a higher PASP 5 minutes after calcium administration compared with 2 minutes before administration (35 mmHg v 33 mmHg, p = 0.01), and a higher PASP 10 minutes after calcium administration compared with2 minutes before administration (35 mmHg v 33 mmHg, p = 0.008).Calcium bolus administration led to an increase in pulmonary arterial pressure in patients after pulmonary artery reconstruction or unifocalization surgeries. It may be prudent to avoid bolus administration in this patient population immediately after repair or in patients with right ventricular dysfunction.

  View details for DOI 10.1053/j.jvca.2024.08.008

  View details for PubMedID 39227189

• The Effect of Night Float Rotation on Resident Sleep, Activity, and Well-Being. Anesthesia and analgesia Ruan, A., Klein, A., Jhita, P., Hasan-Hill, N., Shafer, S. L., Flood, P. D. 2022

  Abstract

  BACKGROUND: Night float call systems are becoming increasingly common at training programs with the goal of reducing fatigue related to sleep deprivation and sleep disturbance. Previous studies have shown that trainees obtain less sleep during the night float rotation and have decreased sleep efficiency for several days after the rotation. The impact on physical and emotional well-being has not been documented.METHODS: Twenty-seven anesthesia residents were enrolled in a study using wearable sleep and activity trackers and National Institutes of Health Patient-Reported Outcome Measurement Information System (NIH PROMIS) surveys for sleep disturbance, fatigue, and positive affect to record data the week before ("baseline"), during ("night float"), and 1 week after ("recovery") their night float rotation. Each subject's data during the night float week and recovery week were compared to his or her own baseline week data using a paired, nonparametric analysis. The primary outcome variable was the change in average daily sleep hours during the night float week compared to the baseline week. Average daily rapid eye movement (REM) sleep, daily steps, and NIH PROMIS scores comparing night float and recovery weeks to baseline week were prespecified secondary outcomes. NIH PROMIS scores range from 0 to 100 with 50 as the national mean and more of the construct having a higher score.RESULTS: There was no difference in average daily sleep hours between the night float and the baseline weeks (6.7 [5.9-7.8] vs 6.7 [5.5-7.7] hours, median [interquartile range]; P = .20). Residents had less REM sleep during the night float compared to the baseline weeks (1.1 [0.7-1.5] vs 1.4 [1.1-1.9] hours, P = .002). NIH PROMIS fatigue scores were higher during the night float than the baseline week (58.8 [54.6-65.1] vs 48.6 [46.0-55.1], P = .0004) and did not return to baseline during the recovery week (51.0 [48.6-58.8], P = .029 compared to baseline). Sleep disturbance was not different among the weeks. Positive affect was reduced after night float compared to baseline (39.6 [35.0-43.5] vs 44.8 [40.1-49.6], P = .0009), but returned to baseline during the recovery week (43.6 [39.6-48.2], P = .38).CONCLUSIONS: The residents slept the same number of total hours during their night float week but had less REM sleep, were more fatigued, and had less positive affect. All of these resolved to baseline except fatigue, that was still greater than the baseline week. This methodology appears to robustly capture psychophysiological data that might be useful for quality initiatives.

  View details for DOI 10.1213/ANE.0000000000006261

  View details for PubMedID 36342844

• The Effect of Night Float Rotation on Resident Sleep, Activity, and Wellbeing: An Observational Study Ruan, A., Klein, A., Hasan, N., Flood, P. LIPPINCOTT WILLIAMS & WILKINS. 2022: 433-436

  View details for Web of Science ID 000840283000166

• Standing cough test for evaluation of post-prostatectomy incontinence: a pilot study. The Canadian journal of urology Morey, A. F., Singla, N., Carmel, M., Klein, A., Tausch, T. J., Siegel, J., Tachibana, I., Scott, J. 2017; 24 (1): 8664-8669

  Abstract

  We implemented a standardized Standing Cough Test (SCT) for assessment of men with post-prostatectomy incontinence (PPI) and stratified results according to an objective clinical grading scale in an attempt to facilitate male anti-incontinence surgical procedure selection.SCT was routinely performed during the initial outpatient consultation for PPI. Incontinence severity was recorded based on a novel Male Stress Incontinence Grading Scale (MSIGS) to stratify PPI. Each patient was assigned an incontinence grade score of 0 through 4 during the SCT. Men with mild stress urinary incontinence (SUI) (grades 0-2) were offered sling surgery while those with heavier SUI (grades 3-4) were offered artificial urinary sphincter (AUS). MSIGS grade was correlated to preoperative patient-reported pads per day (PPD), and patient-reported outcomes of anti-incontinence surgery were assessed.Among 62 consecutive PPI patients, 20 (32%) were graded as mild based on SCT, while the majority (42/62, 68%) were graded as moderate-severe. Average time from prostatectomy to treatment was 6 years. MSIGS grade demonstrated a strong correlation with preoperative PPD (r = 0.74). Among the 53 patients who underwent surgery for PPI, 14 with mild SUI received a sling, while 39 (74%) more severe cases received an AUS. Patient-reported improvement was high overall in both groups (median 95%).Most men with chronic PPI present for definitive treatment in a delayed manner after prostatectomy despite having severe incontinence. The SCT provides immediate, objective information about the severity of PPI which strongly correlates with patient-reported pads-per-day and may expedite anti-incontinence surgical procedure selection.

  View details for PubMedID 28263134

• Inflatable penile prosthesis as tissue expander: what is the evidence? International braz j urol : official journal of the Brazilian Society of Urology Chung, P. H., Siegel, J. A., Tausch, T. J., Klein, A. K., Scott, J. M., Morey, A. F. 2017; 43 (5): 911-916

  Abstract

  Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion.We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection).Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm.As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

  View details for DOI 10.1590/S1677-5538.IBJU.2016.0528

  View details for PubMedID 28537700

  View details for PubMedCentralID PMC5678524

• Low Serum Testosterone Level Predisposes to Artificial Urinary Sphincter Cuff Erosion. Urology Hofer, M. D., Morey, A. F., Sheth, K., Tausch, T. J., Siegel, J., Cordon, B. H., Bury, M. I., Cheng, E. Y., Sharma, A. K., Gonzalez, C. M., Kaplan, W. E., Kavoussi, N. L., Klein, A., Roehrborn, C. G. 2016; 97: 245-249

  Abstract

  To examine the association between decreased serum testosterone levels and artificial urinary sphincter (AUS) cuff erosion.We evaluated serum testosterone levels in 53 consecutive patients. Low testosterone was defined as <280 ng/dL and found in 30/53 patients (56.6%). Chi-square and Student t tests, Kaplan-Meier analysis, binary logistic regression, and Cox regression analysis were used to determine statistical significance.Nearly all men with AUS cuff erosions had low serum testosterone (18/20, 90.0%) compared to those without erosions (12/33, 36.4%, P < .001). Mean time to erosion was 1.70 years (0.83-6.86); mean follow-up was 2.76 years (0.34-7.92). Low testosterone had a hazard ratio of 7.15 for erosion in a Cox regression analysis (95% confidence interval 1.64-31.17, P = .009) and Kaplan-Meier analysis demonstrated decreased erosion-free follow-up (log-rank P = .002). Low testosterone was the sole independent risk factor for erosion in a multivariable model including coronary artery disease and radiation (odds ratio 15.78; 95% confidence interval 2.77-89.92, P = .002). Notably, history of prior AUS, radiation, androgen ablation therapy, or concomitant penile implant did not confound risk of cuff erosion in men with low testosterone levels.Men with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. Appropriate counseling before AUS implantation is warranted and it is unclear whether testosterone resupplementation will mitigate this risk.

  View details for DOI 10.1016/j.urology.2016.04.065

  View details for PubMedID 27450351

• Rapid excision of massive localized lymphedema of the male genitalia with vessel sealing device CANADIAN JOURNAL OF UROLOGY Siegel, J. A., Zhao, L., Tachibana, I., Carlson, S., Tausch, T. J., Klein, A. K., Vanni, A., Rozanski, T., Morey, A. F. 2016; 23 (3): 8292-8296

  View details for Web of Science ID 000379635800008

• Male Stress Incontinence Grading Scale (MSIGS) for Evaluation of Men with Post-Prostatectomy Incontinence: A Pilot Study. Video journal of prosthetic urology Morey, A., Singla, N., Chung, P., Klein, A., Tausch, T., Siegel, J., Tachibana, I., Scott, J., Carmel, M. 2016; 2

  Abstract

  We developed an objective clinical grading scale to characterize post-prostatectomy incontinence (PPI) and evaluated its use as a tool to facilitate male anti-incontinence procedure selection.Between September 2014 and July 2015, we prospectively implemented a novel Male Stress Incontinence Grading Scale (MSIGS) to stratify PPI patients based on incontinence severity. Patients included were those referred for PPI who had no prior anti-incontinence surgery. During the initial outpatient consultation, each patient was prospectively assigned an incontinence grade score of 0 through 4 based on the consensus of 2 examiners performing a standing cough test (SCT). All patients refrained from voiding for at least 60 minutes prior to the SCT. Men with mild SUI (MSIGS grades 0-2) were offered AdVance sling surgery while those with heavier SUI (MSIGS grades 3-4) were offered artificial urinary sphincter (AUS). MSIGS grade was correlated to patient-reported pads-per-day (PPD), and patient-reported outcomes of anti-incontinence surgery were assessed.Of 62 consecutive new PPI patients, 20 were graded as mild based on SCT [five (8%) grade 0, 10 (16%) grade 1, five (8%) grade 2] while 42 were graded as moderate-severe [10 (16%) grade 3, 32 (52%) grade 4]. MSIGS grade demonstrated a strong correlation with preoperative PPD (r=0.74). Among the 53 patients who underwent surgical intervention for PPI, 14 with mild SUI were treated with AdVance® male urethral sling (MSIGS grade 0, 1, or 2) while 39 more severe cases received AUS (MSIGS grade 3 or 4). Patient-reported improvement was high overall (median 95%) and similar for sling and AUS patients (95% and 96.5% respectively, p=0.596). The median time from radical prostatectomy to anti-incontinence surgery was 5.4 years (range 1-20).The Male Stress Incontinence Grading Scale provides a rapid, simple, non-invasive, objective assessment of PPI severity which strongly correlates with patient-reported pads-per-day and appears to facilitate anti-incontinence surgical procedure selection.

  View details for PubMedID 32259169

  View details for PubMedCentralID PMC7133709

• Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture. The Journal of urology Siegel, J. A., Panda, A., Tausch, T. J., Meissner, M., Klein, A., Morey, A. F. 2015; 194 (5): 1316-22

  Abstract

  We compared the results of initial excision and primary anastomosis urethroplasty to the excision and primary anastomosis outcomes of other challenging reoperative clinical settings, including secondary cases (prior urethroplasty of any technique other than excision and primary anastomosis) and repeat cases (prior excision and primary anastomosis).We reviewed our database of patients who underwent excision and primary anastomosis urethroplasty for bulbar urethral stricture at our tertiary referral center from 2007 to 2014. Patients without available data and those with a history of lichen sclerosus, radiation, pelvic fracture urethral injuries, distal strictures and/or hypospadias were excluded from analysis. Patient characteristics and outcomes were compared between those undergoing initial, secondary, and repeat excision and primary anastomosis urethroplasty for bulbar urethral stricture.Among 898 urethroplasties performed during the study period we identified 305 men who underwent excision and primary anastomosis urethroplasty of the bulbar urethra, including an initial procedure in 268 of 305 (88%) and reoperation in 37 (12%). Of patients with reoperation 18 of 37 (49%) underwent secondary excision and primary anastomosis following a different type of prior urethroplasty and 19 (51%) underwent repeat excision and primary anastomosis. Repeat excision and primary anastomosis in the bulbar urethra was successful in 18 of 19 patients (95%), which was comparable to the success rate of initial bulbar excision and primary anastomosis (251 of 268 or 94%) as well as secondary bulbar excision and primary anastomosis (17 of 18 or 94%, p = 0.975) with a similar mean stricture length. Mean followup for all patients was 41.5 months (range 6 to 90) and mean followup in each group was greater than 30 months.Repeat excision and primary anastomosis urethroplasty has excellent results for short bulbar strictures, comparable to those achieved in the initial and secondary setting.

  View details for DOI 10.1016/j.juro.2015.05.079

  View details for PubMedID 26003205

• Intraoperative Decision-making for Precise Penile Straightening During Inflatable Penile Prosthesis Surgery. Urology Tausch, T. J., Chung, P. H., Siegel, J. A., Gliga, L., Klein, A. K., Morey, A. F. 2015; 86 (5): 1048-52

  Abstract

  To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures.Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction.Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36°, and all patients were corrected to < 10°. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P <.05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction.Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively.

  View details for DOI 10.1016/j.urology.2015.06.042

  View details for PubMedID 26190086

• '7-flap' perineal urethrostomy: an effective option for obese men with devastated urethras. The Canadian journal of urology Starke, N. R., Simhan, J., Clinton, T. N., Tausch, T. J., Scott, J. F., Klein, A. K., Morey, A. F. 2015; 22 (4): 7902-6

  Abstract

  To present an updated experience using our previously reported lateral perineal '7-flap' technique for perineal urethrostomy (PU), highlighting its role in a variety of patients with advanced urethral stricture disease.All patients who underwent 7-flap PU from 2009-2013 were reviewed. PU was constructed by advancing a "7"-shaped laterally based perineal skin flap into a spatulated, amputated bulbomembranous urethra. The contralateral side of the amputated proximal urethra was then matured to the advanced perineal skin. Patients were stratified by body mass index (BMI) and outcomes were compared.Among 748 patients undergoing urethroplasty during the study period, 22 men (2.9%; mean age 61, range 31-80) received a 7-flap PU for advanced stricture disease (mean follow up 32 months). A majority of patients (14/22, 64%) were obese (BMI = 30). Disease etiologies consisted primarily of lichen sclerosus (9/22, 41%) while 6/22 (27%) had failed prior urethral reconstructions elsewhere. Mean operative time was 108 min (range 54-214), mean estimated blood loss (EBL) was 76 cc (30-200), and all patients were discharged immediately after surgery. Urethrostomy creation was possible in all patients regardless of BMI (mean 33, range 22-43), and there were no differences with regards to EBL (p = 0.71), operative time (p = 0.38), or success rate (p = 0.76) in obese versus non-obese patients undergoing 7-flap PU. Nearly all patients (21/22, 95%) are voiding spontaneously on follow up without the need for any additional procedure.In our updated experience, performance of 7-flap urethrostomy has resulted in durable long term success with acceptable performance in technically challenging cases.

  View details for PubMedID 26267029

• Does Pressure Regulating Balloon Location Make a Difference in Functional Outcomes of Artificial Urinary Sphincter? The Journal of urology Singla, N., Siegel, J. A., Simhan, J., Tausch, T. J., Klein, A., Thoreson, G. R., Morey, A. F. 2015; 194 (1): 202-6

  Abstract

  We compared functional outcomes in patients who received an artificial urinary sphincter in the space of Retzius vs the same device placed at a high submuscular location.We reviewed a prospectively maintained database of patients who received an artificial urinary sphincter between July 2007 and December 2014. After cuff placement was completed via a perineal incision, a 61 to 70 cm H2O pressure regulating balloon was placed through a separate high scrotal incision in the space of Retzius or in a high submuscular tunnel. Demographics, perioperative comorbidities and functional outcomes were compared between the groups.A total of 294 consecutive patients underwent artificial urinary sphincter placement. Mean followup was 23 months. Space of Retzius and high submuscular placement was performed in 140 (48%) and 154 patients (52%), respectively. Functional outcomes were similar between the groups, including the continence rate (defined as 0 or 1 pad daily) in 81% vs 88% (p = 0.11), the erosion rate in 9% vs 8% (p = 0.66) and the explantation rate in 10% vs 11% (p = 0.62). Artificial urinary sphincter revision for persistent incontinence was required in a similar proportion of the 2 groups (13% vs 8%, p = 0.16) with a comparable mean followup (24 vs 23 months, p = 0.30). Kaplan-Meier analysis revealed no difference between the groups in the rate of explantation (p = 0.70) or revision (p = 0.06).High submuscular placement of a pressure regulating balloon at artificial urinary sphincter surgery is a safe, effective alternative with functional outcomes equivalent to those of traditional placement in the space of Retzius.

  View details for DOI 10.1016/j.juro.2015.01.115

  View details for PubMedID 25711196

• Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome. Urology Westerman, M. E., Tausch, T. J., Zhao, L. C., Siegel, J. A., Starke, N., Klein, A. K., Morey, A. F. 2015; 85 (6): 1501-4

  Abstract

  We present a novel technique using ventral slit with scrotal skin flaps (VSSF) for the reconstruction of adult buried penis without skin grafting.An initial ventral slit is made in the phimotic ring, and the penis is exposed. To cover the defect in the ventral shaft skin, local flaps are created by making a ventral midline scrotal incision with horizontal relaxing incisions. The scrotal flaps are rotated to resurface the ventral shaft. Clinical data analyzed included preoperative diagnoses, length of stay, blood loss, and operative outcomes. Complications were also recorded. Fifteen consecutive patients with a penis trapped due to lichen sclerosus (LS) or phimosis underwent repair with VSSF. Each was treated in the outpatient setting with no perioperative complications. Mean age was 51 years (range, 26-75 years), and mean body mass index was 42.6 kg/m(2) (range, 29.8-53.9 kg/m(2)). The majority of patients (13 of 15, 87%) had a pathologic diagnosis of LS. Mean estimated blood loss was 57 cc (range, 25-200 cc), mean operative time was 83 minutes (range, 35-145 minutes), and all patients were discharged on the day of surgery. The majority of patients (11 of 15, 73.3%) remain satisfied with their results and have required no further intervention. Recurrences in 3 of 15 (20.0%) were due to LS, panniculus migration, and concealment by edematous groin tissue; 2 of these patients underwent subsequent successful skin grafting.VSSF is a versatile, safe, and effective reconstructive option in appropriately selected patients with buried penis, which enables reconstruction of penile shaft skin defects without requiring complex skin grafting.

  View details for DOI 10.1016/j.urology.2015.02.030

  View details for PubMedID 25872692