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125 Paterson St
Suite 4100
New Brunswick, NJ 08901
Locations and availability (1)

Education ?

Medical School Score Rankings
Kansas City University of Medicine
  • Currently 3 of 4 apples
Top 50%

Awards & Distinctions ?

Young scientist award gold medal - 1993 urolithiasis society of india
Yamanouchi best abstract prize-stone disease-aua 2001 meetin american urological association
Pfizer scholars in urology award-2002 pfizer
David weinstein award in urodynamics-awarded in 2008 david weinstein
Umdnj-robert Wood Johnson Medical School
American Urological Association

Affiliations ?

Dr. Tunuguntla is affiliated with 3 hospitals.

Hospital Affilations



  • Robert Wood Johnson Univ Hosp
    1 Robert Wood Johnson Pl, New Brunswick, NJ 08901
    • Currently 2 of 4 crosses
  • Robert Wood Johnsonuniversityhospital
  • Robert Wood Johnson University Hospital, New Brunswick, New Jersey
  • Publications & Research

    Dr. Tunuguntla has contributed to 21 publications.
    Title Neobladder Reconstruction Following Radical Cystoprostatectomy for Invasive Bladder Cancer.
    Date October 2009
    Journal Minerva Urologica E Nefrologica = The Italian Journal of Urology and Nephrology

    A survey on neobladder reconstruction after radical cystectomy due to invasive bladder cancer is presented. Stress is laid on the selection patients, factors affecting the choice of urinary diversion, contraindications for neobladder, oncological factors influencing selection of neobladder, continence, complications and other factors which may affect a favourable outcome.

    Title Diagnostic and Prognostic Molecular Markers in Renal Cell Carcinoma.
    Date June 2008
    Journal The Journal of Urology

    PURPOSE: We reviewed the contemporary literature on molecular biomarkers in renal cell carcinoma and their prognostic significance. MATERIALS AND METHODS: Articles published during 1981 to 2007 in English on renal cell carcinoma were surveyed using the MEDLINE/PubMed database. The subject headings included were genetics, biomarkers, prognosis and risk models of renal cell carcinoma. We present a synthesis of currently known renal cell carcinoma biomarkers at various stages of development and their clinical significance, and prognostic nomograms incorporating biomarkers. RESULTS: The beneficiary role of biomarkers in renal cell carcinoma is challenged by the relatively low prevalence of the disease. Even if a biomarker for renal cell carcinoma had 100% sensitivity and 99.4% specificity, the positive predictive value of the marker in men older than 65 years would be only 10%. Several biomarkers are being investigated in renal cell carcinoma, of which many relate to pathogenic molecular changes that are currently therapeutic targets. Carbonic anhydrase IX is a von Hippel-Lindau mediated enzyme that is expressed in most renal cell carcinoma cases. High (greater than 85%) expression of this marker indicates favorable prognosis and may predict the response to interleukin-2 therapy. B7-H1 expression in renal cell carcinoma cells/lymphocytes may indicate worse survival, possibly through impaired host antitumor immunity. Prognostic nomograms incorporating clinical variables and molecular markers to refine the prediction of treatment outcomes are in active development and await prospective clinical validation. CONCLUSIONS: Several renal cell carcinoma molecular markers appear promising to refine the prognosis and prediction of localized, advanced or metastatic renal cell carcinoma. Currently carbonic anhydrase IX is the best studied and promising marker. Prospective, multicenter clinical validation aimed at the practical clinical usefulness of renal cell carcinoma biomarkers is warranted.

    Title Predictors of Success for First Stage Neuromodulation: Motor Versus Sensory Response.
    Date July 2006
    Journal The Journal of Urology

    PURPOSE: We investigated whether intraoperative motor or sensory response is more predictive of successful sacral neuromodulation using the InterStim system. MATERIALS AND METHODS: A total of 35 patients with medically refractory frequency, urgency and urge incontinence were enrolled in the study. All patients underwent lead placement for quadripolar test stimulation under local anesthesia with intravenous sedation. Confirmation of correct lead placement was by observation of known motor and sensory responses that result from third sacral nerve stimulation. Motor and sensory responses were documented intraoperatively. Patients had a 1-week trial of stimulation, and those who had greater than 50% improvement in symptoms had placement of the implantable pulse generator. Those without at least 50% improvement in their symptoms had the quadripolar lead removed. RESULTS: Of the 35 patients enrolled 21 had successful quadripolar test stimulation and went on to permanent implantable pulse generator placement. Of the patients who had successful quadripolar test stimulation 95% demonstrated positive intraoperative motor response whereas only 21.4% of patients with unsuccessful quadripolar test stimulation demonstrated positive motor response. If only a positive sensory response was elicited, patients had only a 4.7% chance of having a positive quadripolar test stimulation. CONCLUSIONS: A positive quadripolar test stimulation (greater than 50% improvement in symptoms) with InterStim sacral neuromodulation is more likely when intraoperative lead placement results in positive motor response vs only sensory response.

    Title Female Sexual Dysfunction Following Vaginal Surgery: a Review.
    Date February 2006
    Journal The Journal of Urology

    PURPOSE: Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse. MATERIALS AND METHODS: Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed. RESULTS: Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence CONCLUSIONS: Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.

    Title Management of Neobladder-vaginal Fistula and Stress Incontinence Following Radical Cystectomy in Women: a Review.
    Date February 2006
    Journal World Journal of Urology

    Contemporary literature regarding the management of neobladder-vaginal fistula and stress urinary incontinence following radical cystectomy and neobladder reconstruction in women is reviewed in this article. Neobladder-vaginal fistula is uncommon but mandates meticulous repair. Compared to the native bladder, the wall of the neobladder is much thinner that may render it vulnerable to fistulization. Preservation of the anterior vaginal wall during radical cystectomy decreases the likelihood of pouch-vaginal fistula. Omental flap interposition between the vaginal stump and neobladder at cystectomy may not always prevent fistulization if anterior vaginal wall is violated or overlapping suture lines are not avoided. Surgery for intractable stress incontinence following neobladder reconstruction is fraught with severe complications and requires judicious use of allograft pubovaginal slingplasty possibly with bone anchors. Martius flap interposition appears to play a crucial role in improving the outcome following transvaginal repair of the neobladder-vaginal fistula in multiple non-overlapping layers.

    Title Two-stage Management of Severe Postprostatectomy Bladder Neck Contracture Associated with Stress Incontinence.
    Date October 2005
    Journal Urology

    OBJECTIVES: To report our experience using a two-stage, rather than a synchronous, approach in the management of bladder neck contracture (BNC). Anastomotic BNC associated with urinary incontinence is a major complication after radical prostatectomy. Patients may present with a decreased force of stream, urinary retention, or stress, urge, or overflow urinary incontinence. METHODS: The pertinent data of 15 patients (age range 52 to 78 years, mean 62) with postradical prostatectomy BNC associated with stress urinary incontinence (mean pad use 3 per day) were retrospectively reviewed. Video-urodynamic evaluation in 10 of 15 patients revealed a Valsalva leak point pressure of less than 80 cm H2O in all 10 patients. Bladder outlet obstruction was noted in 4 of 10 patients. Of the 15 patients, 2 declined an artificial urinary sphincter (AUS), the other 13 proceeded with our two-stage management. Step one consisted of deep transurethral incision of the BNC (TUIBNC) with Collin's knife electrocautery. Step two consisted of implantation of an AUS (AMS-800) 6 to 8 weeks after TUIBNC once bladder neck patency had been demonstrated cystoscopically. RESULTS: During a mean follow-up of 15 months, 3 patients developed early recurrence of BNC: 2 at the 5-week cystoscopy, 1 at 8 weeks discovered at the scheduled AUS placement. All 3 patients underwent repeat TUIBNC and remained clinically patent at a mean follow-up of 9 months. The remaining 10 patients were clinically patent after a single TUIBNC, with good subjective flow and postvoid residual volume of less than 30 mL at a mean follow-up of 11 months. Of the 13 patients who underwent AUS placement, 12 were socially continent (wearing 0 to 1 thin pad daily). The thirteenth patient remained incontinent after AUS placement. One of the 12 continent patients developed an infection at the device 8 months postoperatively and required explantation. CONCLUSIONS: We recommend a two-stage approach (TUIBNC followed by AUS insertion) rather than synchronous management for postprostatectomy BNC associated with stress urinary incontinence. Such an approach allows identification of BNC recurrence and its safe management before AUS implantation.

    Title Standard Reconstruction Techniques: Techniques of Ureteroneocystostomy During Urinary Diversion.
    Date June 2005
    Journal Surgical Oncology Clinics of North America
    Title Female Sexual Dysfunction Following Vaginal Surgery: Myth or Reality?
    Date March 2005
    Journal Current Urology Reports

    This article reviews the mechanisms by which vaginal surgery affects female sexual function and related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as they apply to vaginal surgery. Methods to avoid neurovascular damage during pelvic floor surgery have been corroborated by supporting literature. The incidence of female sexual dysfunction after various transvaginal procedures for indications such as stress urinary incontinence and pelvic organ prolapse, anterior/posterior colporrhaphy, perineoplasty, and vaginal vault prolapse has been discussed. Current literature regarding female sexual dysfunction following other procedures such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair also are reviewed.

    Title Bilateral Infundibulopelvic Stenosis Without Renal Insufficiency: is Surgery Necessary?
    Date December 2004
    Journal Nephrology (carlton, Vic.)

    The following case describes the clinical course of a patient with bilateral infundibulopelvic stenosis from her initial presentation at age 2 through the age of 14 years. This condition is associated with hypoplasia of segments of the upper collecting system and is characterized by dilated calyces that drain through stenotic infundibulae. Our patient is unique in that, although her renal function has slowly deteriorated with time, she has a persistently non-obstructive pattern on dynamic imaging studies. Only a minority of patients reported in the literature with this condition progress to renal insufficiency or failure. Although some patients have undergone surgery for presumed obstruction, surgical intervention has no proven benefit. Patients are at risk for hyperfiltration injury and should be followed for the development of hypertension, proteinuria and renal insufficiency. Without evidence of obstruction, medical management remains the cornerstone of treatment.

    Title Missed Bilateral Bladder Perforation During Pubovaginal Sling Procedure.
    Date August 2004
    Journal The Journal of Urology
    Title Intractable Chronic Pelvic Pain Relieved After Bone Anchor Removal.
    Date March 2004
    Journal The Journal of Urology
    Title Can Single Dose Preoperative Intrathecal Morphine Sulfate Provide Cost-effective Postoperative Analgesia and Patient Satisfaction During Radical Prostatectomy in the Current Era of Cost Containment?
    Date March 2003
    Journal Prostate Cancer and Prostatic Diseases

    We retrospectively analyzed the analgesic efficacy and surgical outcomes of a single preoperative intrathecal long-acting morphine sulfate injection (0.25-0.5 mg) and postoperative intravenous (i.v.) ketorolac in 62 patients who underwent radical retropubic prostatectomy (RRP). Total postoperative analgesic requirement was documented along with assessment of length of hospital stay, pain control and time for resumption of normal activity. Postoperatively, 45% of patients required only nonsteroidal agents (ketorolac), whereas 55% needed a mean of 13.3 mg of supplemental i.v. morphine sulfate. Mean hospital stay was 2.3+/-0.3 days. Eighty-two per cent of patients felt the length of hospital stay adequate. Ninety-seven per cent of patients were satisfied with anesthesia selected and 95% of patients considered pain control on postoperative days 1 and 2 as effective. All patients resumed to full physical activity by 5.3+/-0.4 weeks after surgery. We conclude that a single preoperative injection of intrathecal morphine sulfate combined with i.v. ketorolac postoperatively results in effective analgesia, diminished supplemental narcotic requirement and high patient satisfaction during radical retropubic prostatectomy.

    Title Does Retroperitoneal Lymphadenectomy for Testicular Germ Cell Tumor Require a Different Approach in the Presence of Horseshoe Kidney?
    Date February 2003
    Journal The Journal of Urology

    PURPOSE: We report our management of stage II testicular nonseminomatous germ cell tumor in 2 patients with horseshoe kidney and discuss the technical challenges posed by this renal fusion anomaly. The embryology and clinical anatomy of horseshoe kidney are discussed with particular reference to the anomalous vascular pattern and routes of testicular lymphatic drainage in this setting. Modifications and innovations of the standard technique of retroperitoneal lymphadenectomy in the presence of horseshoe kidney are discussed in light of our experience with these patients at 2 major tertiary care cancer centers. The significance of contemporary advanced noninvasive radiological techniques, such as helical computerized tomographic angiography with digital 3-dimensional reconstruction and magnetic resonance angiography, in the surgical planning and safe performance of surgery is emphasized. MATERIALS AND METHODS: Two young male patients treated at 2 major American teaching hospitals who had coexistent stage II testicular nonseminomatous germ cell tumor and horseshoe kidney underwent salvage retroperitoneal lymph node dissection. RESULTS: There was no evidence of recurrence in these 2 patients 12 and 15 months after surgery, respectively. CONCLUSIONS: Horseshoe kidney poses special technical problems during retroperitoneal lymphadenectomy for testicular tumors due to anomalous renal and intra-abdominal vascular patterns. Helical computerized tomography angiography is useful for meticulous surgical planning and the safe performance of surgery in this setting.

    Title Minimally Invasive Therapies for Benign Prostatic Hyperplasia.
    Date December 2002
    Journal World Journal of Urology

    A number of minimally invasive therapies have been studied in the last decade for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). Most of these utilize thermal energy to ablate the prostate. Paucity of long-term efficacy, safety and re-treatment rates are, however, the main concerns of all these forms of treatment. Minimally invasive therapies can be positioned between pharmacotherapy and transurethral resection of the prostate (TURP). Studies have shown that some of these therapies stand the test of time, with low and acceptable re-treatment rates and shorter hospital stay. Therapies such as transurethral needle ablation (TUNA) and high energy transurethral microwave thermotherapy (HE-TUMT) effectively relieve symptoms with less morbidity. Laser prostatectomy is less commonly used due to the slow and difficult resection/vaporization. Minimally invasive therapies are particularly useful in those on anticoagulants, in whom anesthesia is contraindicated and younger men with an active sex life. However, these devices have not been compared with TURP in large-scale controlled trials and, therefore, will not be able to replace TURP until their long-term durability of symptom relief is known.

    Title Klinefelter's Syndrome and Precocious Puberty: a Harbinger for Tumor.
    Date November 2002
    Journal Urology

    Boys with Klinefelter's syndrome are at an increased risk of precocious puberty. Most cases are either idiopathic or due to a mediastinal tumor. Patients with Klinefelter's syndrome are at a high risk of primary, extragonadal germ cell tumors, which are usually nonseminomatous, but can be a mixed type with seminomatous elements. The differential diagnosis of precocious puberty includes mediastinal tumors, especially in boys with Klinefelter's syndrome.

    Title Initial Report of Bladder Carcinoma Following Combined Bladder-drained Pancreas and Kidney Transplantation.
    Date October 2002
    Journal Clinical Transplantation

    Although long-term survival of a functional allograft requiring long-term immunosuppressive therapy is responsible for higher incidence of non-urothelial cancers in renal allograft recipients than in normal population, the incidence of bladder cancer is uncommon and carcinoma of the bladder in the setting of combined kidney-pancreas transplantation has not been reported to date. We herein report a case of poorly differentiated invasive adeno-squamous cell carcinoma of the bladder following renal and bladder-drained pancreatic transplantation in a 44-yr-old lady with long-standing insulin dependent diabetes mellitus, which necessitated radical extirpation. Management implications are reviewed.

    Title Management of Peyronie's Disease--a Review.
    Date January 2002
    Journal World Journal of Urology

    Peyronie's disease is an uncommon condition involving middle-aged men and probably resulting from penile trauma. The injury causes an inflammation in the tunica and ultimately scarring and penile curvature develop. It may also occur due to nonspecific inflammation. The use of medications such as beta-blockers can sometimes result in Peyronie's disease. In Peyronie's disease, the normal elastic tissue of the tunica is replaced by scar tissue. The penile plaque, or scar tissue in this condition, is not elastic but hard and will not stretch with erection. The side that does not stretch results in penile curvature to the side of the scar. One third of men with Peyronie's disease have painful erections. A low percentage of men with Peyronie's disease develop erectile dysfunction. Because inflammation is initially associated with the scar tissue, some amount of discomfort occurs during erection. Most patients with early stage Peyronie's disease can continue to function sexually with the curvature in the penis. Others with a severe penile deformity will have difficulty in sexual intercourse. Literature regarding the effectiveness of conservative therapy in the early phase with pain and inflammation is limited, with only modest and at times anecdotal benefits. The commonly used agents include 400 units of vitamin E (vitamin E promotes healing and prevents scarring), ibuprofen (anti-inflammatory) and Colchicine (useful for pain during erection). Fexofenadine is recently being used in the early phase of Peyronie's disease for its antiinflammatory effect. Radiation and ultrasound are not usually very helpful. When the disease process stops, there is usually some residual distortion of the penis but the majority of patients are able to have satisfactory sexual intercourse. However, if there is severe penile distortion interfering with intercourse, surgery is indicated. Surgical techniques for Peyronie's disease include tightening or plication (Nesbit's tuck) of the penis opposite the curvature to produce straightening. This usually results in some small loss of length. The other type of surgery consists of incision of the plaque or scar tissue and patching with a vein (saphenous vein graft) or dermal graft. Laser therapy is occasionally used. A penile prosthesis is the treatment of choice in patients with Peyronie's disease and erectile dysfunction.

    Title Balanitis Xerotica Obliterans--a Review.
    Date March 2001
    Journal World Journal of Urology

    Balanitis xerotica obliterans (BXO) is a scarcely known disease, wrongly considered rare. With a high degree of suspicion and histologic examination, the condition will prove to be much more frequent than one generally believes. The etiology of the condition is unknown at present. Many cases of BXO occurring after circumcision may be cases of secondary phimosis due to BXO not being recognized at the time of surgery. Most of the cases of BXO are seen in the third to fifth decades of life, even though they may occur at the extremes of age. Biopsy of the lesions is not essential in all cases and is indicated to differentiate from penile cancer and in atypical cases. Early diagnosis and treatment of BXO are very important in preventing the urological complications of the diseases such as urethral stricture. Treatment of BXO depends on the anatomic location of the lesions and their extent and severity, together with the rapidity of progression of the disease process. The treatment may vary from topical corticosteroids, laser vaporization in early cases to meatoplasty and urethroplasty in extensive cases. Topical pharmacotherapy is useful in the early stages to reduce the initial symptoms and slow down the progression, but is not effective in all cases and is not the curative treatment of disease. Meatal stenosis, phimosis, scar adhesions, fissures, erosions of glans and prepuce and involvement of the urethra are indications for surgical treatment. Surgery seems to be the only treatment that can relieve the symptoms of advanced disease. Modified circumcision, with total removal of inner preputial layer, definitively relieves phimosis without any recurrence. Meatotomy will not prevent the recurrence of meatal stenosis. Excision of the scleroatrophic tract and grafting of the glans base, coronal sulcus, and the end of the shaft give a complete relief of pain during erection and intercourse in circumcised patients with balanopreputial adhesions and restore the elasticity of the skin of penile shaft. These procedures have been shown to yield excellent functional results during a follow-up period of up to 4 years. BXO involving anterior urethra can be treated by 2-stage urethroplasty or substitution urethroplasty. The complete excision of the stricture and flap urethroplasty seems to be better than a 2-stage procedure. However, at the present time, it is not possible to say that surgery can completely resolve this chronic and progressive disease. Despite many reports in the literature of cases of BXO associated with squamous cell carcinoma, the etiologic relationship between the two conditions is uncertain.

    Title Endoscopic Injection Sclerotherapy Control of Intractable Hematuria Following Radiation-induced Hemorrhagic Cystitis. A Novel Approach.
    Date August 2000
    Journal Archivos Españoles De Urología

    OBJECTIVE: To establish the utility of endoscopic sclerotherapy using 1% ethoxysclerol for the control of intractable hematuria following post-irradiation telangiectatic cystitis (PTC). METHODS: Our experience of treating 4 patients (one female and three male) with massive exsanguinating hematuria resulting from PTC, using a combined intralesional and perilesional injection of 1% ethoxysclerol, is presented. Observation on the distribution, grading of telangiectasis and pattern of bleeding are made. RESULTS: A dramatic and lasting cessation of the hematuria in all the 4 patients was achieved during the follow-up period varying from 1 month to 4 years. CONCLUSION: Endoscopic injection sclerotherapy is a simple, highly effective, less invasive new technique in the management of massive and intractable hematuria due to radiation-induced telangiectasia of the urinary bladder.

    Title Long-term Efficacy and Safety of Tamsulosin for Benign Prostatic Hyperplasia.
    Journal Reviews in Urology

    The treatment approach for recent benign prostatic hyperplasia has changed since the recent introduction of medical therapies with evidence-based efficacy. The choice of treatment to achieve symptom relief must take into account factors such as clinical benefits, potential for morbidity, probable long-term efficacy, and costs. alpha(1)1-Adrenergic receptor antagonists are the primary therapy for patients with benign prostatic hyperplasia presenting with lower urinary tract symptoms and are used by 80% of physicians as the first-line agent to treat this common condition in the aging male. Tamsulosin has been available in the United States since 1997 and has demonstrated its efficacy. Of patients completing 6 years of treatment, 80.7% demonstrated consistent positive response with extremely low incidence of orthostasis, the response being greatest during the first year and largely maintained over the following 5 years.

    Title Construction-related Differences Seen in Ureteral Access Sheaths: Comparison of Reinforced Versus Nonreinforced Ureteral Access Sheaths.
    Journal Urology

    OBJECTIVES: Ureteral access sheaths (UASs) are used to facilitate ureteroscopic procedures. Difficulties with use have been reported. Manufacturers have redesigned these devices to ameliorate these problems, including reinforcement of the sheath wall. This study compared reinforced (RUASs) and nonreinforced UASs (NRUASs) of the same manufacturer to determine whether RUASs expedite ureteroscopy and how relevant the reinforced structure is in terms of overall success. METHODS: We prospectively followed up patients undergoing ureteroscopy for urolithiasis with 1 of 2 UASs; the Applied NRUAS and the Applied RUAS. The demographics, operative parameters, and outcomes were assessed. Statistical analysis was performed. RESULTS: A total of 98 UASs were used in 68 male and 30 female patients (47 NRUASs and 51 RUASs). No significant differences were found between the groups in terms of demographic parameters, operative parameters, or successful sheath deployment. The overall success rate for sheath deployment was 95%. A pre-existing stent was significantly associated with successful deployment (P = .004). The sheath-specific limitations included kinking (NRUASs, 10%) and sheath angulation/deformity (RUASs, 21%). The mean follow-up time was 43.4 months; and 93.9% of the patients had radiologic follow-up. No ureteral strictures were noted. CONCLUSIONS: No significant difference was found in the overall success rates between the use of Applied NRUASs and RUASs. The presence of a pre-existing stent was significantly associated with successful sheath deployment. Each UAS design had its own unique limitations, seen with low frequency. Successful sheath use might relate to both the sheath itself and the patient/operative parameters.

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