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1.
J Urol ; 203(2): 304-310, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31487219

RESUMO

PURPOSE: Prostate specific antigen screening for prostate cancer has recently been challenged due to poor sensitivity. In addition to prostate cancer, a number of conditions elevate prostate specific antigen, of which benign prostatic hyperplasia is most common. The objective of this study was to assess the positive predictive value of prostate specific antigen and prostate specific antigen density for prostate cancer risk following holmium laser enucleation of the prostate. MATERIALS AND METHODS: We queried an institutional review board approved database of holmium laser enucleation of the prostate performed at Indiana University from 1999 to 2018 to identify 1,147 patients with prostate specific antigen data available after holmium laser enucleation. A total of 55 biopsies after enucleation were recorded. Demographics, prostate specific antigen, prostate volume and oncologic details were analyzed. The primary outcome was biopsy proven prostate cancer. RESULTS: A total of 55 patients underwent transrectal ultrasound prostate biopsy for cause after holmium laser enucleation of the prostate. Cancer was identified in more than 90% of biopsied cases. Men with prostate specific antigen above 1 ng/ml at biopsy had a 94% probability of cancer detection and an 80% risk of clinically significant disease. Prostate specific antigen density above 0.1 ng/ml2 was associated with a 95% risk of cancer and an 88% risk of clinically significant cancer. Prostate specific antigen greater than 5.8 ng/ml or prostate specific antigen density greater than 0.17 ng/ml2 was universally associated with biopsy proven cancer. CONCLUSIONS: Prostate specific antigen and prostate specific antigen density have high positive predictive value for prostate cancer risk after holmium laser enucleation of the prostate. Thresholds for biopsy should be lower than in patients who do not undergo holmium laser enucleation. Those who undergo that procedure and have prostate specific antigen above 1 ng/ml or prostate specific antigen density above 0.1 ng/ml2 are at higher risk for harboring clinically significant disease and should undergo biopsy. Referring physicians should be aware of these significant risk shifts.


Assuntos
Calicreínas/sangue , Lasers de Estado Sólido , Antígeno Prostático Específico/sangue , Próstata/patologia , Prostatectomia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/cirurgia , Idoso , Humanos , Masculino , Monitorização Fisiológica , Tamanho do Órgão , Valor Preditivo dos Testes , Prostatectomia/métodos , Neoplasias da Próstata/patologia , Estudos Retrospectivos
2.
Can J Urol ; 26(4): 9859-9862, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31469642

RESUMO

INTRODUCTION: Artificial urinary sphincters (AUS) are used to treat significant urinary incontinence. Flexible cystoscopy at the time of AUS placement provides relevant intraoperative feedback including confirmation that the AUS is functioning, visualization of coaptation, and evaluation for urethral injury. Current guidelines for placement of an AUS do not include flexible cystoscopy. The objective was to evaluate whether flexible cystoscopy at time of AUS placement changed cuff size at the time of surgery. MATERIALS AND METHODS: A retrospective cohort study was performed to evaluate all patients undergoing AUS placement by a single surgeon between March 2013 and March 2017. The primary endpoint of the study was change in cuff size based on cystoscopy. RESULTS: A total of 109 AUS were placed in 96 patients. In five (4.6%) cases flexible cystoscopy identified a lack of coaptation of the urethra despite appropriate sizing which resulted in down-sizing of the cuff. Five patients were identified as having a bladder neck contracture that was previously unrecognized as clinic cystoscopy was performed by the referring urologist and was reportedly normal. Three patients developed postoperative infections, two of these patients had a history of multiple AUS placement and revisions and the third patient had a history of cystectomy and neobladder. CONCLUSIONS: Flexible cystoscopy at time of AUS placement changed the cuff size in nearly 5% of cases. Flexible cystoscopy at time of AUS placement provides valuable feedback and should be recommended for low volume prosthetic surgeons.

3.
Urology ; 129: e1, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31009741

RESUMO

Penetrating perineal trauma is an unusual urologic injury. Even less common is a delayed presentation. Herein we present the case of a patient with delayed development of a corporal cutaneous fistula 3 months following perineal trauma.


Assuntos
Fístula Cutânea/etiologia , Fístula/etiologia , Doenças do Pênis/etiologia , Períneo/lesões , Humanos , Masculino , Fatores de Tempo , Adulto Jovem
4.
Urology ; 129: 223-227, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31005654

RESUMO

OBJECTIVE: To evaluate the feasibility and outcomes of full thickness penile skin grafting (FTSG) for phalloplasty during acquired buried penis repair. MATERIALS AND METHODS: A retrospective cohort study of patients undergoing complex genital reconstruction for buried penis between January 2013 and April 2018 was performed. Patients undergoing FTSG were identified. All patients underwent escutcheonectomy, scrotoplasty, and penile skin grafting by a single Urologist (MM) and Plastic surgeon (JS). Escutcheon tissue was used for the FTSG. The primary outcome was graft take and the secondary outcome was recurrence requiring surgical revision. RESULTS: Thirteen patients were identified for inclusion in the study with average age of 43.4 and average BMI of 42. Median (range) follow-up for the cohort was 8 (3-44) months. Surgical indication was lymphedema in 6 (46.2%), morbid obesity in 6 (46.2%), and hidradenitis suppurativa in one (7.7%). Seven required concurrent urethromeatoplasty for meatal stenosis and fossa navicularis strictures. All grafts were successful. Two patients developed postoperative wound infections requiring antibiotics. One patient redeveloped lymphedema of the scrotum and required complete revision surgery although the FTSG remained intact. No patients had reburying of the penis. Minor outpatient surgical revision was performed for 2 patients for scarring and edema of the glans. CONCLUSION: Full thickness skin grafts provide a useful option for penile reconstruction during surgical management of buried penis. Patients had excellent graft acceptance and minimal wound complications. Further research and comparative cohorts are warranted to fully determine the role of FTSG in genital reconstruction.


Assuntos
Obesidade Mórbida/complicações , Doenças do Pênis/cirurgia , Pênis/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Transplante de Pele/métodos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adulto , Seguimentos , Humanos , Masculino , Doenças do Pênis/etiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
5.
Transl Androl Urol ; 7(6): 907-911, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30505726

RESUMO

Background: To evaluate the feasibility of use of rectal mucosal grafts for augmentation urethroplasty. Methods: A series of five patients who underwent rectal mucosal graft urethroplasty for urethral stricture disease were identified. Descriptive statistics were used to describe these patients. Primary endpoints were recurrence of stricture and perioperative morbidity. Results: Five patients underwent rectal mucosal graft augmentation urethroplasty. Four had a history of prior buccal mucosal graft (BMG) urethroplasty and one had a history of head and neck cancer. Rectal mucosa was noted to be thinner and required more tailoring than buccal mucosa. All patients had patent urethras at time of postoperative retrograde urethrogram. A small diverticulum was noted in one patient with no further sequelae. No complications from rectal mucosal graft harvest were noted. All patients with prior buccal grafting subjectively preferred the rectal graft due to fewer side effects. Subjectively, patients with prior buccal grafts preferred the post-operative recovery following rectal mucosal graft urethroplasty. Conclusions: Rectal mucosal graft augmentation urethroplasty is a safe alternative in patients with contraindications to buccal grafting with limited morbidity.

6.
Indian J Urol ; 34(4): 283-286, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30337784

RESUMO

Introduction: We aim to present a modified technique and outcomes of a novel method allowing for direct visualization of the reservoir placement during a penoscrotal inflatable penile prosthesis (IPP). Methods: Out of165 patients who underwent IPP placement from August 2012 to March 2015, 157 underwent a modified technique and comprised the cohort of this study. A Deaver's retractor was placed lateral to the penis and over the pubic bone to allow for direct visualization of the tissues overlying the lower abdomen. After dissecting through the superficial layers, the Deaver's was slowly advanced, allowing for visualization of the fascia, which was incised. Using blunt dissection, a space for the reservoir was created between the bladder and the pubic bone. The reservoir was then placed safely into this space and the Deaver's retractor was removed. Results: The causes of ED in the study cohort included postprostatectomy ED (n = 107), organic impotence (n = 40), Peyronie's disease (n = 3), ED following cystoprostatectomy (n = 2), ED due to spinal cord injury (n = 2), ED resulting from priapism (n = 2), and ED after pelvic injury (n = 1); all of which were refractory to medical management. The median age of study population was 66 years and the mean (standard deviation) operative time was 72.8 (14.7) min. Eighty percent of the procedures were performed on outpatient basis. Complication rates were low (<5%), with four infections, one proximal pump migration, one scrotal hematoma, and one urinary tract infection. Conclusion: The modified technique for placement of the IPP's spherical reservoir under direct visualization through a penoscrotal incision is quick, safe, and effective.

7.
Int Urol Nephrol ; 50(8): 1375-1380, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29948867

RESUMO

PURPOSE: Radiation-induced ureteral stricture disease poses significant surgical challenges. Ureteral substitution with ileum has long been a versatile option for reconstruction. We evaluated outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction due to radiation-induced ureteral stricture versus other causes. METHODS: Between July 1989 and June 2013, 155 patients underwent consecutive ileal ureter creation. The study cohort included 104 patients with complete data sets and at least 7 months of follow up. Records were retrospectively reviewed with regard to demographics, indications, complications, and renal deterioration. RESULTS: Surgical indications included radiation-induced stricture in 23 (22%) and non-radiation-induced stricture in 81 (78%). Comparing ileal ureter substitution due to radiation versus other stricture etiologies, no statistical significance was observed in regard to age (45.6 vs. 51.2, p = 0.141), hospital length of stay in days (8.8 vs. 7.7, p = 0.216), percent GFR loss (MDRD-4 vs. -5%, p = 0.670 and CKD-EPI-7 vs. -6%, p = 0.914), 30-day surgical complications (26.1 vs. 30.1%, p = 0.658), metabolic acidosis (8.7 vs. 1.2%, p = 0.059), and renal failure requiring dialysis (4.3 vs. 1.2%, p = 0.337). Fistula formation (13.0 vs. 3.7%, p = 0.095), partial small bowel obstructions (21.7 vs. 7.4%, p = 0.063), and small bowel obstructions requiring reoperation (13.0 vs. 1.2%, p = 0.033) approached or reached statistical significance. Using Kaplan-Meier methodology, there was no difference in time to worsening renal outcome between the radiation and non-radiation groups (p > 0.05). CONCLUSION: Ureteral substitution with ileum is an effective reconstructive option for radiation-induced ureteral strictures in carefully selected patients.


Assuntos
Íleo/efeitos da radiação , Lesões por Radiação/etiologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Ureter/efeitos da radiação , Obstrução Ureteral/etiologia , Micção/fisiologia , Procedimentos Cirúrgicos Urológicos/métodos , Anastomose Cirúrgica/efeitos adversos , Feminino , Seguimentos , Humanos , Íleo/cirurgia , Masculino , Pessoa de Meia-Idade , Lesões por Radiação/cirurgia , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Ureter/cirurgia , Obstrução Ureteral/fisiopatologia , Obstrução Ureteral/cirurgia
8.
Urology ; 104: 225-229, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28237532

RESUMO

OBJECTIVE: To assess long-term renal preservation and surgical outcomes in patients undergoing ureteric substitution with ileum. This has been a mainstay of reconstruction options for lengthy ureteral defects. METHODS: Consecutive patients aged 18 or older undergoing ileal ureters at our institution were retrospectively reviewed (from 1989 to June 2013). Patients with <6 months of follow-up were excluded. Demographic, surgical, and renal functional outcomes were reviewed. Renal function was assessed by the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease Study equations. RESULTS: Of the 108 patients meeting the inclusion criteria, 86 (79.6%) had single-renal unit reconstruction and 22 had bilateral reconstruction. Eighty-four (77.8%) had radiation-induced stricture and 24 had iatrogenic or trauma-induced strictures. The median follow-up was 51 months (interquartile range: 22-112). Short-term complications included Clavien grade I (16 [14.8%]), Clavien grade II (3 [2.8%]), Clavien grade III (9 [8.3%]), and Clavien grade IV (3 [2.8%]). Long-term complications included fistula in 6 patients (5.6%), renal failure requiring dialysis in 2 patients (1.9%), hyperchloremic metabolic acidosis in 4 patients (3.7%), and incisional hernia in 11 patients (10.2%). Nine patients (8.3%) had small-bowel obstructions; 3 (2.8%) required adhesiolysis. Four patients (3.7%) had an anastamotic stricture. Nineteen patients (17.6%) had worsening renal function. Cox proportional hazards regression found that those with bilateral repair were at 3.7 times increased risk of worsening renal function (P = .02). CONCLUSION: Ureteral substitution with ileum provides an effective and versatile long-term reconstructive option with minimal renal function compromise in properly selected patients. Bilateral reconstruction may contribute to worse long-term renal function.


Assuntos
Íleo/cirurgia , Rim/fisiologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Ureter/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Adulto , Anastomose Cirúrgica , Constrição Patológica/cirurgia , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Estimativa de Kaplan-Meier , Rim/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Obstrução Ureteral/cirurgia , Adulto Jovem
9.
J Endourol ; 30(8): 890-5, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27246319

RESUMO

OBJECTIVES: To evaluate the impact of obesity on patients developing wound complications within 30 days of open and robotic radical prostatectomy using the National Surgical Quality Improvement Program (NSQIP). METHODS: Patients undergoing radical prostatectomy in 2011 to 2012 were identified from NSQIP, which is a multi-institutional database of comprehensive 30-day postoperative outcomes. Wound complication included superficial surgical site infections (SSIs), deep SSI, organ space infections, and dehiscence. Descriptive statistics and multiple logistic regression examined the relationship between obesity and wound complications in open and robotic radical prostatectomy. RESULTS: Of the 12,454 radical prostatectomy cases reported in the study period, 9248 were robotic (74%), 2244 (18%) patients were normal weight (body mass index [BMI] <25), 5836 (47%) were overweight (BMI 25-30), and 4374 (35%) were obese (BMI >30). Wound complications occurred in 134 (4%) of open and 114 (1%) of robotic radical prostatectomies. After adjusting for age, history of smoking, history of diabetes, history of chronic steroid use, and operative time, it was determined that obese patients were at 71% increased odds of developing a wound complication after open prostatectomy (p = 0.034), while there was no difference in the odds of a wound complication after robotic radical prostatectomy (odds ratio 1.14, p = 0.665). CONCLUSIONS: Obese patients are at increased risk of developing wound complications when undergoing open vs robotic radical prostatectomy. Obese patients likely benefit from robotic radical prostatectomy whenever feasible.


Assuntos
Obesidade/epidemiologia , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Comorbidade , Bases de Dados Factuais , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Duração da Cirurgia , Sobrepeso/epidemiologia , Neoplasias da Próstata/epidemiologia , Melhoria de Qualidade , Fatores de Risco
10.
J Sex Med ; 12 Suppl 7: 432-6, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26565572

RESUMO

INTRODUCTION: Inflatable penile implants are a mainstay for the surgical correction of erectile dysfunction. For the last 40 years they have provided reliable outcomes with durable patient satisfaction. Infection of the implant continues to remain the primary surgical concern, despite the advent of antibiotic-coated devices and improved skin preparation solutions. METHODS: In this article, we review and evaluate the published literature for important contributions surrounding the various salvage techniques and washout strategies. In addition, the role of biofilm in prosthetic infection will be discussed. RESULTS: First described by Mulcahy for instances of device infection, the salvage or rescue procedure was established to avoid complete removal and staged replacement. This approach, with its avoidance of difficult revision surgery, penile shortening and patient discomfort, has produced success as high as 84%. CONCLUSION: Mulcahy's innovative approach at salvage or rescue reimplantation has proven to be a highly successful approach to this difficult surgical problem. Without question, the report of the long-term results of his salvage patients has directly influenced a generation of prosthetic surgeons.


Assuntos
Disfunção Erétil/cirurgia , Prótese de Pênis/microbiologia , Pênis/cirurgia , Terapia de Salvação/métodos , Antibacterianos/uso terapêutico , Contaminação de Equipamentos/prevenção & controle , Disfunção Erétil/fisiopatologia , História do Século XX , História do Século XXI , Humanos , Masculino , Satisfação do Paciente , Prótese de Pênis/efeitos adversos , Prótese de Pênis/estatística & dados numéricos , Pênis/microbiologia , Reoperação , Terapia de Salvação/tendências , Infecção da Ferida Cirúrgica/prevenção & controle
11.
Urol Oncol ; 33(12): 503.e17-22, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26278363

RESUMO

INTRODUCTION: This study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer. METHODS: We retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction-based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI. RESULTS: Of the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5-19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02-3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11-4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06). CONCLUSIONS: The development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.


Assuntos
Clostridium difficile/metabolismo , Cistectomia/efeitos adversos , Neoplasias da Bexiga Urinária/complicações , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Clostridium difficile/citologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
12.
Urology ; 86(2): 338-42, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26189134

RESUMO

OBJECTIVE: To examine predictors of enucleation and morcellation times within a large cohort of men undergoing holmium laser enucleation of the prostate (HoLEP) for benign prostatic hypertrophy. MATERIALS AND METHODS: Preoperative, perioperative, and postoperative clinical characteristics were available from men treated with HoLEP between 1998 and 2013 at Indiana University Health Methodist Hospital. Stepwise linear regression was performed to determine clinical variables which are associated with enucleation and morcellation times. RESULTS: We identified 960 patients who underwent HoLEP. Average (range) enucleation time was 65.7 (11-245) minutes and morcellation time was 19.7 (3-260) minutes. History of anticoagulation was associated with a small decrease in enucleation time (P = .013) whereas increasing HoLEP specimen weight was associated with increasing enucleation time (P <.001). History of intermittent catheterization, urinary tract infections (UTI), presence of dense prostatic tissue (colloquially referred to as "beach balls"), and increasing specimen weight were associated with increasing morcellation time (P <.05 each). Having HoLEP performed by a less experienced urologist was associated with longer enucleation and morcellation times. CONCLUSION: Prostate volume is significantly associated with increased enucleation and morcellation times during HoLEP. Additionally, history of UTI and clean intermittent catheterization (CIC) is associated with modest increases in enucleation and morcellation times. Dense enucleated prostate tissue significantly impacts the ability to morcellate effectively. Increasing surgeon experience can significantly improve both enucleation and morcellation efficiency.


Assuntos
Terapia a Laser , Lasers de Estado Sólido/uso terapêutico , Duração da Cirurgia , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Idoso , Estudos de Coortes , Previsões , Humanos , Masculino , Estudos Retrospectivos
14.
Urology ; 85(4): 777-81, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25704996

RESUMO

OBJECTIVE: To provide a contemporary look at vascular complications after percutaneous nephrolithotomy (PNL) with access performed solely by a urologist using fluoroscopic guidance. METHODS: A retrospective review of 2792 patients who had 3338 PNLs at Indiana University Health Methodist Hospital and Mayo Clinic Rochester was performed. Patients who experienced significant bleeding requiring diagnostic renal angiography and superselective embolization (SSE) were reviewed and compared with the overall database. RESULTS: There were 15 patients (16 renal units) requiring renal angiography and SSE (0.48%). Mean time from PNL to bleeding was 7 days (range, 1-15 days) and to SSE was 9.6 days (range, 2-18 days). Mean drop in hemoglobin was 5.3 g/dL (range, 2-9 g/dL). Transfusion was needed in 9 patients (60%). There were no differences between the vascular complications group and the uneventful PNL group in mean age (55.06 vs 52.2 years; P = .519), UTI history (40% vs 38%; P = .92), mean operative time (125.8 vs 102.47 minutes; P = .192), the need for multiple access (18.75% vs 18%; P = .939), and access location. The vascular complications group had a lower stone burden than the uneventful PNL group (stones > 2 cm; 43.7% vs 74.03%; P = .014). CONCLUSION: The incidence of vascular complications in this contemporary series is one of the lowest reported to date. At our centers, vascular bleeding complications appear to be a random and rare event after PNL as we were unable to identify any specific risk factors. Early SSE avoided the need for blood transfusion in many patients.


Assuntos
Embolização Terapêutica , Cálculos Renais/cirurgia , Nefrostomia Percutânea/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Angiografia , Transfusão de Sangue , Feminino , Fluoroscopia , Hemoglobinas/metabolismo , Humanos , Cálculos Renais/patologia , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
15.
J Endourol ; 29(5): 548-55, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25616087

RESUMO

BACKGROUND AND PURPOSE: To assess the safety of omitting cortical renorrhaphy during robot-assisted partial nephrectomy and measure preliminary functional outcomes. PATIENTS AND METHODS: Fifteen robot-assisted partial nephrectomies were performed with a running, base-layer suture for the collecting system and vessel hemostasis but without cortical renorrhaphy. The nonrenorrhaphy group was matched 1:2 by R.E.N.A.L. nephrometry score to a running, sliding-clip cortical renorrhaphy group retrospectively. Intraoperative blood loss, urine leaks, postoperative bleeds, and functional outcomes were evaluated. Predictors of %volume loss were evaluated using multivariable regression. RESULTS: No differences were seen between renorrhaphy and nonrenorrhaphy in sex (P=0.53), age (P=0.14), body mass index (P=0.08), Charlson score (P=0.44), tumor diameter (P=0.55), nephrometry score (P=0.77), preoperative glomerular filtration rate (GFR, P=0.63), or the amount of resected healthy kidney margin (P=0.21). Warm ischemia time was less for the nonrenorrhaphy group (P<0.002). One pseudoaneurysm necessitating embolization (1/30=3%) was seen in the renorrhaphy group compared with none in the nonrenorrhaphy group. No urine leaks occurred in either group. The median %GFR loss was 8.8% for renorrhaphy and 4.4% for nonrenorrhaphy (P=0.14) at a median follow-up of 4.1 months. The median %volume loss was 17 cm(3) for renorrhaphy and 9 cm(3) for nonrenorrhaphy (P=0.003). In a multivariable model, both cortical renorrhaphy (P=0.004) and tumor diameter (P=0.004) were predictors of %volume loss. CONCLUSION: Omission of cortical renorrhaphy appears feasible with no urine leaks or bleeding complications observed. The percent renal volume loss was improved by omission of cortical renorrhaphy. Reconstruction technique is important to control for when studying renal function after partial nephrectomy.


Assuntos
Perda Sanguínea Cirúrgica , Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Rim/cirurgia , Nefrectomia/métodos , Hemorragia Pós-Operatória/epidemiologia , Procedimentos Cirúrgicos Robóticos/métodos , Técnicas de Sutura , Adulto , Idoso , Índice de Massa Corporal , Estudos de Viabilidade , Feminino , Taxa de Filtração Glomerular , Humanos , Rim/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Tamanho do Órgão , Procedimentos Cirúrgicos Reconstrutivos , Estudos Retrospectivos , Suturas , Isquemia Quente , Adulto Jovem
16.
Can Urol Assoc J ; 9(11-12): E882-5, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26834898

RESUMO

We present a case report of successful management of ureteropelvice junction avulsion during ureteroscopy successfully managed with simultaneous percutaneous nephrolithotomy and early endoscopic ureteral realignment.

17.
BJU Int ; 115(2): 288-94, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24974910

RESUMO

OBJECTIVE: To explain differences over time between operative approach and surgeon type for adrenal surgery in the USA. PATIENTS AND METHODS: A retrospective cohort analysis was performed on all patients undergoing adrenalectomy between 2002 and 2011 using the Nationwide Inpatient Sample. Patients undergoing concurrent nephrectomy were excluded. Surgeon specialty was only available for 2003-2009. Descriptive analyses and multivariable logistic regression models were used to assess variables associated with minimally invasive surgery (MIS) and urologist-performed procedures. RESULTS: In all, 58,948 adrenalectomies were identified. A MIS approach was used in 20% of these operations. There was a 4% increase in MIS throughout the study period (P < 0.001). Cases performed at teaching hospitals were more likely to be MIS (odds ratio [OR] 1.47, P < 0.001). We were able to identify surgical specialty in 23,746 cases, of which 60% were performed by urologists. Cases performed in the Midwest compared with Northeast were at increased adjusted odds of being performed by urologists (OR 1.38, P = 0.11). Despite most cases being performed by urologists, adrenalectomy by urologists showed a 15% annual decrease over the analysed period (P < 0.001). CONCLUSIONS: The use of a MIS technique to perform adrenalectomy is increasing at a slower rate compared with most other surgical extirpative procedures. Further investigation to explain the decreased performance of adrenalectomy by urologists is warranted.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Adrenalectomia/tendências , Padrões de Prática Médica , Cirurgiões , Neoplasias das Glândulas Suprarrenais/mortalidade , Adrenalectomia/mortalidade , Adrenalectomia/estatística & dados numéricos , Adulto , Competência Clínica , Feminino , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/tendências , Estudos Retrospectivos , Estados Unidos/epidemiologia
18.
Int J Urol ; 21(2): 190-3, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23980634

RESUMO

OBJECTIVE: To report our experience, and to evaluate the long-term outcomes and complication profiles of ventral onlay buccal mucosal graft urethroplasty (BMU) after prior urological intervention. METHODS: We retrospectively reviewed 114 consecutive patients between February 2001 and April 2009 who underwent buccal mucosal graft urethroplasty for recurrent anterior urethral stricture disease. Seven patients were excluded for incomplete data. The remaining 107 patients comprised the study cohort. The mean follow-up time was 39.3 months (range 6.6-127.3 months). All patients had prior urological attempts at operative management. RESULTS: The mean stricture length was 3.14 cm (range 1.0-8.0 cm). Indications for buccal mucosal graft urethroplasty included: lichen sclerosis (2.8%), iatrogenic (24.3%), infection (4.7%) and perineal trauma/straddle injury (20.6%). Of these patients, 78 had bulbo-membranous stricture disease, 20 had penile involvement and nine were multifocal strictures. The average number of prior urological procedures was 2.83 (range 1-9). The overall graft failure rate was 6.5%. Importantly, the re-operation rate was 20.6%, primarily for stricture recurrence (18), meatal stenosis (3) and urethral diverticulum. The mean time to complication was 10.8 months. CONCLUSIONS: Ventral onlay buccal mucosal graft urethroplasty offers satisfactory results in the setting of recurrent and complicated urethral stricture disease. Graft failures and complications generally occur within the first year after surgery. Bulbar strictures enjoy greater graft patency and lower complication rates than other stricture locations. In particular, guarded expectations should be given for stricture length >4 cm and multifocal disease.


Assuntos
Mucosa Bucal/transplante , Uretra/cirurgia , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adolescente , Adulto , Idoso , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Adulto Jovem
19.
Int Urol Nephrol ; 45(2): 381-5, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23386247

RESUMO

PURPOSE: Open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) are widely utilized techniques for small renal masses. The lack of tactile feedback and limitations of laparoscopy may result in differences in the surgical specimen that may impact oncologic outcome. We present postoperative pathological outcomes data in a cohort of patients matched for nephrometry score, tumor size, gender and age. MATERIALS AND METHODS: We reviewed 81 patients who underwent partial nephrectomy between January 2003 and March 2010. Twenty-seven underwent RPN and 54 received OPN. Two OPN cases were matched for nephrometry score, tumor size, gender and age for each RPN. Postoperative pathological specimens were reviewed by a urologic pathologist regarding margin status, pathologic stage, histology, renal capsule violation, among other variables. RESULTS: Sixty-two (76.5 %) patients were found to have renal cell carcinoma on final pathology. Frozen sectioning with tumor bed sampling was intra-operatively employed in 70 cases (86.4 %). The overall positive margin occurrence was 1 of 81 patients, which occurred during an RPN for a hilar tumor and converted to radical nephrectomy to achieve negative clinical margins. Additionally, 14.8 % of OPN patients had renal capsule violation as compared to 3.7 % of RPN cases (p = 0.34). Importantly, the mean distance to the proximal margin edge for RPN specimens (2.77 mm) was equivalent to OPN (3.01 mm), p = 0.46. CONCLUSION: When matched for nephrometry score, tumor size, gender and age, RPN produces similar pathological outcomes to OPN.


Assuntos
Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Robótica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
20.
JSLS ; 16(4): 581-7, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23484568

RESUMO

INTRODUCTION: Comparison of treatments for partial nephrectomy is limited by case selection. We compared robotic (RPN), laparoscopic (LPN), and open partial nephrectomy (OPN), controlling for tumor size, patient age, sex, and nephrometry score. METHODS: RPN, LPN, and OPN procedures between March 2003 and March 2010 were reviewed. All RPN and LPN were included, and 2 OPN were matched for each RPN in tumor size (±0.5cm), patient age (±10 y), sex, and nephrometry score. Perioperative outcomes were compared. RESULTS: Ninety-six partial nephrectomy procedures were reviewed: 27 RPN, 15 LPN, and 54 OPN. RPN, LPN, and OPN had similar median tumor size (2.4, 2.2, and 2.3cm, respectively), nephrometry score (6.0 each), and preoperative glomerular filtration rate (71.5, 84.6, and 77.0 mL/min/1.73m(2), respectively). Blood loss was higher for OPN (250 mL) than for RPN or LPN (100 mL), P < 0.001. Operative time was shorter in OPN (147 min) than in RPN (190 min) or LPN (195 min), P < .001. Median warm ischemia time was shorter for OPN (12.0 min) than for RPN (25.0 min) or LPN (29.5 min), P Kt; .05. Cold ischemia time for OPN was 25.0 min. A 10% glomerular filtration rate decline occurred in 10 RPN, 5 LPN, and 29 OPN cases (P < .252). Median hospital stay for LPN and RPN was 2.0 d versus 3.0 d for OPN (P < .001). Urine leak occurred in 1 RPN and 3 OPN cases. Postoperative complications occurred in 4 RPN (3 were Clavien grade 2 or less), 1 LPN (grade 1), and 7 OPN (6 were grade 2 or less) cases. CONCLUSION: Renal function preservation and complications are similar for each treatment modality. OPN offers faster operative and ischemia times at the expense of greater blood loss and hospital stay.


Assuntos
Neoplasias Renais/cirurgia , Laparoscopia/métodos , Nefrectomia/métodos , Robótica , Feminino , Seguimentos , Humanos , Incidência , Indiana/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento
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