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1.
Eur Urol Focus ; 2020 Jun 23.
Artigo em Inglês | MEDLINE | ID: mdl-32591285

RESUMO

BACKGROUND: The RENAL (radius [R], exophytic/endophytic [E], nearness to collecting system/sinus [N], anterior/posterior [A], and location relative to polar lines [L]) and the PADUA (preoperative aspects and dimensions used for an anatomical classification) scores help in quantifying tumor complexity. However, nephrometry scoring systems have low interobserver variability. To simplify and improve score reproducibility, a new Simplified PADUA Renal (SPARE) scoring system was introduced. OBJECTIVE: To externally validate the SPARE nephrometry scoring system and to determine its interobserver variability. DESIGN, SETTING, AND PARTICIPANTS: A total of 202 patients were included in the analysis. We performed a retrospective analysis of robot-assisted partial nephrectomy (RAPN) cases for a single renal mass performed at a single academic institution during the period 2008-2018. For each renal mass, PADUA, RENAL, and SPARE nephrometry scores were calculated. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Three urology residents (URs), two urology attendings (UAs), two radiology residents (RRs), and one radiology attending (RA) retrospectively reviewed computed tomography scans blinded to clinical outcomes. The accuracy of the SPARE nephrometry score in the prediction of any complication (Clavien grade ≥1) was compared with other scoring systems in a univariable and a multivariate fashion. The area under the curve (AUC) and kappa statistics were used to assess interobserver variability of the SPARE score. RESULTS AND LIMITATIONS: The SPARE score was not inferior to the PADUA and RENAL scores (AUC 0.61, 0.59, and 0.57, respectively, p = 0.43). Patients with intermediate to high SPARE scores had longer operative time (158 vs 135 min, p = 0.10) and a higher rate of complications (28% vs 14%, p = 0.012). Univariable analysis predicting overall complications showed that RRs performed slightly better than URs and UAs using the SPARE score. Interobserver agreement was 84% between an RA and an RR (kappa 0.42), 85% between an RA and a UA (kappa 0.39), and 85% between an RA and a UR (kappa 0.45). CONCLUSIONS: These findings confirm that the SPARE nephrometry scoring system is a reproducible and easy tool offering overall fair interobserver agreement regardless of years of training or type of practice, while maintaining the predictive capabilities of more established nephrometry scores. PATIENT SUMMARY: In this study, a novel and simple classification system was assessed using a sample of cases from our institution to define surgical complexity renal masses detected on radiological imaging. Our findings suggest that this tool can be useful in clinical practice to facilitate the characterization of renal masses and predict the complications of surgical treatment.

2.
Clin Adv Hematol Oncol ; 18(2): 116-125, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32558805

RESUMO

Prostate cancer is the most frequently diagnosed cancer in men after skin cancer. Owing to the rising popularity of prostate-specific antigen screening, large numbers of patients are receiving a diagnosis of prostate cancer and undergoing whole-gland treatment. Some patients with a diagnosis of low-risk, localized disease may not benefit from whole-gland treatment, however, given its known morbidity. In response to advances in prostate imaging and evidence suggesting that the prognosis in prostate cancer is related to the index lesion, many patients have begun to opt for focal therapy, which targets a lesion rather than the entire prostate. This "middle ground" of therapy, between active surveillance and whole-gland treatment, is appealing to patients because the risk for side effects is believed to be lower with focal therapy than with whole-gland treatment. This review discusses the oncologic rationale for focal therapy in localized prostate cancer, examines the major therapy modalities, and addresses future directions.

3.
Can J Urol ; 26(4): 9829-9834, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31469637

RESUMO

INTRODUCTION: The aim of this study was to investigate conventional 3D ultrasound and portable BladderScan volume measurements and implement correction factors to ensure accurate volume metrics. MATERIALS AND METHODS: Healthy participants without urinary urgency were recruited for a prospective hydration study in which three consecutive voids were analyzed for two separate visits. Just before and after voiding, 3D ultrasound and BladderScan volumes were measured. Estimated voided volumes were calculated as the volume immediately prior to void minus any post void residual and were compared to actual voided volumes measured using a graduated container. Percent errors were calculated, and an algebraic method was implemented to create correction factors for 3D ultrasound and BladderScan. RESULTS: Sixteen individuals completed the study, and six voids were recorded for each participant. A total of 96 volume measurements ranging from 0 mL to 1050 mL with an average of 394 +/- 26 mL were analyzed. Both 3D ultrasound and BladderScan significantly underestimated voided volumes with averages of 296 +/- 22 and 362 +/- 27, respectively. Average percent error for the 3D ultrasound group was 30.1% (pre-correction) and 20.7% (post-correction) (p < 0.01) and 22.4% (pre-correction) and 21.8% (post-correction) for the BladderScan group (p = 0.20). The voided volume correction factors for 3D ultrasound and BladderScan were 1.30 and 1.06, respectively. CONCLUSION: BladderScan and 3D ultrasound typically underestimate voided volumes. Correction factors enabled more accurate measurements of voided volumes for both 3D ultrasound and BladderScan. Accurate volume measurements will be valuable for the development of non-invasive urodynamics techniques.

4.
Neurourol Urodyn ; 38(5): 1222-1228, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30947371

RESUMO

INTRODUCTION: Dynamic elasticity is an acutely regulated bladder material property through which filling and passive emptying produce strain softening, and active voiding restores baseline pressure. The aim of this study was to test the hypothesis that strain softening produced by filling-passive emptying is equivalent to that produced by compression-release in a porcine bladder model. METHODS/MATERIALS: Latex balloons and ex vivo perfused pig bladders were used for a series of alternating fill-passive emptying ("Fill") and external compress-release ("Press") protocols. For the Fill protocol balloons/bladders were (1) filled to defined volumes (prestrain softening), (2) filled to capacity to strain soften (reference), and (3) passively emptied to the original volume (poststrain softening). For the Press protocol, balloons/bladders were (1) filled to defined volumes (prestrain softening), (2) externally compressed to reference pressure and then released for five cycles (poststrain softening). After each protocol, bladders were voided with high-KCl buffer to induce "active" voiding. RESULTS: In both balloons and porcine bladder, both the Fill and Press protocols produced significant strain softening (P < 0.05) and poststrain softening pressures were not different for Fill and Press protocols (P > 0.05), indicating a similar degree of strain softening with both methods. CONCLUSIONS: Repeated external compression can induce bladder strain softening similar to filling and passive emptying. This technique may represent a means to acutely regulate bladder compliance and potentially be used as a mechanical treatment for urinary urgency.


Assuntos
Bexiga Urinária Hiperativa/terapia , Bexiga Urinária/patologia , Animais , Fenômenos Biomecânicos , Elasticidade , Feminino , Masculino , Cloreto de Potássio/farmacologia , Pressão , Suínos , Urodinâmica
5.
J Endourol ; 32(7): 615-620, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29790375

RESUMO

OBJECTIVES: To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches. METHODS: We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics. RESULTS: Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001). CONCLUSIONS: Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.


Assuntos
Neoplasias Renais/cirurgia , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos , Idoso , Feminino , Taxa de Filtração Glomerular/fisiologia , Humanos , Neoplasias Renais/fisiopatologia , Tempo de Internação/estatística & dados numéricos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos
6.
Urol Ann ; 10(1): 7-14, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29416268

RESUMO

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

7.
Clin Adv Hematol Oncol ; 15(9): 708-715, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28949942

RESUMO

Seminomas account for approximately 50% of all cases of testicular cancer. Testicular cancer is a highly curable disease that can be broadly classified as either seminomatous or nonseminomatous; the management and treatment of the 2 forms vary widely. Although surgery plays a large role in the management of nonseminoma, its role in the management of seminoma is much more limited. Most clinicians in the United States choose orchiectomy followed by surveillance for patients with stage I seminomatous disease, and chemotherapy or radiation-followed by surgery for the management of residual masses-for patients with disease that is stage II and higher. Recently, clinicians have proposed a larger role for surgery in stage II seminoma to avoid the long-term toxic effects of chemotherapy and radiation therapy. In this review, we discuss the oncologic rationale for the treatment of seminoma, the role of surgery, and the use of minimally invasive operative techniques for retroperitoneal lymph node dissection.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Orquiectomia/métodos , Seminoma/cirurgia , Neoplasias Testiculares/cirurgia , Humanos , Masculino , Estadiamento de Neoplasias , Seminoma/patologia , Neoplasias Testiculares/patologia
8.
J Clin Aesthet Dermatol ; 9(5): 18-25, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27386042

RESUMO

OBJECTIVE: The objective of this study was to assess the ability of optical coherence tomography to detect clinical and subclinical actinic keratoses confirmed by histopathology. The efficacy of ingenol mebutate treatment of actinic keratosis was also evaluated using optical coherence tomography, and correlation of treatment efficacy with severity of local skin reactions was determined. DESIGN: Single-arm, open-label, split-face study. SETTING: Hospital outpatient clinic. PARTICIPANTS: Male subjects (N=30) with seven actinic keratoses. MEASUREMENTS: A suspected actinic keratosis and the normal-appearing, perilesional skin were imaged, biopsied for histopathologic analysis, and the results compared with the clinical and a blinded optical coherence tomography diagnosis. Treatment with ingenol mebutate gel 0.015% was randomly administered to three clinically suspected actinic keratoses and the perilesional skin; three additional, suspected actinic keratoses lesions and perilesional areas were left untreated. Clinical and optical coherence tomography images were obtained for all lesions. Severity of local skin reactions was recorded to evaluate the relationship between local skin reaction and treatment effect. RESULTS: Optical coherence tomography analysis had a 100-percent (28/28) correlation with the clinical diagnosis of actinic keratosis and detected 16 of 22 (73%) histopathologically confirmed subclinical lesions from perilesional skin sites. By optical coherence tomography assessment, the clearance rate for clinically observed lesions was 76 percent for ingenol mebutate-treated areas versus 11 percent for untreated areas; the clearance rate for treated subclinical lesions was 88 percent versus 43 percent for untreated areas. Clearance rates did not vary with the severity of the local response. CONCLUSION: Optical coherence tomography is effective at detecting clinical and subclinical actinic keratoses and monitoring their response to treatment.

9.
J Drugs Dermatol ; 15(5): 545-50, 2016 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-27168263

RESUMO

BACKGROUND: Optical coherence tomography (OCT) is a technique that enables real-time in-vivo examination of tissue. This technology provides the clinician with the potential to use a non-invasive tool in the identification and diagnosis of many skin lesions. However, the diagnostic features of basal cell carcinoma have not yet been described with comparison to their histopathology.
OBJECTIVES: To identify and describe key features of basal cell carcinoma (BCC) and its subtypes as they present in multi-beam Swept Source - OCT (MSS-OCT), and to correlate those against conventional histopathology.
METHODS: A total of 40 lesions were assessed by MSS-OCT prior to biopsy. 60-slice OCT images of the lesions were obtained and correlated with histology sections taken in the same plane. OCT scans were assessed retrospectively by a panel to determine the OCT criteria for BCC and its subtypes.
RESULTS: The following diagnostic criteria were identified: hyporeflective ovoid structures (40/40), dark halo boundaries (38/40), epidermal thinning (28/40), and collagen compression (14/40). Lesional tissue also showed a destruction of layers when compared to the surrounding normal tissue. In addition to the shared criteria, other subtypes showed distinct diagnostic criteria.
CONCLUSION: With its higher sensitivity, using MSS-OCT allowed for non-invasive, accurate identification of the key diagnostic features of BCC and its subtypes with high correlation to the histopathologic features found with biopsy.

J Drugs Dermatol. 2016;15(5):545-550.


Assuntos
Carcinoma Basocelular/classificação , Carcinoma Basocelular/diagnóstico por imagem , Neoplasias Cutâneas/classificação , Neoplasias Cutâneas/diagnóstico por imagem , Tomografia de Coerência Óptica/métodos , Diagnóstico Diferencial , Feminino , Humanos , Masculino
10.
Urology ; 90: 200-3, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26743393

RESUMO

INTRODUCTION: To demonstrate the feasibility of robotic anterior pelvic exenteration with intracoporeal ileal conduit for bladder cancer in a patient with previous kidney-pancreas transplantation. TECHNICAL CONSIDERATIONS: Technical considerations included avoiding injury to transplant graft, minimizing devascularization of transplant ureter, intracorporeal mobilization of bowel with pancreas graft, and positioning of ileal conduit. Surgical approach required multidisciplinary approach for surgical planning and medical management. CONCLUSION: The patient's preoperative serum creatinine was 1.22 ng/mL and was unchanged at 1.21 ng/mL 1 month following surgery. Total robotic console time was 4 hours and 21 minutes and estimated blood loss is 30 cc. There were no intraoperative complications. Final pathology demonstrated pT1N0 high-grade multifocal micropappilary urothelial cell carcinoma with carcinoma in situ, and all surgical margins were negative. Robotic anterior pelvic exenteration with intracorporeal urinary diversion for bladder cancer in patient with previous kidney-pancreas transplantation is a challenging but a feasible surgical technique that requires a multidisciplinary team and a low threshold to convert to open surgery.


Assuntos
Cistectomia/métodos , Transplante de Rim , Transplante de Pâncreas , Exenteração Pélvica/métodos , Procedimentos Cirúrgicos Robóticos , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária , Estudos de Viabilidade , Feminino , Humanos , Íleo/cirurgia , Pessoa de Meia-Idade
11.
J Urol ; 195(6): 1664-70, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26778713

RESUMO

PURPOSE: We estimated the differences in intensity, cost, radiation exposure and cancer control of published surveillance guidelines screening for secondary renal cell carcinoma in patients treated with partial nephrectomy. MATERIALS AND METHODS: We developed a Monte Carlo simulation model to contrast the existing guidelines in terms of cost, radiation exposure and cancer control. Model inputs were extrapolated from the existing literature. Surveillance guidelines were analyzed from the AUA, CUA, EAU and NCCN®. Risk stratification among patients treated with partial nephrectomy was based on tumor characteristics. RESULTS: Expected costs during the 5 years after partial nephrectomy were $587 (CUA), $1,076 (AUA), $1,705 (EAU) and $1,768 (NCCN) for low risk patients, and $903 (CUA), $2,525 (EAU) and $3,904 (AUA and NCCN) for high risk patients. Radiation exposure ranged from 31.41 mSv (CUA) to 104.34 mSv (NCCN) for low risk patients and 46.88 mSv (CUA) to 231.61 mSv (AUA and NCCN) for high risk patients. The EAU and CUA guidelines led to the diagnosis of the highest percentage of low risk patients (more than 95%) while all guidelines diagnosed more than 92% of high risk patients with recurrence. CONCLUSIONS: Renal cell carcinoma surveillance guidelines differ greatly in terms of intensity, cost and radiation exposure. It is important for clinicians to adopt standardized surveillance strategies that limit unnecessary cost and radiation exposure without compromising cancer control.


Assuntos
Carcinoma de Células Renais/diagnóstico , Detecção Precoce de Câncer/métodos , Neoplasias Renais/diagnóstico , Carcinoma de Células Renais/economia , Análise Custo-Benefício , Detecção Precoce de Câncer/efeitos adversos , Detecção Precoce de Câncer/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Rim/patologia , Neoplasias Renais/economia , Modelos Teóricos , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/economia , Guias de Prática Clínica como Assunto , Exposição à Radiação/estatística & dados numéricos , Medição de Risco , Sensibilidade e Especificidade , Estados Unidos
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