Biomedical subjects

Albert A Mikhail

Publications and source records attributed to Albert A Mikhail.

10 recordsLinked to original sources

PubMed2007

Laparoscopic ice slurry coolant for renal hypothermia.

PURPOSE: We assessed the safety and efficacy of microparticulate ice slurry for laparoscopic hypothermia during renal ischemia in a single kidney porcine model. MATERIALS AND METHODS: A total of 18 farm pigs were randomized to 3 groups of 6 each. All groups underwent initial right laparoscopic nephrectomy, followed by 1 of 3 procedures on the left kidney. Group 1 underwent 90-minute hilar clamping under warm ischemia, group 2 underwent 90-minute hilar clamping under cold ischemia using laparoscopically delivered microparticulate ice slurry and control group 3 underwent hilar dissection, no clamping and no microparticulate ice slurry. Body and renal cortical temperatures were measured. Serum creatinine and the glomerular filtration rate were assessed preoperatively, and on postoperative days 1, 3, 8 and 15. RESULTS: Average time to achieve a renal temperature of 20C or less was 9.7 minutes and it remained constant during the 90-minute cold ischemia time. Mean serum creatinine was significantly higher in the warm ischemia group than in the cold ischemia and control groups on postoperative days 1 and 3. Additionally, mean serum creatinine in the cold ischemia and control groups was similar at all time points. The mean glomerular filtration rate was significantly lower in the warm ischemia group than in the cold ischemia and control groups on postoperative days 1, 3 and 8. The mean glomerular filtration rate in the cold ischemia group was lower than in the control group on postoperative day 1, while it was similar on postoperative days 3, 8 and 15. CONCLUSIONS: In the porcine model laparoscopic renal hypothermia achieved with microparticulate ice slurry was safe and efficient. It significantly decreased renal dysfunction secondary to an ischemic insult with no adverse effects or complications associated with microparticulate ice slurry use.

Animals↗

PubMed2006

Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation.

INTRODUCTION: Robotic-assisted laparoscopic radical prostatectomy (RLRP) is increasingly becoming an alternative to open and laparoscopic radical prostatectomy in the treatment of localized prostate cancer. RLRP has been associated with low morbidity, short convalescence and comparable oncologic and functional outcomes. We report our initial experience of 300 consecutive cases with selective use of interfascial nerve preservation (IFNP). METHODS: Between February 2003 and September 2005, 300 consecutive men underwent RLRP at our institution. Patients were followed prospectively with validated questionnaires. RESULTS: Mean operative time was 282 minutes with an estimated blood loss of 273 ml. The intra-operative complication rate was 2.3% with no mortality. Return to baseline (RTB) urinary function and subjective continence at 12 months were 71% and 90.2%, respectively. RTB sexual function and subjective potency at 12 months were 53% and 80.4%, respectively. Overall, the positive surgical margin (PSM) rate was 20.9%: 15.1% for pT2 and 52.1% for pT3 disease and 93.1% had an undetectable PSA (<0.1 ng/mL) with a mean follow-up of 17.3 months. Fifty-four percent of PSMs occured in a poster-lateral (PL) location. Retrospectively, IFNP was performed in 86.5% and 62.5% of pT2 and pT3 PSMs, respectively. Pathologic-T3 PSMs were found to occur significantly more often in a PL location when ipsilateral IFNP was performed when compared to non-IFNP (73% vs 33%, p=0.05). CONCLUSIONS: IFNP appears to result in favorable return of potency, however, postero-lateral PSMs appear to occur more frequently with this technique. Proper patient selection for robotic surgery and nerve-preservation appears to be critical in order to reduce PSM and optimize the oncologic efficacy of this technology.

Adult↗

PubMed2006

Minimizing knot tying during reconstructive laparoscopic urology.

OBJECTIVES: Intracorporeal knot tying during urologic reconstructive surgery is one of the most technically challenging skills of laparoscopic surgery. We describe our experience using the Lapra-Ty clip to substitute for knot tying. METHODS: Our technique for minimizing knot tying entails the use of the Lapra-Ty clip during closure of the collecting system and renal parenchyma for laparoscopic partial nephrectomy, the vesicourethral anastomosis during robotic laparoscopic radical prostatectomy, and the collecting system during laparoscopic pyeloplasty. From October 2002 to July 2005 at our institution, 75 patients underwent laparoscopic partial nephrectomy, 300 underwent robotic laparoscopic radical prostatectomy, and 14 underwent laparoscopic pyeloplasty. We reviewed the charts retrospectively for intraoperative and postoperative parameters related to the use of these clips. RESULTS: In the laparoscopic partial nephrectomy group, the mean tumor size, warm ischemia time, and estimated blood loss was 2.53 cm, 30.1 minutes, and 189 mL, respectively. Two postoperative urine leaks (2.7%) developed, and 3 patients experienced postoperative bleeding (4%). In the robotic laparoscopic radical prostatectomy group, the mean operative time was 295 minutes and the mean estimated blood loss was 303.6 mL. Only 3 patients had a urine leak (1%), and 4 patients had bladder neck contracture (1.3%). With regard to the laparoscopic pyeloplasty group, the mean operative time and estimated blood loss was 224 minutes and 36 mL, respectively. No intraoperative complications or urinary leaks occurred. CONCLUSIONS: Using the Lapra-Ty clip, we have safely and efficiently supplemented knot tying in patients undergoing reconstructive laparoscopic surgery.

Adult↗

PubMed2006

Open versus laparoscopic simultaneous bilateral adrenalectomy.

OBJECTIVES: To compare our experience with synchronous bilateral adrenalectomy using laparoscopic and open techniques. Laparoscopic adrenalectomy has become the reference standard for management of benign unilateral adrenal pathologic findings. METHODS: This was a nonrandomized retrospective chart review of 12 known patients who underwent simultaneous bilateral adrenalectomy, comparing five laparoscopic and seven open procedures. One urologic surgeon performed all laparoscopic cases, and one general surgeon performed all open procedures. RESULTS: All patients had Cushing's disease or syndrome. The average patient age was 47.4 years (range 24 to 71) and 42.4 years (range 19 to 70), with an average body mass index of 38.2 kg/m2 and 36.0 kg/m2 for the laparoscopic and open groups, respectively. The operating time was on average 60 minutes longer for the laparoscopic group. No open conversions were necessary. The median blood loss (100 versus 500 mL, P < 0.01) and hematocrit drop (8.5% versus 12.6%, P = 0.05) were lower for the laparoscopic group. The transfusion rates and hospital stay trended lower in the laparoscopic group (20% versus 57% and 3 versus 8.5 days, respectively). Specimen weights for both the right and left glands trended larger for the laparoscopic group. The complication rates were similar between groups at 60% for the laparoscopic versus 71% for the open groups. CONCLUSIONS: Simultaneous laparoscopic bilateral adrenalectomy is safe and effective. Compared with the open approach, it resulted in decreased blood loss, lower transfusion rate, and a trend toward a shorter hospital stay, although the operating time was longer. The laparoscopic approach should be the treatment of choice for bilateral adrenalectomy.

Adrenalectomy↗

PubMed2006

Robotic-assisted laparoscopic prostatectomy in overweight and obese patients.

OBJECTIVES: To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight and obese patients, defined as those with a body mass index (BMI) of 25 to 30 kg/m2 and greater than 30 kg/m2, respectively. METHODS: This was a nonrandomized study evaluating all of our RLRP patients. Patients were divided into three groups: BMI of 25 kg/m2 or less (group 1), BMI greater than 25 kg/m2 and less than 30 kg/m2 (group 2), and BMI of 30 kg/m2 or more (group 3). Patients were evaluated prospectively with the validated Rand 36-Item Health Survey (version 2) and with the University of California, Los Angeles Prostate Cancer Index questionnaire. RESULTS: Between February 2003 and November 2004, 150 RLRPs were performed at our center. Average follow-up was 8 months. Groups 1, 2, and 3 had 39, 65, and 46 patients, respectively. Average BMIs for all three groups were statistically different (P < 0.01). When compared with group 1, open conversion rates, hospital stay, positive margin, and complication rates were not statistically different for groups 2 or 3. Operative time (P < 0.004) and estimated blood loss (P < 0.03), however, were statistically greater for group 3 compared with group 1. Transfusion rate was highest in group 2 (P = 0.04 compared with group 1). Prostate weights were also statistically greater in groups 2 (P = 0.003) and 3 (P = 0.02) compared with group 1. Overall, BMI did not increase perioperative and postoperative morbidity. CONCLUSIONS: Robotic laparoscopic radical prostatectomy is safe in overweight and obese patients and might be the surgical management of choice in this subset of patients. Further long-term follow-up with more patients is required to verify this initial observation.

Adult↗

PubMed2006

Solitary ureteral metastases of renal cell carcinoma.

Metachronous presentation of metastatic renal cell carcinoma (RCC) to the ureter is extremely rare. We report a solitary metachronous metastatic RCC in the contralateral ureter 14 months after right radical nephrectomy for Fuhrman grade 2 pT3a clear cell disease after the patient re-presented with gross hematuria. The proximal left ureteral lesion was excised followed by ileal-ureteral interposition. Pathologic examination confirmed metastatic RCC. To date, only 51 cases of metastatic RCC to the ureter have been reported, with only 6 occurring metachronously in the contralateral ureter. Also, we report the presence of focal extramedullary hematopoiesis occurring within this metastatic lesion.

Carcinoma, Renal Cell↗

PubMed2006

Robotic-assisted laparoscopic prostatectomy: first 100 patients with one year of follow-up.

OBJECTIVES: To report our initial experience of 100 patients with robotic-assisted laparoscopic radical prostatectomy. Continued technological advances have expanded our armamentarium of minimally invasive devices and techniques to offer our patients. Robotic-assisted laparoscopic radical prostatectomy has been adopted at many centers. METHODS: This was a nonrandomized prospective study evaluating our initial 100 patients who underwent robotic-assisted laparoscopic radical prostatectomy. The follow-up data were obtained prospectively using the validated Rand 36-item health survey, version 2, and the University of California, Los Angeles, Prostate Cancer Index preoperatively and at 1, 3, 6, and 12 months postoperatively. Patients who required open conversion were excluded from the outcome analysis. Patients who received a sural nerve graft were excluded from the operative analysis. RESULTS: The average age and body mass index of all patients were 58.4 years (range 42 to 70) and 28.5 kg/m2 (range 18.1 to 50.6), respectively, with a median follow-up of 12 months. The average prostate-specific antigen level was 6.07 ng/mL. Seven patients required conversion to an open technique, and four underwent sural nerve grafting. The positive surgical margin rate was 16% (15 of 92). Using the Rand 36-item health survey, version 2, and the University of California, Los Angeles, Prostate Cancer Index health surveys, the average percentage of return to baseline urinary function was 52%, 70%, 79%, and 84% at 1, 3, 6, and 12 months, respectively. The overall average percentage of return to baseline sexual function was 51%, 58%, 66%, and 80% at 1, 3, 6, and 12 months, respectively. CONCLUSIONS: Robotic-assisted laparoscopic radical prostatectomy is a safe and efficient method for achieving prostate cancer control even during the initial learning curve for this procedure.

Adult↗

PubMed2005

Modified clipless antegrade nerve preservation in robotic-assisted laparoscopic radical prostatectomy with validated sexual function evaluation.

INTRODUCTION: We present our technique for clipless antegrade neurovascular bundle preservation during robotic laparoscopic radical prostatectomy, along with short-term follow-up of our patients' sexual function. TECHNICAL CONSIDERATIONS: Using the da Vinci three-arm robotic system, we performed robotic laparoscopic radical prostatectomy using a transperitoneal approach in an antegrade fashion. After division of the bladder neck, the posterior plane of the prostate was developed distally toward the apex of the prostate in the midline. This plane was then developed completely, releasing the vascular pedicles and neurovascular bundles in a medial to lateral direction, with occasional use of bipolar cautery and without the use of clips or monopolar cautery. Patients with a minimal follow-up of 3 months who did not require open conversion were included in this study. A total of 56 patients met these inclusion criteria between February 2003 and May 2004, with a mean follow-up of 6 months. Patients were given the validated Rand Medical Outcomes Study 36-Item Health Survey, version 2, with the University of California, Los Angeles, Prostate Cancer Index preoperatively and at 1, 3, 6, and 12 months postoperatively. The overall score for both unilateral and bilateral nerve-sparing groups was 35.0, 39.7, 49.4, and 49.6 at 1, 3, 6, and 12 months postoperatively, respectively. These coincided with a return to baseline potency rate of 47%, 54%, 66%, and 69% at 1, 3, 6, and 12 months, respectively. CONCLUSIONS: Antegrade dissection of the neurovascular bundle, avoiding the use of clips or monopolar cautery during robotic laparoscopic radical prostatectomy, may result in early return of sexual function and overall outcome similar to that after radical retropubic prostatectomy.

Adult↗

PubMed2005

Simplifying laparoscopic partial nephrectomy: technical considerations for reproducible outcomes.

OBJECTIVES: To present our technique, modifications, and experience of laparoscopic partial nephrectomy (LPN). Nephron-sparing surgery is an increasingly accepted treatment for selected T1a kidney tumors. Because of the more complex surgical technique involved, LPN is evolving more slowly than laparoscopic radical nephrectomy. METHODS: The data of 41 consecutive patients with T1a tumors who had undergone LPN from October 2002 to March 2004 were retrospectively reviewed. Four main considerations in our surgical technique were consistently used: (a) LPN was performed in the transperitoneal approach, (b) a suture traction system was placed on the kidney when tumor visualization was challenging, (c) sutures and bolsters were preloaded on the abdominal wall, and (d) hemostasis and closure of the renal defect was performed using Lapra-Ty clips, eliminating knot-tying. RESULTS: The mean patient age was 63.1 years. The mean warm ischemia time was 29.7 minutes, and the mean surgical time was 226.5 minutes. In 26 of 41 patients, the collecting system was entered and repaired. The median estimated blood loss was 150 mL, with a mean tumor size of 2.2 cm. Three cases were converted to open surgery. Five complications (13.2%) occurred. The median hospital stay was 2 days. Of the 41 specimens, 11 were benign. All surgical margins were negative. The mean follow-up was 7.5 months. CONCLUSIONS: Although technically challenging, LPN is emerging as an alternative to open partial nephrectomy. With several easily applied technical considerations, we have simplified LPN, making the procedure more efficient. We believe that the technical considerations we describe can increase the feasibility and ease of LPN for Stage T1a exophytic renal tumors.

Adult↗

PubMed2003

Use of fibrin glue in percutaneous nephrolithotomy.

OBJECTIVES: To report our experience with the use of fibrin glue during tubeless percutaneous nephrolithotomy. We addressed the safety of this approach and evaluated its use for any clinical benefit with respect to length of hospital stay, bleeding, analgesic usage, and urinary extravasation. METHODS: This was a retrospective review of 43 patients who underwent tubeless percutaneous nephrolithotomy. In 20 consecutive patients (one bilateral), percutaneous tracts were injected with 2 to 3 mL of Tissel Vapor Heated sealant at the conclusion of the procedure. The fibrin glue was instilled during simultaneous removal of the percutaneous sheath. These 20 patients were compared with a control group (23 consecutive patients) in which fibrin glue was not used. The length of hospitalization, hematocrit drop, analgesic use, stone burden, operative times, postoperative complications, and any noted computed tomography scan findings were compared. RESULTS: Postoperatively, the average length of hospital stay was less in the experimental than in the control group by 0.71 day (P <0.05). Differences in hematocrit drop between the experimental (6.8%) and control (5.6%) groups were not statistically significant. The total analgesic use was less in the experimental group, but the difference was not statistically significant. No statistical difference was found between the operative times for both groups. Postoperative fevers and wound seroma were noted in the experimental group. No abscesses or any significant changes along the percutaneous tracts were seen on postoperative computed tomography scans. In the control group, no procedure-related complications were noted. CONCLUSIONS: The use of fibrin glue is safe in percutaneous nephrolithotomy procedures and additional prospective randomized studies are needed to evaluate for any clinical benefit.

Adolescent↗