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Biomedical subjects

David M Albala

Publications and source records attributed to David M Albala.

At least 19 recordsLinked to original sources
PubMed2007

Age adjusted prostate specific antigen and prostate specific antigen velocity cut points in prostate cancer screening.

PURPOSE: We identified age adjusted prostate specific antigen and prostate specific antigen velocity cut points for prostate cancer biopsy. MATERIALS AND METHODS: A cohort of 33,643 men was retrieved from the Duke Prostate Center database. Of this group 11,861 men with 2 or more prostate specific antigen values within 2 years were analyzed for age adjusted prostate specific antigen and prostate specific antigen velocity performance in cancer risk assessment using a receiver operating characteristic curve. RESULTS: In the 11,861 men prostate cancer prevalence was 273 (8.0%), 659 (14.9%) and 722 (17.9%) in the groups of men 50 to 59 years old, 60 to 69 and 70 years old or older. In prostate cancer groups median prostate specific antigen and prostate specific antigen velocity in men 50 to 59 vs 70 years old or older were 5.6 vs 8.1 ng/ml and 1.37 vs 1.89 ng/ml per year (<0.0001). In men 50 to 59 years old the sensitivity and specificity were 82.1% and 80.7% at prostate specific antigen 2.5 ng/ml, and 84.3% and 72.4% at prostate specific antigen velocity 0.40 ng/ml per year, higher than those in men 70 years old or older at prostate specific antigen 4.0 ng/ml or prostate specific antigen velocity 0.75 ng/ml per year. Decreasing the prostate specific antigen cut point to 2.0 ng/ml and the prostate specific antigen velocity cut point to 0.40 ng/ml per year in men 50 to 59 years old improved the cancer detection rate but decreased the positive predictive value. CONCLUSIONS: Current biopsy guidelines (prostate specific antigen 4.0 ng/ml or greater, or prostate specific antigen velocity 0.75 ng/ml or greater per year) underestimated cancer risk in men 50 to 59 years old. Prostate specific antigen and prostate specific antigen velocity cut points should be age adjusted. In men 50 to 59 years old prostate specific antigen and prostate specific antigen velocity cut points could be decreased to 2.0 ng/ml and 0.40 ng/ml per year, respectively. Factors of age, sensitivity, specificity, positive predictive value and cancer prevalence are critical for obtaining the desired balance between cancer detection and negative biopsy.

Age Factors↗
PubMed2006

Use of Stone Cone minimizes stone migration during percutaneous nephrolithotomy.

We describe a simple and effective method using the Stone Cone to prevent migration of stone fragments into the ureter during percutaneous nephrolithotomy. This maneuver may reduce the need for antegrade ureteroscopy to remove residual fragments, thereby saving time and obviating the need for placement of an occlusion balloon.

Humans↗
PubMed2006

Prostate specific antigen testing in men older than 75 years in the United States.

PURPOSE: Although there is general agreement that men older than 75 years are unlikely to benefit from prostate specific antigen testing, patient reported testing rates in these patients exceed 30%. We examined physician reported PSA testing in elderly men, and physician and practice characteristics associated with testing. MATERIALS AND METHODS: Using the 1999 to 2002 National Ambulatory Medical Care Survey, a nationally representative sample of outpatient visits to nonfederal office based physicians, we measured rates of prostate specific antigen testing by age group in men without prostate cancer who were 40 years or older and who visited outpatient family medicine, internal medicine or urology clinics. RESULTS: An estimated 42.3 million prostate specific antigen tests were performed from 1999 to 2002, of which 5.91 million (14.0%) were performed in men older than 75 years. The population based testing rate was 6.1% in patients 40 to 49-year-old, 26.0% in patients 50 to 75-year-old and 27.8% in patients older than 75 years. Urologists performed 35.4% of prostate specific antigen tests in men older than 75 years. Controlling for sociodemographic variables physicians with a laboratory on site were more likely to perform a prostate specific antigen test (OR 1.35, 95% CI 1.07 to 1.71). In men older than 75 years the odds of prostate specific antigen testing were 1.58 times higher (95% CI 1.01 to 2.50) in practices with a laboratory on site. CONCLUSIONS: Up to a third of men older than 75 years undergo prostate specific antigen testing despite an average life expectancy of less than 10 years. Physician and practice characteristics are associated with prostate specific antigen PSA testing.

Adult↗
PubMed2006

Prospective health-related quality-of-life assessment in an initial cohort of patients undergoing robotic radical prostatectomy.

OBJECTIVES: To prospectively assess the health-related quality-of-life outcomes of patients undergoing robot-assisted laparoscopic prostatectomy using a validated patient self-assessment questionnaire. METHODS: Patients undergoing robot-assisted laparoscopic prostatectomy between September 2003 and May 2005 were given the Expanded Prostate Cancer Index Composite questionnaire preoperatively and 1, 3, 6, 9, 12, and 18 months postoperatively. Patients with a minimum follow-up of 3 months were included in the analysis. The mean domain-specific health-related quality-of-life scores +/- SD and the proportion of patients achieving their baseline scores were calculated. Multivariate proportional hazards regression analysis was used to determine the potential prognostic factors for a return to baseline of the domain scores and continence. RESULTS: The median follow-up was 9.5 months. The median time to recovery of the baseline summary scores was 6.6 months (95% confidence interval [CI] 5.9 to 7.2) in the urinary domain, 2.8 months (95% CI 2.0 to 3.7) in the bowel domain, and 3.0 months (95% CI 2.2 to 3.9) in the hormonal domain. The baseline sexual summary score was recovered by 19.2% of patients at 12 months. The median time to return of continence (0 to 1 pads/day) was 4.0 months (95% CI 3.0 to 4.9). The median time to the return of erections firm enough for intercourse was 13.5 months (95% CI 9.9 to 17.1). On multivariate proportional hazards regression analysis, age, body mass index, prostate size, nerve-sparing technique, and number of comorbidities were not significantly associated with the time to recovery of the baseline domain scores or continence. CONCLUSIONS: Patients undergoing robot-assisted laparoscopic prostatectomy have a favorable health-related quality-of-life recovery profile that appears comparable to those of established surgical approaches.

Follow-Up Studies↗
PubMed2006

Geographic variations in the use of medical and surgical therapies for benign prostatic hyperplasia.

PURPOSE: Patients with BPH have several treatment options. Little is known about geographic variations in surgical rates for BPH and the market relationships to medical therapy, health resources and sociodemographic factors. MATERIALS AND METHODS: We conducted a cross-sectional study using administrative data from 5 states in 2000. Rates of surgical and medical therapy were calculated per 100,000 men 55 years old or older. Main outcome measures were county level weighted coefficient of variation and systematic component of variation in therapy rates, as well as surgery rates as a function of medication dispensing rates, health care resources and sociodemographic characteristics. RESULTS: North Carolina had the lowest surgery rates (26.3 minimally invasive procedures and 332.1 invasive surgeries per 100,000) and finasteride dispensing rates (503.5 per 100,000). Overall rates of medical therapy were 5 times higher than surgery rates. Geographic variations in surgical and medical therapy rates were significant for each state, and North Carolina had the greatest variation. An increase of 11.6 per 100,000 (95% CI, 6.5-55.8) in annual county level finasteride dispensing would be associated with a decrease in the surgery rate of 1 per 100,000, controlling for other variables. CONCLUSIONS: There is significant systematic variation in rates of surgical and medical therapy for BPH at county and state levels. The relationship between finasteride and surgery in randomized clinical trials is generalizable to the marketplace. Finasteride rates are inversely related to surgery rates, and tamsulosin rates are positively associated with surgery rates. Surgery rates are not significantly associated with urologists per capita.

Adrenergic alpha-Antagonists↗
PubMed2006

Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial.

BACKGROUND AND PURPOSE: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic. PATIENTS AND METHODS: Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p < 0.05. RESULTS: Stone size was equivalent in the two treatment groups (p > 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p > 0.05). CONCLUSIONS: Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.

Adult↗
PubMed2005

Supplement use among men with prostate cancer.

OBJECTIVES: To characterize supplement use within a sample population of men diagnosed with prostate cancer. METHODS: A census of men diagnosed with prostate cancer at Duke University Medical Center from 1997 to 2002 (n = 1402) was mailed a survey that ascertained data on health status, education, diet, exercise, smoking status, and information on supplement use. Differences between demographic and treatment subgroups were described and tested, as was change in supplement use after diagnosis. RESULTS: Data from 805 respondents indicated that a majority (73%) used supplements, and 68% claimed that this information was shared with their cancer care provider. The most commonly reported supplements were multivitamins (56%), vitamin E (43%), vitamin C (33%), and calcium (26%). On average, 2.7 +/- 2.8 supplements per day were taken, and use increased significantly after diagnosis for most supplements. Use was significantly higher among men who were white (P = 0.043), were more highly educated (P = 0.002), exercise regularly (P = 0.020), and who consume five or more daily servings of fruits and vegetables (P = 0.040). CONCLUSIONS: A high percentage of men with prostate cancer take supplements, especially those who are white, more educated, and who pursue healthful behaviors. Systematic means of capturing these data are necessary to begin to understand the potential impact of supplements on disease outcome, especially because no data exist to suggest that supplements are of any benefit after diagnosis.

Aged↗
PubMed2005

Effect of ureteral access sheath on stone-free rates in patients undergoing ureteroscopic management of renal calculi.

OBJECTIVES: To evaluate the effect of ureteral access sheaths (UASs) on stone-free rates (SFRs) during ureteroscopic treatment of renal calculi. Several advantages of UASs during flexible ureteroscopy have been documented. However, no study has evaluated their impact on SFRs. METHODS: We retrospectively reviewed all ureteroscopic cases for the management of renal stones performed at our Stone Center. Data were stratified according to the use or lack of use of the UAS. The groups were stratified by stone location within the kidney. Stone-free status was determined at 2 months postoperatively by either intravenous urography with tomograms or noncontrast renal computed tomography in patients with contrast allergies. RESULTS: A total of 256 ureteroscopic procedures for the removal of renal calculi were performed between 1997 and 2003 (173 with UAS and 83 without). The groups were similar in age, sex, and stone burden. Stents were placed in nearly 80% of patients. The lower renal pole represented the most common presenting location. Stone displacement with a ureteroscopic basket for efficient fragmentation was necessary in 34%. The overall SFR in the UAS group and non-UAS group was 79% and 67%, respectively (P = 0.042). The SFRs were improved for calculi in all portions of the kidney. CONCLUSIONS: In addition to facilitating ureteroscopic access, reducing costs, and lowering intrarenal pressures, the results of the current study suggest that UASs improve SFRs during the management of renal calculi. It is now our current practice to use the UAS routinely during ureteroscopic treatment of renal and upper ureteral calculi.

Equipment Design↗
PubMed2005

Location and etiology of flexible and semirigid ureteroscope damage.

OBJECTIVES: To perform an analysis of currently available manufacturer data regarding the character of ureteroscope damage. The high costs associated with the repair of flexible and semirigid ureteroscopes are well documented. Increased knowledge of the etiology of ureteroscope damage should aid urologists in prolonging the lives of these delicate instruments. METHODS: We requested data from the four major ureteroscope manufacturers (ACMI, Olympus America, Karl Storz, and Richard Wolf) on the types, speculated causes, costs, and frequency of ureteroscope damage. The results were tabulated in a blinded fashion and analyzed for trends. We then formulated guidelines that could be applied by practicing urologists. RESULTS: For both flexible and semirigid ureteroscopes, the frequency of repair increased with decreasing ureteroscope diameter and increasing instrument length. The cost of the repair was generally greater for flexible ureteroscopes (mean 4597 dollars) than for semirigid ureteroscopes (mean 2437 dollars). The major causes of flexible ureteroscope damage were working channel damage from laser burn or instrument passage and extreme scope deflection with an indwelling instrument. The primary reasons for semirigid ureteroscope repair included overtorquing and improper handling in the operating room and during sterile processing. CONCLUSIONS: Urologists can minimize the repair costs of flexible and semirigid ureteroscopes by taking precautions to eliminate laser fiber-induced damage and by avoiding overdeflection. Improved storage and handling of these instruments is also necessary. Although small-diameter ureteroscopes are favorable because of their increased mobility and ease of passage, physician and staff awareness of their increased fragility is vital in maximizing the longevity of these commonly used instruments.

Equipment Design↗
PubMed2005

Controlled survival study of the effects of Tisseel or a combination of FloSeal and Tisseel on major vascular injury and major collecting-system injury during partial nephrectomy in a porcine model.

PURPOSE: We report the results of a controlled survival study in a porcine model investigating Tisseel or a combination of FloSeal and Tisseel in dealing with vascular and collecting-system injury during partial nephrectomy. MATERIALS AND METHODS: We performed an open right lower-pole partial nephrectomy on 15 large female pigs. The defect was repaired using standard open techniques (N = 5; controls), Tisseel only (N = 6; group I), or FloSeal followed by Tisseel (N = 4; group II). A Jackson-Pratt drain was placed. Nephrectomy and retrograde pyelography were performed at 1 week. RESULTS: Operative times were shorter in both study groups, achieving statistical significance in group I (P = 0.008). Warm-ischemia times were significantly improved in both study groups (P = 0.029 and P = 0.00005 in groups I and II, respectively). Time to hemostasis was significantly shorter in group II only (P = 0.002) but approached significance in Group I as well (P = 0.09). Estimated blood loss was not significantly different from the controls in either group. When Tisseel was placed alone after hilar control, hematoma formation under the Tisseel was noted on release of the hilar clamp. After 1 week, there was one urinoma and three urine leaks in the control group. In group I, there was one urinoma and four urine leaks, and there was only one urine leak and no urinomas in group II. There were no hematomas in any of the groups. CONCLUSIONS: Tisseel alone is not adequate for either hemostasis or management of major collecting-system injury. FloSeal capped with Tisseel appears sufficient to control major vascular and collecting-system injuries without adjunctive surgical measures. A proposed technique for laparoscopic partial nephrectomy without reconstructive techniques is presented that warrants clinical study.

Animals↗
PubMed2005

In vitro comparison of stone retropulsion and fragmentation of the frequency doubled, double pulse nd:yag laser and the holmium:yag laser.

PURPOSE: The frequency doubled, double pulse Nd:YAG (FREDDY) laser (World of Medicine, Berlin, Germany) functions through the generation of a plasma bubble. Upon bubble collapse a mechanical shock wave is generated, causing stone fragmentation. This mechanism of action is in contrast to the holmium laser, which cause stone destruction by vaporization. Observed clinical stone retropulsion and fragmentation with the FREDDY and holmium lasers has prompted a series of in vitro experiments designed to compare laser induced retropulsion and fragmentation with those of a holmium laser and pneumatic lithotrite. MATERIALS AND METHODS: For retropulsion a hands-off underwater laboratory setup, including a horizontally oriented silicone tube 1.3 cm in diameter and a holder to keep the stone phantom in contact with the quartz laser fiber or pneumatic probe, was used. Previously weighed, cylindrical Bego stone phantoms (Bego USA, Smithfield, Rhode Island) were placed in the apparatus. Stone fragmentation was performed with the FREDDY or holmium laser, or the pneumatic lithotripter. The FREDDY and holmium lasers were tested at similar pulse energy and frequency settings. As a standard for comparison, a pneumatic lithotrite was tested with a semirigid probe and single pulse settings of 100, 200 and 300 kPa. Stone phantoms underwent 30 shocks per setting. Mean net retropulsion, defined as the final resting point of the stone, as determined by direct measurement, was recorded for each setting. For fragmentation plaster of Paris stone phantoms of known weights were used to compare the fragmentation ability of each laser. Stones phantoms were placed in a hands-off underwater setup, consisting of an inverted silicon syringe and holder immersed in tap water. The laser fiber (365 microm for the holmium and 280 microm for the FREDDY) was placed through the tip of the syringe in contact with the stone phantom. A total of 24 stones were divided into 4 groups of 6 per group. Two groups were fragmented with the FREDDY laser at 300 and 400 J total energy. The other 2 groups were fragmented using the holmium laser at 300 and 480 J total energy. Fragmentation efficiency was determined as percent weight loss. RESULTS: For retropulsion at 160 mJ the FREDDY laser caused stone retropulsion to a mean distance of 7.6, 8.1 and 6.8 cm at settings of 5, 10 and 15 Hz, respectively. At 0.8 J the holmium laser retropulsed the stone to a mean distance of 3.3 and 4.9 cm at settings of 5 and 10 Hz, respectively. The pneumatic device caused stone retropulsion a mean distance of 8.5, 9.9 and 13.8 cm at pressure settings of 100, 200 and 300 kPa, respectively. The FREDDY laser generally caused less retropulsion than the pneumatic device, although this difference was only significant at the highest pneumatic lithoclast setting (p <0.05). At clinically relevant settings the FREDDY laser caused significantly more retropulsion than the holmium laser (p <0.05). For fragmentation at total energy settings of 300 and 400 J the FREDDY laser resulted in 44.9% and 86.8% weight loss, respectively (p <0.05). At settings of 300 and 480 J the holmium:YAG laser resulted in 3.3% and 7.1% weight loss, respectively (p <0.05). CONCLUSIONS: At lower frequency settings stone retropulsion was significantly greater with the FREDDY laser compared with the holmium laser. However, retropulsion was significantly less than that caused by the pneumatic lithotripter at all settings. Therefore, we recommend the use of an occlusive device, such as the Stone Cone (Boston Scientific, Natick, Massachusetts) proximal to the calculus during intracorporeal ureteral lithotripsy and in the ureteropelvic junction during percutaneous laser nephrostolithotomy. In vitro stone fragmentation was significantly greater with the FREDDY laser than with the holmium:YAG laser, suggesting that the FREDDY may offer a low cost alternative to the holmium:YAG laser lithotrite in select patients.

Equipment Design↗
PubMed2005

Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less.

PURPOSE: The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial. MATERIALS AND METHODS: A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. RESULTS: A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. CONCLUSIONS: This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.

Adult↗
PubMed2005

Local cost structures and the economics of robot assisted radical prostatectomy.

PURPOSE: Robot assisted prostatectomy (RAP) is more costly than traditional radical retropubic prostatectomy (RRP) under the cost structures at certain hospitals. However, this finding may not be the case in all care settings. We investigated the sensitivity of RAP and RRP inpatient costs to variations in length of stay (LOS), local hospitalization costs and robotic case volume in the specialist and generalist settings. MATERIALS AND METHODS: We developed a model of RAP vs RRP costs in the specialist and generalist settings using published data on operative time and LOS, and cost data from our academic medical center. All inpatient cost centers were included, namely surgery costs, professional fees, postoperative care, robotic equipment and service. Extensive 1 and 2-way sensitivity analyses were performed. RESULTS: Our base case model demonstrated a cost premium for RAP vs RRP of USD $783 and $195 in the specialist and generalist settings, respectively. Sensitivity analysis of our model assumptions demonstrated that RAP could achieve cost equivalence with RRP at a surgical volume of 10 cases weekly. If case volume increased to 14 cases weekly, RAP would be less expensive than RRP in some practice settings in which RAP LOS was less than 1.5 days. CONCLUSIONS: The inpatient costs of robotic assisted prostatectomy are volume dependent and cost equivalence with generalist radical retropubic prostatectomy is possible at higher volume RAP specialty centers. While RAP may be cost competitive with RRP at high cost hospitals or high volume RAP specialist centers, this procedure would exist at a cost premium to RRP in other practice settings.

Health Care Costs↗
PubMed2005

Extracorporeal shock wave lithotripsy with a transportable electrohydraulic lithotripter: experience with >300 patients.

OBJECTIVE: To review a multicentre experience of using a transportable lithotripter (STS-T, Medstone, Inc, Aliso Viejo, CA. USA) for treating patients with urolithiasis in all parts of the urinary tract. PATIENTS AND METHODS: In all, 326 patients with a total of 370 stones were treated as outpatients with the STS-T lithotripter. All patients received a single shock wave lithotripsy treatment and were followed after 4-6 weeks in the outpatient clinic, the primary endpoint being to determine the efficacy (as defined by the stone-free rate). Secondary objectives included establishing a database of patient demographic information, stone characteristics, stone location, procedural endpoints, and complication rates. RESULTS: In all there were 370 procedures, with a mean of 2394 shocks administered at an energy level of 24 kV. The mean treatment time was 51 min, excluding anaesthesia-induction time. The mean stone aggregate size was 8.2 mm; 62% of the stones were in the kidney while 38% were in various locations in the ureter. Of the treated stones, 90% had definite or probable evidence of fragmentation. The overall stone-free rate after one treatment with the STS-T was 52.8%. Of patients with residual fragments, most (61%) had fragments of <4 mm in aggregate diameter. The overall complication rate was 3.8%, the most common complication being postoperative pain. CONCLUSION: The Medstone STS-T lithotripter was an effective device for treating urolithiasis in all parts of the urinary tract. This system had a high margin of safety, as shown by the low complication rate. With no apparent sacrifice of efficacy compared to first-generation or fixed (not transportable) second-generation devices, the Medstone STS-T represents an important advance in the development of a truly transportable lithotripter.

Adult↗
PubMed2005

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi.

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.

Adult↗
PubMed2004

Bilateral renal calculi: assessment of staged v synchronous percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: Percutaneous stone removal has replaced open renal surgery and has become the treatment of choice for large or complex renal calculi. However, patients with large bilateral stone burdens still present a challenge. Simultaneous bilateral percutaneous nephrolithotomy (PCNL) has been demonstrated to be a well-tolerated, safe, cost-effective, and expeditious treatment. We present what is, to our knowledge, the first large retrospective series comparing synchronous and asynchronous bilateral PCNL. PATIENTS AND METHODS: A chart review was performed on 26 patients undergoing 57 PCNLs for bilateral renal calculi over a 7-year period. Seven patients received synchronous PCNL (same anesthesia; Group 1), and 19 patients underwent asynchronous PNL (procedures separated by 1-3 months; Group 2). Complete surgical and hospital records were available on all patients. The average stone burden for Group 1 was 8.03 cm(2) on the left and 9.18 cm(2) on the right v 10.1 cm(2) on the left and 14.23 cm(2) on the right for Group 2 (P> 0.05). Variables of interest included anesthesia time, operative time, blood loss, transfusion rates, length of hospital stay, and complication rates. Each variable was evaluated per operation and per renal unit. Follow-up imaging with stone assessment was available on 20 patients. RESULTS: Group 1 required 1.14 access tracts per renal unit to attempt complete clearance of the targeted stones v 1.88 tracts per renal unit in Group 2 (P> 0.05). The average operative time per renal unit was significantly less in Group 1 (83 minutes) than in Group 2 (168.5 minutes) (P< 0.0001), as was blood loss (178.5 mL v 307.4 mL, respectively; P= 0.02). However, blood loss per operation was similar at 357 mL in Group 1 and 282 mL in Group 2. Comparable transfusion rates of 28.6% and 36.8%, respectively, were noted. Forty percent of the patients in Group 1 were completely stone free compared with 36% of the patients in Group 2; however, an additional 50% and 57%, respectively, had residual stone burden <4 mm (P> 0.05). Complications occurred in 2 of 7 operations (28%) in Group 1 and 8 of 42 operations (19%) in Group 2. The total length of hospital stay was nearly doubled for patients undergoing staged PCNL (P= 0.0005). CONCLUSIONS: These results demonstrate similar stone-free rates, blood loss per operation, and transfusion rates for simultaneous and staged bilateral PCNL. The reduced total operative time, hospital stay, and total blood loss, along with the requirement for only one anesthesia, makes synchronous bilateral PCNL an attractive option for select individuals. However, in patients with larger, less easily accessible stones, excessive bleeding may be encountered more frequently on the first side, thereby delaying management of the second side to a later date. Synchronous bilateral PCNL should be considered in patients in whom the first stage of stone removal is accomplished quickly and safely.

Adolescent↗
PubMed2004

Hand-assisted laparoscopic approach to simple nephrectomy.

Laparoscopic nephrectomy is commonly employed today for both malignant and benign renal conditions, yet the learning curve for all but the simplest procedures remains quite steep. Hand-assisted laparoscopic nephrectomy (HALN) bridges the gap between standard laparoscopy and open surgery, allowing urologists to develop laparoscopic skills while offering the advantages of minimally invasive surgery. Simple laparoscopic nephrectomy, performed for benign disorders, can at times prove to be challenging because of inflammation around the renal hilum. Meticulous dissection during HALN utilizing the intra-abdominal hand for tactile feedback, retraction, and blunt dissection may improve one's capabilities compared with the standard laparoscopic approach.

Humans↗