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Biomedical subjects

G N Sklar

Publications and source records attributed to G N Sklar.

At least 19 recordsLinked to original sources
PubMed2001

Penile prosthesis in the organ transplant recipient.

OBJECTIVES: To determine whether pelvic organ transplant recipients are at a higher risk of developing complications after placement of a penile prosthesis relative to those receiving a penile prosthesis who did not undergo pelvic organ transplantation. METHODS: Two hundred eleven men underwent placement of a penile prosthesis by a single urologist at our institution between July 1994 and March 2000. Of these, 46 patients had undergone pelvic organ transplantation before placement of the penile prosthesis. The average time from transplantation was 43 months. The average follow-up after prosthesis placement was 23 months. These patients were monitored for various complications, including infection, malfunction, autoinflation, and injury to the prosthesis. They were compared with a cohort of men who had had a prosthesis placed but had not received pelvic organ transplantation. RESULTS: The overall complication rate was significantly higher in the transplant patients (22%) than in the nontransplant patients (7.9%) receiving prostheses (P <0.01). Infection was seen in 2 transplant patients (4.3%) and in 7 nontransplant patients (4.2%) (P <1). Malfunction occurred in 4 of the transplant patients (8.7%) and 6 of the nontransplant patients (3.6%) (P <0.2). In those patients with a prosthesis malfunction, 9 of 10 involved a three-piece prosthesis. All four malfunctions in the transplant group occurred in three-piece prostheses. The difference in the rate of malfunction was statistically significant (P <0.001) when comparing the three-piece prosthesis in the transplant and nontransplant patients (P <0.001). Surgical injury to the retroperitoneal reservoir occurred in 4 transplant patients (8.7%) (all with three-piece prostheses) and in none of the nontransplant patients (P <0.001). CONCLUSIONS: The risk of infection after insertion of penile prostheses in patients with pelvic organ transplantation was similar to that in nontransplant patients. The risk of malfunction and injury to the prosthesis (three-piece) was higher in transplant patients. The overall complication rate was significantly higher in patients after transplantation and can be attributed to the reservoir complications related to three-piece prostheses. In patients with a prosthesis that did not have a retroperitoneal reservoir, no significant difference in the overall complication rate was observed. Pelvic organ transplant recipients in whom traditional conservative therapy for erectile dysfunction fails should be considered candidates for penile prosthesis placement. However, three-piece prostheses should be avoided, as these patients are best served with prostheses that do not require a retroperitoneal reservoir.

Adult↗
PubMed2001

Use of in situ spermatic cord patch for inguinal lymph node dissection.

Inguinal lymph node dissection for diagnosis of metastatic squamous cell carcinoma of the penis can cause significant morbidity and mortality for patients due to local wound breakdown, lymphedema, and vascular erosion. Various methods have been described to cover exposed femoral vessels to preserve their integrity, the most common being transposition of the sartorius muscle. We describe the successful use of in situ spermatic cord for coverage of the femoral artery and vein after inguinal lymph node dissection for squamous cell carcinoma of the penis in two patients. To our knowledge, this has not been previously described and is a simple and successful alternative way to cover the femoral vessels after inguinal lymphadenectomy.

Aged↗
PubMed2000

The plug and patch: a new technique for repair of corporal perforation during placement of penile prostheses.

PURPOSE: Proximal corporal perforation is an uncommon intraoperative complication during placement of a penile prosthetic device. Unrecognized corporal perforation can result in migration or malfunction of the prosthesis. A windsock repair using a nonabsorbable mesh plug has been described. We describe a new technique called the plug and patch to treat this complication. MATERIALS AND METHODS: From July 1994 to May 1999, 175 patients underwent placement of a penile prosthesis at our institution. Of the patients 8 (4.5%) had proximal corporal perforation. Each perforation was repaired using our plug and patch technique. A 5x7 cm. polyglycolic acid patch was folded on itself and passed into the area of the corporal perforation to act as a plug. A solitary absorbable suture was placed affixing the tail of the patch to the corpora. The corpus was subsequently re-dilated and remeasured, and the prosthesis was placed as usual. RESULTS: All 8 patients were satisfied with the penile prosthesis. There were no infectious complications or proximal migration of the prosthetic cylinders. The plug repair added an average of 6 minutes to the operating time. Only 1 patient had discomfort in the area of the repair, which resolved spontaneously approximately 6 weeks postoperatingly. CONCLUSIONS: The plug and patch is a rapid and effective technique to repair intraoperating proximal corporal perforations. Potential advantages include shorter operating time, technical simplicity and the use of only absorbable materials. This technique may result in lower infection rates compared to the standard windsock repair.

Humans↗
PubMed1999

Endoscopic retrograde stenting for allograft hydronephrosis.

BACKGROUND AND OBJECTIVES: Ureteral obstruction occurs in 2% to 10% of all renal transplant recipients. Antegrade endourologic intervention has been the gold standard of therapy but carries significant morbidity. This study was designed to investigate the feasibility of retrograde stenting of these difficult ureters and to determine whether it can be performed with minimal morbidity without general or regional anesthesia. METHODS: Ninety-seven consecutive patients were found to have renal allograft hydronephrosis by ultrasonography, between August 1993 and March 1997. Of these, 61 (63%) had confirmation of obstruction by MAG-3 imaging, with equivocal results in 25 (26%). The remaining 11 patients had a rising creatinine concentration despite Foley catheter drainage. All patients had retrograde stenting attempted under local anesthesia followed by intravenous sedation if necessary. If stent placement was unsuccessful, the procedure was repeated under regional or general anesthesia. RESULTS: A total of 85 patients (88%) were managed successfully with retrograde stenting. Of these procedures, 24 (28%) were performed under local anesthesia alone, while 57 (67%) required both local anesthesia and intravenous sedation. Only 4 patients (5%) required general anesthesia. No patient suffered any morbidity associated with retrograde stenting. Of the 12 patients in whom retrograde stenting failed, 2 had renal allograft rupture and 10 had ureteral necrosis at surgical exploration. CONCLUSIONS: Retrograde stenting of the hydronephrotic renal allograft can be achieved with a high success rate and minimal morbidity, usually without general or regional anesthesia. If the ureter cannot be managed in a retrograde fashion, a high index of suspicion for a serious allograft complication should exist.

Adult↗
PubMed1999

O'Brien peel-away sheath: an alternative for allograft percutaneous nephroscopy.

Percutaneous access and antegrade intervention remains the gold standard in the management of renal and ureteral complications in the renal transplant recipient. Current techniques with large nephrostomy sheaths and instrumentation carry significant morbidity in this patient population. We present our experience with a modification of the standard nephroscopic approach using a smaller (16F) O'Brien suprapubic peel-away introducer and sheath to access the allograft renal pelvis and allow manipulation with a smaller-caliber endoscope, with the purpose of attaining similar treatment outcomes with less morbidity in this subset of patients. Fourteen renal transplant patients with indications for antegrade management of renal or proximal ureteral complications had successful endoscopic intervention through the smaller sheaths without suffering any intraoperative or postoperative complications at a mean follow-up of 22 months (range 8-37 months). The mean operative time was 140 minutes (33-190 minutes), which is not significantly different from our operative time using standard instrumentation.

Follow-Up Studies↗
PubMed1999

Helical computerized tomography arteriography for evaluation of live renal donors undergoing laparoscopic nephrectomy.

PURPOSE: Traditionally, live renal donors are evaluated with excretory urography and renal arteriography. Helical computerized tomography (CT) arteriography offers a less invasive alternative for demonstrating necessary anatomical information before laparoscopic allograft harvest. We evaluate the accuracy of helical CT arteriography in depicting renal vascular anatomy with an emphasis on the detection of arterial and venous anomalies. MATERIALS AND METHODS: Imaging studies were done on 175 patients according to a standard CT arteriography protocol with early arterial phase scanning (14 to 20-second delay), and 1 mm. axial and 3-dimensional maximum intensity projection reconstructions. Renal vascular anatomy was mapped with attention to aberrant arterial and venous anatomy. Intraoperative findings were correlated at laparoscopic donor nephrectomy. RESULTS: There was overall agreement between CT arteriography and laparoscopic findings in 163 cases (93%). Supernumerary renal arteries were identified in 40 cases (23%). Sensitivity, specificity and accuracy of CT arteriography for arterial anatomy were 91, 98 and 96%, respectively. Cases with less than 2 mm. accessory arteries or early branching single vessels simulating dual arteries were misdiagnosed. Venous anomalies occurred in 11 patients (6.3%). Sensitivity, specificity and accuracy of CT arteriography for venous anatomy were 65, 100, and 97%, respectively. Misdiagnoses included early venous bifurcations and supernumerary tributary veins, which were poorly opacified. CONCLUSIONS: Helical CT is highly accurate and specific for the demonstration of renal arterial anatomy. Poor opacification resulted in a lower sensitivity for venous anatomy. Overall, helical CT provides essential anatomical information, and is an alternative to standard urography and arteriography.

Adult↗
PubMed1999

Living donor nephrectomy.

The need for more organs for kidney transplantation is increasing. Cadaver sources for these organs are stable, therefore living donation must increase if the need is to be met. Less perfect kidneys are now being transplanted. The pool of potential donors is being expanded. The process of kidney donation is being made easier in an effort to increase the number of donors. The donor work-up is being streamlined. Laparoscopic donor nephrectomy has been introduced, and appears to be promising as a technique of lessening donor pain and suffering, while maintaining excellent graft results.

Animals↗
PubMed1999

Real-time transesophageal echocardiography for intraoperative surveillance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy.

PURPOSE: Vena caval tumor thrombus associated with renal cell carcinoma occurs in 4 to 10% of all renal tumors. There is significant operative morbidity and mortality in removing these tumors. We investigate the use of real-time transesophageal echocardiography intraoperatively and to identify tumor thrombus migration and air embolus, which are 2 potentially fatal complications of this procedure. MATERIALS AND METHODS: A total of 13 consecutive patients with renal masses and vena caval extension underwent extirpative surgery monitored with real-time transesophageal echocardiography. RESULTS: In 11 cases the involved kidney and tumor thrombus were removed without morbidity and no evidence of tumor migration or air embolus. Transesophageal echocardiography revealed a 5 cm. tumor thrombus in the right atrium which was removed by immediate atriotomy in 1 of the remaining 2 cases, and a large volume of air in the right atrium that was percutaneously evacuated in the other. These intraoperative complications were unsuspected and only recognized due to the use of transesophageal echocardiography. CONCLUSIONS: Real-time transesophageal echocardiography is a useful adjunct to surgery in patients with renal cell carcinoma and vena caval extension. Transesophageal echocardiography facilitates identification of tumor thrombus migration and air embolization, which are potentially fatal complications, and allows for immediate intraoperative intervention.

Carcinoma, Renal Cell↗
PubMed1998

Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen: long-term followup.

PURPOSE: Hemorrhagic cystitis is a recognized possible side effect of therapeutic radiation administered for a variety of pelvic malignancies. Patients may experience pain, bleeding and clot retention. Various palliative treatments, including instillation of alum, silver nitrate and formalin, may be unsuccessful in alleviating patient symptoms. Hyperbaric oxygen therapy is often used to treat poorly healing wounds. We assess the long-term efficacy of hyperbaric oxygen therapy in treating the manifestations of radiation induced injury to the bladder. MATERIALS AND METHODS: A total of 11 patients with radiation induced hemorrhagic cystitis, confirmed by cystoscopy and biopsy, were treated with hyperbaric oxygen therapy. Symptoms included intractable hematuria in all 11 patients, and some also had other voiding symptoms, including persistent suprapubic pain and urinary urgency. In all patients most other types of management had failed and there was no evidence of active infection or recurrent malignancy. Patients received 100% oxygen in a hyperbaric chamber at 2.0 atmospheres for 90 minutes 5 days a week. Average number of treatments was 40 and median followup was 5.1 years. RESULTS: Of these 11 patients 3 (27%) experienced complete and durable resolution of symptoms, 3 had persistent symptoms despite hyperbaric treatments and required supravesical urinary diversion, and 5 initially responded to hyperbaric oxygen therapy but experienced long-term recurrent symptoms necessitating urinary diversion as definitive therapy. CONCLUSIONS: Hyperbaric oxygen offers a noninvasive therapeutic alternative in the management of radiation cystitis. It appears to produce good short-term benefits but it often does not produce definitive long-term cure of the disease process.

Aged↗
PubMed1998

Urological complications of bladder-drained pancreatic allografts.

OBJECTIVE: To examine the spectrum of urological complications associated with bladder drainage of pancreatic allografts. PATIENTS AND METHOD: Between July 1991 and October 1996, 140 consecutive bladder-drained pancreatic allografts were performed and were reviewed retrospectively to determine the spectrum of post-operative urological complications. Ninety-five patients (68%) underwent simultaneous pancreas-kidney transplantation, 35 (25%) had the pancreas transplanted after the kidney, while 10 (7%) had a pancreas transplant alone. The mean follow-up was 35 months. RESULTS: Seventy patients (50%) had urological complications necessitating intervention: 17 (12%) had retained foreign bodies, bladder tumours occurred in three, 14 had bladder calculi and 15 (11%) had cystoscopic evidence of duodenitis. One patient developed an arteriovenous fistula and one had a necrotic duodenal allograft. Reflux pancreatitis occurred in six patients. Other complications included urethral stricture (three), urethral erosion (three), epididymitis (three), acute prostatitis (one) and prostatic abscess (one). One patient developed a urethrocutaneous fistula and another developed a vesicocutaneous fistula. In the series, 30 of the 140 patients (21%) required eventual conversion to enteric drainage of their allograft as definitive therapy. CONCLUSIONS: Pancreatic transplantation with bladder drainage is associated with a wide range of significant urological problems. Although appropriate treatment can resolve most of the complications, this often entails additional operative intervention, which may increase the long-term morbidity or jeopardize graft function. As a result of the severity of these urological complications, some centres use primary enteric drainage as the method of choice for pancreatic transplantation.

Bacteriuria↗
PubMed1998

Ureteroscopic evaluation in renal transplant recipients.

Percutaneous access and antegrade intervention have been the gold standard for the management of renal and ureteral complications in the renal transplant patient. We reviewed 540 consecutive renal allografts performed between July 1991 and September 1996 to determine the feasibility and morbidity of diagnostic and therapeutic ureteroscopy in renal allograft ureters. Of these, 14 patients (2.5%) had indications for endoscopic intervention of the allograft ureter. Four patients had obstructive ureteral calculi, three had migrated double-pigtail stents, three had persistent suspicious urinary cytology findings necessitating diagnostic ureteroscopy, three had persistent funguria, and one had multiple ureteral filling defects seen on retrograde ureteropyelography. Ureteropyeloscopy was successful in 93% of the patients. A diagnosis was made in all cases, including the one unsuccessful ureteroscopy, as this patient had allograft ureteral necrosis preventing passage of the endoscope into the renal pelvis. All of the migrated stents could be seen, and all but one was retrieved. Two of the patients with persistent funguria did have renal fungal balls, which were removed endoscopically, and the other case yielded a urothelial biopsy positive for fungus. All of the ureteral calculi were removed endoscopically. The only complication was ureteral perforation, which occurred in the patient with ureteral necrosis. Transplant ureteral endoscopy is a technically challenging intervention, but both diagnostic and therapeutic ureteroscopy can be performed with acceptable outcomes and minimal morbidity. One should consider ureteroscopy as an alternative to percutaneous and antegrade modalities, as these methods carry significant morbidity.

Antifungal Agents↗
PubMed1998

The use of bladder for total transplant ureteral reconstruction.

PURPOSE: Although complete necrosis of a transplanted renal allograft ureter is uncommon, it is a difficult complication to manage. Long or multisegment ureteral strictures, most commonly ischemic in nature, are formidable problems for the reconstructive surgeon. We reviewed 655 consecutive renal allografts to determine the incidence of these complex ureteral complications, and the effectiveness and morbidity of complete ureteral reconstruction using bladder alone. MATERIALS AND METHODS: Of 20 patients (3.0%) who required ureteral reconstruction 9 had complete ureteral necrosis and 11 had long (4) or multisegment (7) ureteral strictures. Total ureteral reconstruction was performed using a modified Boari flap in 15 patients and direct pyelovesicostomy in 5. All patients were followed postoperatively with renal ultrasound as well as 99mtechnetium mercaptoacetyltriglycine-3 diuretic renal scans. Mean followup was 28 months. RESULTS: All 20 patients had successful reconstruction of the transplant ureter using bladder for substitution. Four patients had persistent dilatation of the renal collecting system without evidence of obstruction as measured by diuretic renal scan (half-time less than 20 minutes). Reflux into the transplant renal pelvis occurred in 6 patients. Two patients had reversible deterioration in renal function secondary to rejection episodes. Of the group reconstructed via Boari bladder flap prolonged stenting (mean 27 days) and prolonged high volume drain output (mean 22 days) were not uncommon. CONCLUSIONS: Complete ureteral reconstruction is a complex problem in the renal allograft recipient. Using the bladder for reconstruction via Boari flap or direct pyelovesicostomy is an effective technique with minimal morbidity.

Constriction, Pathologic↗
PubMed1997

Complete transplant ureteral reconstruction: a modification of the Boari flap.

Total loss of a transplanted renal allograft ureter from long or multisegment ureteral strictures or ischemic necrosis represents a formidable challenge to the reconstructive surgeon. Direct reimplantation is often not possible due to insufficient length of undamaged ureter or in cases where the native ureter is abnormal, short, nonfunctional, or absent. Using the bladder for reconstruction via Boari flap circumvents these problems and permits successful restoration of the urinary tract. The psoas minor muscle is the classic landmark used for fixation of the bladder after mobilization. Often after renal transplantation, the psoas muscle is not accessible due to position and orientation of the allografted kidney. We present our experience with a modified Boari bladder flap for complete transplant ureteral reconstruction using the fibrotic plate of the demucosalized allograft ureter as the structure used to hitch the recipient bladder.

Humans↗
PubMed1997

Loss of the cyclin-dependent kinase inhibitor p27(Kip1) protein in human prostate cancer correlates with tumor grade.

Loss of expression or mutational deletion of the cyclin-dependent kinase inhibitor p27(Kip1) has recently been implicated in malignant development. In this study, we investigated the relationship between p27(Kip1) protein expression and tumor grade in human prostate cancer by conducting an immunohistochemical analysis in a series of normal prostate, benign prostatic hyperplasia, and malignant prostate cancer specimens. The proliferative activity of prostatic tumors was determined on the basis of the Ki-67 nuclear antigen staining. A uniformly intense immunoreactivity for p27(Kip1) was localized to the nuclei of glandular epithelial cells of normal prostates. The benign glandular epithelia exhibited moderate immunostaining. In the malignant prostate tissue, however, a heterogeneous pattern of substantially reduced p27(Kip1) immunoreactivity was found among the glandular epithelial cells. The majority of primary prostate cancer specimens (68%) were totally negative for p27(Kip1) immunoreactivity, whereas the rest exhibited a significantly decreased p27(Kip1) expression, compared with the normal prostate (P < 0.01). Moreover, there was progressively diminished p27(Kip1) immunostaining with increased tumor grade. This loss of p27(Kip1) was associated with an increase in the proliferative index of prostatic tumors (r = 0.88). There was no significant relationship between p27(Kip) loss and the transforming growth factor beta receptor status of prostatic adenocarcinomas. These results indicate that frequent loss of the cyclin-dependent kinase inhibitor p27(Kip1) in human prostate cancer cells correlates with advancing histological aggressiveness, implicating deregulation of p27(Kip1) in prostate tumor progression.

Adenocarcinoma↗
PubMed1995

Laparoscopic monitoring of cryosurgical ablation of the prostate.

Cryosurgical ablation of the prostate has resurfaced as a potential treatment option for organ-confined adenocarcinoma of the prostate. This study examines the temperatures achieved at the anterior prostatic capsule during the freeze-thaw cycle of transperineal cryosurgical ablation of the prostate. Additionally, as there was direct laparoscopic visualization of the prostate, frost forming outside the prostate would have been detected. Two patients underwent endoscopic extraperitoneal pelvic lymphadenectomy followed, with patients under the same anesthetic, by transperineal cryosurgical ablation of the prostate. Nadir prostatic capsular temperatures reached - 28 and - 36 degrees C, respectively, occurring approximately 13 min into the freezing phase. At these temperatures, no frost was observed endoscopically at the ventral surface of the prostate. Ice was palpated with endoscopic probes several millimeters below the ventral capsular surface. These nadir temperatures are lower than those of previous studies on cryosurgical ablation of the human prostate. Further studies need to examine the temperatures required to produce cell death and to determine whether periprostatic tissues can be treated safely and effectively for locally advanced disease.

Adenocarcinoma↗