PubMed Health⌕ Search

Biomedical subjects

Gary J Faerber

Publications and source records attributed to Gary J Faerber.

14 recordsLinked to original sources
PubMed2004

Ex vivo ureteroscopic treatment of calculi in donor kidneys at renal transplantation.

PURPOSE: We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) as a means of rendering the donated kidney stone-free at live donor renal transplantation. MATERIALS AND METHODS: A total of 10 suitable kidney donors with small, unilateral nonobstructive calculi underwent live donor nephrectomy (8 open flank, 2 hand assisted transperitoneal). Immediately after cold perfusion, ExURS was performed in an iced saline solution. Access to the collecting system was via the ureteral stump. Calculi were either removed with endoscopic baskets and/or completely fragmented with Holmium laser lithotripsy. RESULTS: Access to the renal collecting system was technically successful in all cases. A total of 10 stones, ranging in largest diameter from 1 to 8 mm (average 5.2) were visualized. Of the kidneys 6 had solitary stones, 2 had 2 stones and 1 had no stone. Of 10 stones 9 were successfully removed and/or fragmented with an average procedure time of 6.5 minutes (range 3 to 28). Indwelling ureteral stents were placed at transplantation in 5 of 10 kidneys. There were no intra-operative or postoperative ureteral complications. At 1 month after transplant serum creatinine ranged from 0.9 to 2.7 mg/dl (average 1.5). At a mean followup of 33.2 months new stones have not formed in any recipients and at mean 36.4-month followup no new calculi have formed in the remaining kidney of any donors. CONCLUSIONS: ExURS is a technically feasible means of rendering a stone bearing kidney stone-free without compromising ureteral integrity or renal allograft function.

Adolescent↗
PubMed2003

Helical computed tomography for identification of crossing vessels in ureteropelvic junction obstruction-comparison with operative findings.

OBJECTIVES: To evaluate the use of contrast-enhanced helical computed tomography (HCT) scanning with three-dimensional reconstructions as a possible identifier of crossing vessels in ureteropelvic junction (UPJ) obstruction. Endoscopic treatment of UPJ obstruction has a success rate that approaches 90%. These results drop to 40% in the presence of crossing vessels. Unrecognized crossing vessels can also result in significant hemorrhage during endopyelotomy. The presence of crossing vessels is, for many, an indication for open or laparoscopic UPJ repair. Therefore, accurate preoperative imaging is crucial for appropriate treatment planning. METHODS: Our study population consisted of 18 patients evaluated and treated for UPJ obstruction at the University of Michigan Health System. These patients underwent routine contrast-enhanced preoperative HCT scanning before UPJ repair. A prior history of failed endoscopic treatment, patient preference, and HCT findings of crossing vessels were indications for open or laparoscopic repair. The imaging findings were compared with open findings during laparoscopic or open pyeloplasty. RESULTS: An HCT finding of the presence of crossing vessels was a significant positive predictor, with a value of 100%. The sensitivity in this population was 91% and the specificity was 100%. No difference was noted between the detection of arterial or venous crossing vessels. The positive predictive value was 100%, and the negative predictive value was 88%. CONCLUSIONS: HCT is an accurate predictor of the presence of crossing vessels in UPJ obstruction. Because crossing vessels may have a profound impact on treatment outcome, HCT can serve as an effective, noninvasive, preoperative screening tool.

Adult↗
PubMed2003

Safety and efficacy of same-session bilateral ureteroscopy.

PURPOSE: Same-session ureteroscopy for bilateral urinary calculi would potentially reduce costs and the need for a second anesthetic compared with staged procedures. We sought to establish the safety and efficacy of same-session bilateral ureteroscopy relative to procedures for staged bilateral and multiple unilateral calculi in the context of contemporary instrumentation. PATIENTS AND METHODS: A series of 626 consecutive patients underwent ureteroscopy for calculi between January 1997 and August 2001. Among these, 34 patients with bilateral calculi (11 staged and 23 treated in one sitting) and 54 patients with multiple unilateral calculi in distinct locations were included in this study. Multivariable regression was used to determine the association of patient-specific and technical factors with postoperative morbidity. RESULTS: Stone-free rates were similar in the two groups and ranged from 50% to 100% depending on stone location. Postoperative complications occurred in 6 (11%) and 3 (14%) of the patients treated for multiple unilateral and for bilateral calculi in a staged procedure, respectively, compared with 7 (29%) of those undergoing same-session bilateral ureteroscopy (P = 0.12). Logistic regression revealed that same-session bilateral ureteroscopy (odds ratio [OR] 4.0; P = 0.02) and absence of a postoperative stent (OR 1.7; P = 0.03) were associated with added morbidity. However, the cumulative risk of performing staged bilateral procedures (14% per procedure) approximated that of bilateral ureteroscopy in one sitting (29%). CONCLUSION: Bilateral ureteroscopy carries an increased risk of postoperative morbidity. The risk is proportional to the number of renal units treated and may be assumed at once (e.g., same-session) or over time (e.g., staged) as it applies to patients requiring bilateral ureteroscopy.

Adult↗
PubMed2003

Identifying patients who are suitable for stentless ureteroscopy following treatment of urolithiasis.

PURPOSE: Foregoing ureteral stents following ureteroscopy for urinary calculi is an evolving practice. Randomized trials support stent omission in select cases though generalizability is unclear and criteria for stentless ureteroscopy are unknown. Therefore, we sought to identify significant clinical characteristics affecting postoperative morbidity in unstented patients to provide a context for future randomized trials. MATERIALS AND METHODS: Of 837 ureteroscopic procedures for urolithiasis performed at our institution from January 1997 through January 2002 a ureteral stent was not placed in 226 (32%). Among these patients 47 had no stone at the time of the procedure leaving 219 (26%) who were treated for urinary calculus disease. Multivariate logistic regression was used to determine the association of 24 variables with postoperative morbidity. RESULTS: Of the 219 patients treated with ureteroscopy 39 (18%) had a postoperative complication, which was obstructive in 26 (12%), infectious in 10 (5%), and related to patient co-morbidity in 3 (1%). Factors associated with postoperative morbidity included renal pelvic location (p = 0.02), lithotripsy (p = 0.03), bilateral procedure (p = 0.07), history of urolithiasis (p <0.0001), diabetes mellitus (p = 0.06), recent/recurrent infection (p <0.0001), operative time 45 minutes or greater (p = 0.07), operative time 45 minutes or greater plus lithotripsy (p = 0.0004), operative time 45 minutes or greater plus ureteral dilation (p = 0.07) and bilateral stentless procedure (p = 0.005). CONCLUSIONS: Multiple patient and operative factors may predispose a patient to postoperative morbidity after a stentless procedure. Future trials should prospectively validate the role of these factors in either promoting (e.g., history of urolithiasis) or preventing (e.g., preoperative stent) a postoperative complication in the setting of stentless ureteroscopy.

Adult↗
PubMed2003

Retrograde ureteroscopy in patients with orthotopic ileal neobladder urinary diversion.

PURPOSE: We assess the feasibility, technique, complications and clinical outcomes of retrograde ureteroscopy in patients with orthotopic ileal neobladder. MATERIALS AND METHODS: We retrospectively reviewed our ureteroscopy experience to identify procedures performed in patients who had previously undergone cystectomy with orthotopic ileal neobladder urinary diversion. These procedures were reviewed and data collected regarding patient characteristics, indication for endoscopic evaluation, surgical technique, findings, complications and followup. RESULTS: Eight patients with neobladder diversion were taken for 9 sessions in the cystoscopy suite for attempted retrograde ureteroscopy on 13 renal units. The indication for ureteroscopy was an upper tract filling defect, positive cytology or calculi. The ureter and renal pelvis were successfully accessed and visualized in 10 of 13 renal units. The cause of failure in the 3 unsuccessful procedures was inability to access the ureteral orifice. Mean operative time +/- SD was 78 +/- 34 minutes. Urothelial abnormalities were identified in 4 patients, extrinsic compression in 2 and stones in 3. In 1 patient postoperative hematuria developed, which spontaneously resolved. Fluoroscopy was essential to identify the afferent limb of the reservoir, and a directional guide wire was helpful in engaging the ureteral orifice. CONCLUSIONS: Ureteroscopic evaluation and treatment of upper tract abnormalities are feasible and practical in most patients with orthotopic neobladder urinary diversion. Identification of the ureteral orifice is challenging but can be accomplished with a combination of endoscopic and fluoroscopic techniques. This procedure avoids the morbidity of percutaneous access, and complications are minimal.

Adult↗
PubMed2003

Evaluating the Accreditation Council on Graduate Medical Education core clinical competencies: techniques and feasibility in a urology training program.

PURPOSE: We describe several traditional and novel techniques for teaching and evaluating the Accreditation Council on Graduate Medical Education (ACGME) core clinical competencies in a urology residency training program. MATERIALS AND METHODS: The evolution and underpinnings of the ACGME Outcome Project were reviewed. Several publications related to the evaluation of clinical competencies as well as current assessment techniques at our institution were also analyzed. RESULTS: Several tools for the assessment of clinical competencies have been developed and refined in response to the ACGME Outcome project. Standardized patient encounters and expanded patient satisfaction surveys may prove useful with regard to assessing resident professionalism, patient care and communication skills. A feasible and possibly undervalued technique for evaluating a number of core competencies is the implementation of formal written appraisals of the nature and quality of resident performance at departmental conferences. The assessment of competency in practice based learning and systems based practice may be achieved through innovative exercises, such as practice guideline development, that assess the evidence for various urologic interventions as well as the financial and administrative aspects of such care. CONCLUSIONS: We describe several contemporary methods for teaching and evaluating the core clinical competencies in a urology training program. While the techniques described are neither comprehensive nor feasible for every program, they nevertheless provide an important starting point for a meaningful exchange of ideas in the urological graduate medical education community.

Accreditation↗
PubMed2003

Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma.

PURPOSE: We report on endoscopic treatment outcomes for upper tract urothelial carcinoma and identify predictive factors for success. MATERIALS AND METHODS: A total of 61 renal units were referred for endoscopic treatment of an upper tract tumor, 69% of which did not have a traditional indication for nephron sparing approaches. Tumor pathology and operative findings were assessed retrospectively for treatment outcomes and influential factors. RESULTS: Initial ureteroscopic inspection was undertaken in 53 renal units with resection attempted in 18 (34%) resulting in an 89% success rate with 16 treated. A percutaneous approach in 19 renal units (11 after ureteroscopy) was 100% successful in achieving tumor-free status, for a total of 35 renal units successfully treated endoscopically. Surveillance then began on 27 renal units with a recurrence rate of 88% and mean time to recurrence of 5.8 months (range 2 to 20). Of patients undergoing surveillance (31% of whom had high grade disease), 54% remain or have died of unrelated disease, during a mean followup of 21.0 months (range 3 to 48). Higher tumor grade, larger size, renal pelvis location (all p <0.01) and multifocality (p = 0.05) significantly correlated with decreased recurrence-free survival, but did not predict failure of local control by endoscopic surveillance. CONCLUSIONS: Although endoscopic techniques can render most patients tumor-free, there is a high associated recurrence rate and many need repeat procedures. Recurrence-free survival is greater in patients with low grade, solitary or less bulky disease. However, rigorous surveillance after endoscopic resection can lead to success even in patients with high grade, multifocal or large volume disease, resulting in preservation of renal units.

Aged↗
PubMed2002

Pubic osteomyelitis following bladder neck surgery using bone anchors: a report of 9 cases.

PURPOSE: We reviewed 9 cases of pubic osteomyelitis associated with placement of bone anchors for bladder neck suspension procedures for risk factors, bacterial speciation and sensitivities, and interventions performed. MATERIALS AND METHODS: Nine women were treated for pubic osteomyelitis following the use of bone anchors for bladder neck suspension surgery. In 8 cases the bone anchors had been placed through a suprapubic incision and in 1 the bone anchors were placed by a vaginal route. RESULTS: Patient ages ranged from 36 to 74 years (mean 51.8). Symptomatic presentation ranged from 2 to 18 months following initial operation. Presenting symptoms included pain over the pubis and/or a draining wound. Staphylococcus species were cultured in all cases, most commonly Staphylococcus epidermidis. Resistance to methicillin was present in 7 cases (78%). Wound débridement and removal of the anchors provided definitive treatment in all but 1 patient, who eventually required partial pubectomy. Pain (3 of 9 cases) and mild incontinence (5 of 9) were present at last followup. CONCLUSIONS: Bone anchors used in surgery for urinary incontinence can be associated with pubic osteomyelitis. Infection characteristics are similar to those seen with other urological prosthetic implantation procedures. Aggressive treatment with surgical débridement and long-term antibiotics is usually effective. Staphylococcus species, especially methicillin resistant strains, are the most common bacteria identified in this setting. Careful attention to implantation technique, including appropriate perioperative antibiotic selection, should be considered when using this technique.

Adult↗
PubMed2002

Ureteroscopy for the treatment of urolithiasis in children.

PURPOSE: Ureteroscopy for treating urolithiasis in prepubertal children has become more common with the advent of smaller instruments. We reviewed our experience with ureteroscopy for urolithiasis in this cohort of patients as well as the literature using this treatment modality in children. MATERIALS AND METHODS: Between 1994 and 2000 we performed 27 ureteroscopic stone extractions in 25 children. Ureteroscopy was done in a manner similar to that in adults. Ureteral dilation was performed when necessary to access the ureter. A stent was placed postoperatively if there was significant ureteral trauma. RESULTS: Of the 25 children 13 were male and 12 were female. Average age was 9.2 years (range 3 to 14). Stones were 2 to 12 mm. in greatest diameter (average 6). Of the 27 procedures the ureteral orifice was dilated before stone treatment in 15 (56%), while in 19 (70%) a stent was placed afterward. No intraoperative and 2 postoperative complications were identified. Overall 92% of the children were rendered stone-free after 1 procedure and 100% were stone-free after 2. CONCLUSIONS: Ureteroscopy for urolithiasis in prepubertal children is safe and effective. Routine ureteral dilation and ureteral stent placement are not always necessary in these patients.

Child↗
PubMed2002

Successful angioembolization of renal artery pseudoaneurysms after blunt abdominal trauma.

We report a case of minimally invasive management of renal artery pseudoaneurysms after blunt abdominal trauma. A 44-year-old man developed gross hematuria after a motor vehicle collision. The initial radiographic evaluation revealed only a parenchymal laceration of the right kidney, and the patient was treated conservatively. Persistent gross hematuria necessitated repeat renal angiography that revealed numerous small pseudoaneurysms. Angioembolization was successfully performed with minimal compromise of the renal parenchyma. Transcatheter embolization is safe and effective for controlling hemorrhage from traumatic renal artery pseudoaneurysms and should be the initial treatment of choice in hemodynamically stable patients.

Abdominal Injuries↗
PubMed2002

Ureteroscopic treatment of renal calculi in morbidly obese patients: a stone-matched comparison.

OBJECTIVES: To report a matched comparison of morbidly obese (MO) patients and normal weight (NW) patients who underwent ureteroscopic (URS) treatment of renal calculi. Shock wave lithotripsy and percutaneous nephrostolithotomy may be precluded in MO patients, and URS treatment offers a minimally invasive alternative. METHODS: We retrospectively reviewed the charts of patients who underwent URS at our institution between 1997 and 2000. Fifty-four patients underwent URS treatment solely for renal calculi. Sixteen MO patients underwent 18 procedures. Thirty-eight NW patients, who underwent 39 procedures, were matched to the MO patients by stone location and size. Stones were categorized by location and size, less than 10 mm or 10 mm or greater. The factors and outcomes assessed were stone length, operative time, presence of a ureteral stent, success, and complications. RESULTS: The overall success rate was 83% (15 of 18 procedures) for MO patients and 67% (26 of 39 procedures) for NW patients, but this difference was not significant (P = 0.23). The difference in the success rate for renal calculi 10 mm or greater (100% versus 38%) approached significance (P = 0.09). This may be related to other distinctions between the groups. URS treatment was often a salvage therapy in the NW group after other modalities failed. No significant differences were found between the other outcomes. CONCLUSIONS: URS treatment of renal calculi when matched for location and size is as successful and no more morbid in MO than in NW patients. URS treatment of renal calculi is a safe and effective first-line treatment for renal calculi in MO patients.

Body Mass Index↗
PubMed2002

Urinary tract abnormalities: initial experience with multi-detector row CT urography.

PURPOSE: To evaluate multi-detector row computed tomographic (CT) urography for detection of urinary tract abnormalities. MATERIALS AND METHODS: Sixty-five patients referred from the urology service, in whom urinary tract abnormalities were strongly suspected, underwent multi-detector row CT urography. The technique included unenhanced, nephrographic, compression, and excretory-phase images through the abdomen and pelvis. Transverse images and three-dimensional reformations were reviewed by one of two radiologists. Findings were retrospectively compared with results of urinalysis, cystoscopy and/or ureteroscopy, and/or surgery. RESULTS: Multi-detector row CT urography depicted many clinically diagnosed urinary tract abnormalities, including 15 of 16 uroepithelial malignancies, five congenital anomalies, five urinary tract calculi, and 18 calyceal and/or papillary, 30 renal pelvic and/or ureteral, and 25 bladder abnormalities. All abnormalities were detected on transverse images. These abnormalities included diffuse urothelial wall thickening in four patients (three of whom had transitional cell carcinoma), a renal abscess, a colovesical fistula, and incidentally detected extrarenal disease (a liver mass, hepatic metastases, lymph node metastases, an aortic dissection, and a pheochromocytoma; each of these findings was seen in one patient). CONCLUSION: Multi-detector row CT urography is a useful method for detecting urinary tract abnormalities.

Adult↗
PubMed2002

Ureteroscopic treatment of lower pole calculi: comparison of lithotripsy in situ and after displacement.

PURPOSE: Ureteroscopic management is a viable option for lower pole calculi less than 2 cm. Recently a technique was described to displace the calculus into a more accessible calix using a nitinol basket or grasper before lithotripsy. We compared the efficacy and safety of this technique with in situ treatment of small and intermediate lower pole calculi. MATERIALS AND METHODS: We retrospectively reviewed the records of 95 ureteroscopy cases performed at our institution from January 1997 through August 2001 for renal calculi located only in the lower pole. Preoperative patient characteristics, stone size, operative details, complications and outcomes were compared for calculi treated in situ and those displaced before treatment. RESULTS: Adequate followup was available on 78 patients. Patients in the displacement group were statistically older, more often had a preoperative indwelling ureteral stent and had a mean operative time that was 16 minutes longer (p = 0.04). Average stone diameter in the in situ and displacement groups was 8 and 10.3 mm., respectively (p = 0.04). In patients with radiographic followup greater than 1 month complete success was obtained for 77% of stones 1 cm. or less treated in situ versus 89% treated with displacement first (p = 0.43). For calculi greater than 1 cm. complete success was obtained for 2 of the 7 (29%) treated in situ versus all 7 (100%) treated with displacement (p = 0.005). CONCLUSIONS: When treating lower pole calculi 1 to 2 cm. via ureteroscopy, a higher success rate can be obtained with displacement into a more accessible calix before treatment.

Adult↗