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J S Wolf

Publications and source records attributed to J S Wolf.

At least 19 recordsLinked to original sources
PubMed2001

Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy.

BACKGROUND: Laparoscopic live donor nephrectomy for renal transplantation is being performed in increasing numbers with the goals of broadening organ supply while minimizing pain and duration of convalescence for donors. Relative advantages in terms of recovery provided by laparoscopy over standard open surgery have not been rigorously assessed. We hypothesized that laparoscopic as compared with open surgical live donor nephrectomy provides briefer, less intense, and more complete convalescence. METHODS: Of 105 volunteer, adult, potential living-renal donors interested in the laparoscopic approach, 70 were randomly assigned to undergo either hand-assisted laparoscopic or open surgical live donor nephrectomy at a single referral center. Objective data and subjective recovery information obtained with telephone interviews and validated questionnaires administered 2 weeks, 6 weeks, and 6-12 months postoperatively were compared between the 23 laparoscopic and 27 open surgical patients. RESULTS: There was 47% less analgesic use (P=0.004), 35% shorter hospital stay (P=0.0001), 33% more rapid return to nonstrenuous activity (P=0.006), 23% sooner return to work (P=0.037), and 73% less pain 6 weeks postoperatively (P=0.004) in the laparoscopy group. Laparoscopic patients experienced complete recovery sooner (P=0.032) and had fewer long-term residual effects (P=0.0015). CONCLUSIONS: Laparoscopic donor nephrectomy is associated with a briefer, less intense, and more complete convalescence compared with the open surgical approach.

Activities of Daily Living↗
PubMed2001

Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations.

The American Urological Association (AUA) convened the Best Practice Policy Panel on Asymptomatic Microscopic Hematuria to formulate policy statements and recommendations for the evaluation of asymptomatic microhematuria in adults. The recommended definition of microscopic hematuria is three or more red blood cells per high-power microscopic field in urinary sediment from two of three properly collected urinalysis specimens. This definition accounts for some degree of hematuria in normal patients, as well as the intermittent nature of hematuria in patients with urologic malignancies. Asymptomatic microscopic hematuria has causes ranging from minor findings that do not require treatment to highly significant, life-threatening lesions. Therefore, the AUA recommends that an appropriate renal or urologic evaluation be performed in all patients with asymptomatic microscopic hematuria who are at risk for urologic disease or primary renal disease. At this time, there is no consensus on when to test for microscopic hematuria in the primary care setting, and screening is not addressed in this report. However, the AUA report suggests that the patient's history and physical examination should help the physician decide whether testing is appropriate.

Algorithms↗
PubMed2001

Complications of ureteroscopy: analysis of predictive factors.

PURPOSE: Although overall and major complication rates of 10% to 20% and 0% to 6%, respectively, have been observed in large series of ureteroscopy, to our knowledge no systemic analysis to determine factors predictive of these complications has been reported. MATERIALS AND METHODS: We retrospectively reviewed all ureteroscopies performed at our institution for calculous disease from January 1997 through September 1999. A total of 322 procedures were performed by 5 attending surgeons. Intraoperative and immediate postoperative complications were identified. Bivariate and multivariate analysis was performed to identify associated factors with ureteral perforation and postoperative complications as the dependent variables. RESULTS: Bivariate analysis showed a significant association of ureteral perforation with increased operative time (p = 0.0001). In addition, we noted a significant association of postoperative complications with stones in the kidney (p = 0.0004), operative time (p = 0.05) and decreased surgeon experience (p = 0.0035) as well as a trend toward significance for the type of ureteroscope used (p = 0.0609). In multivariate logistic regression models ureteral perforation remained highly associated with operative time (p = 0.0005) when controlling for the other factors. Similarly decreased surgeon experience and a stone in the kidney were predictive of postoperative complications when controlling for the other factors (p = 0.004). CONCLUSIONS: Longer duration of the ureteroscopic procedure is strongly associated with ureteral perforation. The likelihood of immediate postoperative complications is greater when renal calculi are treated and less when the surgeon is more experienced.

Adult↗
PubMed2001

Prospective comparison between hand-assisted laparoscopic and open surgical nephroureterectomy for urothelial cell carcinoma.

OBJECTIVES: To prospectively compare open surgical and the new hand-assisted approach to laparoscopic nephroureterectomy for urothelial cell carcinoma. Previous retrospective studies have suggested that standard laparoscopic nephroureterectomy provides a briefer convalescence than open surgical nephroureterectomy. METHODS: Between March 1997 and September 1999, 16 hand-assisted laparoscopic and 11 open surgical nephroureterectomies were performed, without randomization. Validated questionnaires were prospectively administered preoperatively and 2 and 6 weeks postoperatively. RESULTS: The operative time was longer with the laparoscopic approach (320 versus 199 minutes, P <0.001), but the hospital stay was shorter (3.9 versus 5.2 days, P = 0.03). Patient recovery favored the laparoscopic group with regard to time to drive (17.1 versus 37.7 days), time to normal, nonstrenuous activity (18.2 versus 38.1 days), and the mental component score of the SF-12 survey at 6 weeks (57.1 versus 43.0) (P <0.05 for all). Minor complications occurred in 19% of the laparoscopic and 45% of the open surgical procedures; major complications occurred in 19% of laparoscopic and 27% of open surgical procedures (P >0.1 for both). Cancer control was similar between both groups. The mean operating room cost was 56% more for the laparoscopic group (P <0.001), but the overall hospital cost was only 8% greater (P >0.3). CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy is a safe and effective alternative to an open surgical approach. Indexes of patient recovery suggest that patient convalescence is less than after an open surgical nephroureterectomy. Increased operative costs may be offset by a shorter hospital stay and fewer complications, resulting in similar overall hospital costs.

Aged↗
PubMed2001

Comparison of 2-octyl cyanoacrylate adhesive, fibrin glue, and suturing for wound closure in the porcine urinary tract.

OBJECTIVES: To evaluate 2-octyl cyanoacrylate glue (OCG) for wound closure in the urinary tract and compare the ability of OCG, fibrin glue (FG), and suture to withstand physiologic and supraphysiologic stress, because the use of tissue adhesives such as OCG or FG might simplify laparoscopic surgery. METHODS: Female domestic pigs (n = 22) underwent a 7.5-cm cystotomy. Of these, 8 had closure with OCG and 8 with FG (6 open and 2 laparoscopic in each group). The controls were closed with suture (n = 4) or not at all (n = 2). Postoperative catheter drainage was not used. At 2 days or 4 weeks postoperatively, the bladders were filled with saline to 200 mm Hg pressure and the cystotomy scars inspected for leakage. The excised scars were also examined histologically. RESULTS: The 2 OCG and 2 FG pigs tested on postoperative day 2 leaked at less than 200 mm Hg. None of the 6 OCG pigs tested at 4 weeks leaked at less than 200 mm Hg, including the 2 closed laparoscopically. Of the 6 FG pigs intended for study at 4 weeks, 3 (including the 2 closed laparoscopically) died from a massive urine leak, 1 tested at 4 weeks leaked, and 2 did not leak. Thus, 4 of 6 FG pigs leaked by 4 weeks compared with none in the OCG group (P = 0.06). The histologic examination was similar in the two groups. CONCLUSIONS: Preliminary results suggest that OCG provides enough strength to hold together a large bladder wound. In the same model, FG did not consistently provide adequate closure.

Animals↗
PubMed2001

Functional effects of unilateral laser papillectomy in the pig.

OBJECTIVES: To evaluate the use of endoscopic laser papillectomy in a multi-papillary animal model to unilaterally impair concentrating ability and increase the urinary flow rate. METHODS: Domestic pigs underwent unilateral retrograde flexible nephroscopy. With a holmium:yttrium-aluminum-garnet laser, varying numbers of papillae were ablated. Four weeks after the procedure, renal function studies were performed during hydropenia and after hydration, the animals were killed, and the kidneys were examined histologically. RESULTS: The urine flow rate per 100 mL creatinine clearance was significantly increased in the papillectomized kidney compared with the control kidney during hydropenia (1.50 versus 0.94, P <0.01). The papillectomized kidneys were unable to concentrate the urine as well as the control kidneys during both hydropenia (urine osmolarity 430 versus 534 mOsm/L, P <0.01) and after hydration (329 versus 362 mOsm/L, P = 0.02). The free water reabsorption per 100 mL creatinine clearance was impaired in the papillectomized kidneys compared with the control kidneys (0.48 versus 1.00, P = 0.02) after hydration. A significant correlation existed between the percentage of papillae ablated and the difference in osmolarity between the operated and control kidneys (r(2) = 0.50, P = 0.015). Histologic examination demonstrated transitional re-epithelialization with moderate collecting duct dilation and medullary fibrosis underlying the ablated papillae early in the series; however, the histologic features normalized and the creatinine clearance was less impaired with a more proficient technique later in the series. CONCLUSIONS: Endoscopic laser papillectomy results in increased urine flow and impaired urinary concentrating ability. This surgical technique should be investigated further for its role in the prevention of nephrolithiasis.

Animals↗
PubMed2001

Routine placement of ureteral stents is unnecessary after ureteroscopy for urinary calculi.

OBJECTIVES: To report a matched comparison of patients with and without stenting after ureteroscopy for calculi, including middle or proximal ureteral and renal calculi. The elimination of routine stenting after ureteroscopy would prevent stent pain, minimize the need for re-instrumentation, and reduce costs-as long as efficacy and safety are not diminished. METHODS: Of 318 patients who underwent ureteroscopy, 81 (25%) did not have a ureteral stent placed. Of those, 51 were suitable for analysis and included patients with distal ureteral (n = 22), middle or proximal ureteral (n = 11), and renal calculi (n = 18). This cohort was matched to a stented group by stone size and location. RESULTS: The preoperative characteristics of the groups were similar. A stone-free rate of 86% and 94% was achieved in the stented and nonstented groups, respectively (P = 0.32). Complications in the nonstented group were less frequent (flank pain in 3 and postoperative nausea in 1) than in the stented group (hospital visits for flank pain in 12, persistent nausea and vomiting in 1, sepsis in 1, perinephric hematoma in 1, and urinary retention in 1) (total of 4 versus 16, P = 0.025). CONCLUSIONS: Ureteroscopy for distal ureteral stones without ureteral stent placement has been previously described. Our experience expands to include the elimination of stent placement after ureteroscopy for middle or proximal ureteral (22%) and renal (35%) calculi. Our data suggest that after ureteroscopies with short operative times and minimal ureteral trauma, ureteral stents may not be necessary, even if proximal ureteral or renal ureteroscopy has been performed.

Follow-Up Studies↗
PubMed2001

Comparison of outcomes of ureteroscopy for ureteral calculi located above and below the pelvic brim.

OBJECTIVES: To compare the safety and efficacy of ureteroscopy performed for proximal and distal ureteral calculi in a contemporary cohort. Ureteroscopy has been used most often for distal ureteral calculi. However, advances in endoscopic equipment have facilitated access to the proximal urinary tract and have broadened the indications for ureteroscopy. METHODS: One hundred ninety-one patients underwent rigid and/or flexible ureteroscopy for ureteral calculi at the University of Michigan between January 1, 1997 and September 30, 1999. Only 7 patients with either bilateral calculi or steinstrasse were excluded. The final cohort consisted of 184 patients who underwent ureteroscopy for distal stones (n = 103) or middle/upper ureteral stones (n = 81). RESULTS: Bivariate analyses of pretreatment and perioperative characteristics were used to assess the sample population. The initial success rate for the distal and proximal ureteral calculi was 96% and 78%, respectively (P = 0.0008). After a "second-look" procedure in 4 and 7 patients with distal and proximal calculi, respectively, the success rate improved to 99% and 88%, respectively (P = 0.004). No differences were noted between groups regarding the intraoperative (P = 0.51) or postoperative (P = 0.85) complication rates. Multivariate logistic regression analysis confirmed that larger stone size (odds ratio 1.2, P = 0.0006) and proximal ureteral location (odds ratio 4.8, P = 0.01) are independent predictors of treatment failure. CONCLUSIONS: Ureteroscopic management of proximal and distal ureteral calculi is highly successful, and the difference in success rates has narrowed substantially. Currently, no greater risk is conferred to the patient for endoscopy of more proximal ureteral calculi.

Adult↗
PubMed2001

Flexible ureteroscopy in conjunction with in situ lithotripsy for lower pole calculi.

OBJECTIVES: To demonstrate the efficacy and safety of ureteroscopy as a compromise in treating small and intermediate-size lower pole calculi. The optimal management of lower pole calculi remains controversial. Shock wave lithotripsy is associated with minimal morbidity but with suboptimal stone clearance rates. Conversely, percutaneous nephrostolithotomy has greater morbidity but stone-free rates greater than 90% regardless of size. METHODS: Seventy-two patients underwent ureteroscopy for lower pole calculi 2 cm or less (mean 8.7 mm) during a 3-year period. To minimize confounding, 11 patients with additional calculi at other ipsilateral renal sites and 1 patient with large (2.4 cm each) bilateral calculi were excluded. Two patients with bilateral lower pole calculi and four who required a second procedure were included in the analysis. Thus, the final cohort consisted of 60 patients who underwent 66 procedures. RESULTS: Of patients with follow-up longer than 1 month, 79% were stone free after a single procedure, and this improved to 88% after a second procedure in 4 patients. All 7 patients with follow-up less than 1 month had a reduction in stone burden after successful fragmentation. Overall, 8 patients required an auxiliary procedure. No intraoperative complications, and 7 (11%) postoperative complications occurred. CONCLUSIONS: Ureteroscopy for lower pole calculi is associated with minimal morbidity and stone-free rates comparable to shock wave lithotripsy for smaller stones. The greatest utility of ureteroscopy is in the management of intermediate-size calculi, for which it has substantially higher stone-free rates and lower repeated treatment rates than does shock wave lithotripsy.

Chi-Square Distribution↗
PubMed2001

Use of bowel in laparoscopic urology.

Minimally invasive urology is a rapidly expanding field. What once was thought technically impossible is now becoming a reality, especially with the advent of intracorporeal stapling and automated suturing devices. Laparoscopic assistance and pure laparoscopy improve convalescence and cosmesis in comparison with open surgical procedures. Minimally invasive continent urinary stomas, ACE procedures, bladder augmentation, urinary diversion, and urinary undiversion have all been described in clinical practice. Continent urinary diversions and ileal bladder augmentations are being developed. Eventually, even the most challenging urologic procedures will be performed in a minimally invasive manner.

Animals↗
PubMed2001

Indications, technique, and results of laparoscopic pelvic lymphadenectomy.

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Humans↗
PubMed2001

A canine model to assess the biochemical stress response to laparoscopic and open surgery.

PURPOSE: To develop an animal model to assess the stress response to open and laparoscopic surgery. Such a model would allow objective physiologic assessment of the putative benefits of laparoscopy and provide a framework in which to compare modifications in operative and anesthetic technique that might decrease the stress of surgery. MATERIALS AND METHODS: Mongrel dogs underwent laparoscopic (N = 12) or open surgical (N = 12) left nephrectomy. In 11 control animals, after induction of anesthesia and line placement, the animal underwent either no intervention (open surgery sham; N = 6) or pneumoperitoneum only (laparoscopic sham; N = 5). Serum glucose and cortisol were measured preoperatively, at skin closure, and at 4, 8, and 24 hours postoperatively. Values at each time point were compared in the laparoscopic and open surgical nephrectomy groups and in each of the two nephrectomy groups and their respective shams. RESULTS: Compared with baseline, there was a sharp rise in serum cortisol at the time of skin closure, with a gradual decline to baseline values by 24 hours, in all experimental animals. Significantly lower serum cortisol concentrations were seen at 4 and 8 hours postoperatively in the laparoscopic group than in the open surgery group. Cortisol was significantly higher in the open group than in the sham-open group at all time points, whereas cortisol was greater in the laparoscopic group than in the pneumoperitoneum-only group only at the 4-hour time point. No differences were seen in serum glucose between groups. CONCLUSIONS: The serum cortisol concentration appears to be a good measure of surgical stress in the canine model. The rapid decline in serum cortisol after laparoscopy compared with open surgery may indicate a lesser degree, or quicker resolution, of surgical stress in the former. Furthermore, the similarity in cortisol curves between laparoscopy and pneumoperitoneum only suggests that surgical stress in laparoscopic surgery may be attributable mainly to the effects of pneumoperitoneum.

Animals↗
PubMed2001

Comparison of shockwave lithotripsy outcomes in patients receiving sufentanil or lidocaine spinal anesthesia.

PURPOSE: To determine whether the use of intrathecal sufentanil, which allows the patient to move during shockwave lithostripsy (SWL), affects treatment outcomes and operative and recovery times compared with standard lidocaine spinal anesthesia. PATIENTS AND METHODS: We retrospectively studied a series of 62 SWL procedures performed on an unmodified Dornier HM3 lithotripter. The mean calculus size was 10.7 mm. There were 46 renal calculi, 13 ureteral calculi, and 4 patients with calculi in both locations. Of the 63 procedures, 25 were performed using intrathecal sufentanil alone, and 37 were performed with intrathecal lidocaine with or without additional agents. We compared treatment outcomes, as well as treatment time, fluoroscopy time, postanesthesia care unit (PACU) time, time to voiding, and time to ambulation. RESULTS: Sufentanil use was associated with a significantly higher rate of successful treatment, defined as residual fragments absent or <4 mm on follow-up imaging, compared with lodocaine: 68% v. 40% (p = 0.0394). There was no significant difference between the groups in treatment time or fluoroscopy time. Use of sufentanil was associated with significantly shorter PACU time, time to ambulation, and time to voiding postoperatively. These differences persisted when men and women were analyzed separately, although the differences were less significant in women. CONCLUSIONS: The use of intrathecal sufentanil for anesthesia during SWL does not adversely affect treatment outcome; it is, in fact, associated with better outcomes. The advantages of this agent in shortening recovery times and in easing patient transfer into the HM3 gantry argue for increasing its use.

Adult↗
PubMed2001

Evaluation and management of traumatic posterior urethral disruption with flexible cystourethroscopy.

BACKGROUND: We sought to consolidate evaluation and management of traumatic urethral disruption using cystourethroscopic evaluation without retrograde urethrogram or suprapubic cystostomy placement. METHODS: We review our experience with initial flexible cystourethroscopic evaluation of suspected urethral injury from blunt trauma with placement of a Council urethral catheter to provide primary endoscopic realignment of the urethra. RESULTS: Access into the bladder was achieved in 8 of 10 patients. After a mean follow-up of 18 months (range, 9-27 months) in the six living patients, only three have required treatment for urethral stricture--direct vision internal urethrotomy in two, and open perineal urethroplasty in one. Urinary continence has been achieved in five of six patients. CONCLUSION: Primary flexible cystourethroscopy with placement of a urethral catheter streamlines evaluation of traumatic posterior urethral injury. In the presence of partial disruption it provided stricture-free outcomes in three of three surviving patients.

Adult↗