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Biomedical subjects

James E Lingeman

Publications and source records attributed to James E Lingeman.

At least 19 recordsLinked to original sources
PubMed2003

Holmium Laser Enucleation of the Prostate (HoLEP): A Technical Update.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation represents the latest refinement of holmium:YAG surgical treatment for benign prostatic hyperplasia (BPH). Utilizing this technique, even the largest of glands can be effectively treated with minimal morbidity. The learning curve remains an obstacle, preventing more widespread adoption of this procedure. This paper provides an outline of the HoLEP technique as is currently used at two centers in hopes of easing the initial learning curve. TECHNICAL CONSIDERATIONS: Detailed descriptions of the major steps of the HoLEP procedure are provided with attention to critical steps such as identification of the surgical capsule, median and lateral lobe enucleation, and morcellation of enucleated tissue. CONCLUSIONS: HoLEP is a promising alternative for the surgical treatment of BPH which allows complete removal of intact lobes of the prostate. Obstruction is relieved immediately with superior hemostasis, no risk of TUR syndrome, and a minimal hospital stay.

Journal Article↗
PubMed2003

Holmium laser enucleation of the prostate: morbidity in a series of 206 patients.

OBJECTIVES: To review the complications associated with 206 holmium laser enucleation of the prostate (HoLEP) procedures. HoLEP is a minimally invasive surgical treatment for benign prostatic hyperplasia. METHODS: A retrospective review was conducted of HoLEPs performed from April 1, 1999 to October 1, 2001. Patients with previous diagnoses of prostate carcinoma or who had undergone HoLEP after admission for unrelated problems were excluded. Demographic, intraoperative, and immediate postoperative data were recorded to determine the incidence of complications. Patients were also contacted by telephone or mailed surveys for documentation of longer term complications. RESULTS: The mean age and procedure time was 70.5 years (range 45 to 91) and 133.6 minutes (range 25 to 473), respectively. The mean specimen weight was 68.2 g (range 3 to 376), with 20 (9.7%) of 206 patients diagnosed with adenocarcinoma. The mean hospital stay was 1.1 days, with 86.9% of patients discharged after an overnight stay without a catheter. Two patients required postoperative transfusions (1.0%). No deaths, major complications (myocardial infarction or pulmonary embolism), or transurethral resection syndrome episodes occurred. Intraoperative complications consisted of three capsular perforations (1.5%), one bladder neck false passage (0.5%), four incomplete morcellations (1.9%), and four minor bladder mucosal morcellation injuries (1.9%). Of 206 patients, 173 (84.0%) provided follow-up data (mean 19.0 +/- 8.4 months), allowing documentation of longer term complications, including five clot retention episodes (2.4%), five urethral strictures (2.4%), eight bladder neck contractures (3.9%), and 16 patients requiring re-catheterization (7.8%). CONCLUSIONS: HoLEP can be performed with minimal complication risks and blood loss. Patients can expect an overnight hospital stay and discharge without an indwelling catheter.

Adenocarcinoma↗
PubMed2003

Variability of renal stone fragility in shock wave lithotripsy.

OBJECTIVES: To measure, in an in vitro study, the number of shock waves to complete comminution for 195 human stones, representing six major stone types. Not all renal calculi are easily broken with shock wave lithotripsy. Different types of stones are thought to have characteristic fragilities, and suggestions have been made in published reports of variation in the fragility within some types of stones, but few quantitative data are available. METHODS: Kidney stones classified by their dominant mineral content were broken in an unmodified Dornier HM3 lithotripter or in a research lithotripter modeled after the HM3, and the number of shock waves was counted for each stone until all fragments passed through a sieve (3-mm-round or 2-mm-square holes). RESULTS: The mean +/- SD number of shock waves to complete comminution was 400 +/- 333 per gram (n = 39) for uric acid; 965 +/- 900 per gram (n = 75) for calcium oxalate monohydrate; 1134 +/- 770 per gram (n = 21) for hydroxyapatite; 1138 +/- 746 per gram (n = 13) for struvite; 1681 +/- 1363 per gram (n = 23) for brushite; and 5937 +/- 6190 per gram (n = 24) for cystine. The variation for these natural stones (83% +/- 15% coefficient of variation) was greater than that for artificial (eg, gypsum-based) stones (17% +/- 8%). CONCLUSIONS: The variability in stone fragility to shock waves is large, even within groups defined by mineral composition. Thus, knowing the major composition of a stone may not allow adequate prediction of its fragility in lithotripsy treatment. The variation in stone structure could underlie the variation in stone fragility within type, but testing of this hypothesis remains to be done.

Humans↗
PubMed2003

Phase I trial of a temporary ureteral drainage stent.

BACKGROUND AND PURPOSE: The temporary ureteral drainage stent (TUDS; Boston Scientific/Microvasive, Natick, MA) is a biodegradable device that is designed to maintain patency for 48 hours with gradual softening and spontaneous expulsion thereafter. We evaluated the durability, patency, and safety of TUDS in a Phase I clinical trial. PATIENTS AND METHODS: Eighteen stone patients requiring sequential percutaneous nephrolithotomies (PNL) for complex stone disease underwent antegrade TUDS placement following initial percutaneous treatment. Nineteen devices were placed in 21 attempts, with one patient undergoing bilateral TUDS placement. Day 2 nephrostograms were performed to allow assessment of stent status and to demonstrate antegrade flow. Stents were removed at the time of the secondary PNL (day 2 or 3). RESULTS: No complications occurred during TUDS placement. On day 2, 1 stent had passed into the bladder. Eleven stents were completely intact, with seven others partially intact. Day 2 ureteral patency was demonstrated in all 19 stented ureters. Eighteen TUDS were removed completely during the secondary PNL with one incident of partial retention. All stent material had passed out of the body in all patients by 1 month. No adverse events were attributable to the TUDS. CONCLUSIONS: The TUDS appears to facilitate ureteral drainage for at least 48 hours after placement. Although occasional stent tail detachments were noted, these did not interfere with device function. The safety profile of TUDS was favorable, with no complications attributable to the device itself. A larger prospective clinical study in patients receiving TUDS placed retrograde after uncomplicated ureteroscopic manipulation appears appropriate on the basis of these initial findings.

Absorbable Implants↗
PubMed2003

Percutaneous nephrolithotomy: an update.

PURPOSE OF REVIEW: Percutaneous nephrolithotomy has undergone an evolution in technique and in equipment since its introduction in the late 1970s. This evolution continues today and is evidenced by the numerous publications about the technique. This review summarizes some of the important articles over the past year. RECENT FINDINGS: Although ureteroscopy and shock wave lithotripsy predominate in the treatment of urolithiasis, percutaneous nephrolithotomy continues to play an important role. Percutaneous nephrolithotomy is advantageous as it causes minimal renal injury and maximizes stone clearance, especially in patients with complex stone disease. Although nephrostomy drainage tubes have always been placed after percutaneous nephrolithotomy, there may be specific indications for tubeless percutaneous nephrolithotomy. SUMMARY: Percutaneous nephrolithotomy continues to be an important part of the urologist's armamentarium. Recent studies have redefined the role of percutaneous nephrolithotomy and future studies will further delineate the importance of this procedure in the treatment of urolithiasis.

Clinical Trials as Topic↗
PubMed2003

Use of a temporary ureteral drainage stent after uncomplicated ureteroscopy: results from a phase II clinical trial.

PURPOSE: An indwelling ureteral stent is commonly placed for 48 hours after uncomplicated ureteroscopy to maintain drainage and prevent postoperative complications. A propriety temporary ureteral drainage stent (TUDS, Boston Scientific/Microvasive, Natick, Massachusetts) was developed to satisfy this goal with the added advantages of biodegradability and spontaneous passage. We evaluated TUDS performance in a patient population. MATERIALS AND METHODS: A total of 88 patients at 6 centers were selected for TUDS placement. Device safety as well as effectiveness, defined as adequate intervention-free drainage for 48 hours with the maintenance of ureteral position, were the primary study end points. Secondary end points consisted of the time required to eliminate TUDS from the body, tolerability of device presence and passage, and overall patient satisfaction with the stent. RESULTS: A single patient was excluded from primary end point analysis because of inadequate day 2 evaluation, resulting in an overall stent effectiveness rate of 78.2% (68 of 87 patients). Primary end point failure occurred in the remaining 19 patients (21.8%) with early stent extrusion in 17 and intervention required in 2 others within 48 hours of stent placement (cystoscopy and intravenous analgesia in 1, and intravenous analgesia alone in 1). There were no adverse clinical sequelae in 16 patients who experienced early extrusion with only 1 requiring intravenous pain medication. Stent fragments were retained beyond 3 months in 3 patients, of whom 2 were treated in a minimally invasive manner with shock wave lithotripsy, while 1 required ureteroscopy and shock wave lithotripsy to clear the residual fragments. Median time to stent elimination from the ureter and from the body was 8 and 15 days, respectively. Overall 71 of the 80 patients (89%) reported satisfaction with TUDS. CONCLUSIONS: The concept of a self-degrading internal ureteral stent represents a new paradigm in ureteral drainage. TUDS combines adequate ureteral drainage and patient satisfaction after uncomplicated ureteroscopy, eliminating the need for stent removal.

Adolescent↗
PubMed2003

Holmium laser enucleation of prostate (HoLEP): the Methodist Hospital experience with greater than 75 gram enucleations.

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) effectively removes obstructive prostate tissue in minimally invasive fashion. We present our large enucleation outcomes (greater than 75 gm retrieved). We examined post-procedural prostate specific antigen (PSA) and transrectal ultrasound (TRUS) volume changes to assess tissue removal completeness. MATERIALS AND METHODS: We retrospectively reviewed HoLEPs performed from April 1, 1999 through September 30, 2002 to identify all enucleations greater than 75 gm. Demographic, laboratory, operative and pathological data were obtained. Patients were surveyed to document longer term complications. RESULTS: The cohort of 108 patients had a mean age and specimen weight of 71.5 years (range 53 to 90) and 120.6 gm (range 75.3 to 376), respectively. Average procedural time and hospital stay were 166.8 minutes (range 75 to 473) and 1.2 days (range 0 to 4), respectively. No deaths or episodes of transurethral resection syndrome occurred. Postoperative complications included transfusion in 2 cases, a clot retention episode in 3, capsular perforation in 2, morcellator blade malfunction in 4, minor bladder mucosal injury in 1 and bladder neck contracture in 1. American Urological Association symptom scores reassessed in 53 patients without chronic retention an average +/- SD of 10.6 +/- 7.1 months postoperatively showed a mean decrease from 20.3 +/- 6.4 to 4.7 +/- 3.8. PSA in 48 patients a mean of 5.0 +/- 4.1 months postoperatively had decreased an average of 91.7%. In 10 patients TRUS data revealed a mean post-procedural volume decrease of 85.9%. CONCLUSIONS: HoLEP can be performed on extremely large prostates with minimal risk or need for secondary interventions. Most patients are discharged home after an overnight stay. Postoperative decreases in PSA and TRUS volumes support the completeness of enucleation that can be achieved.

Adenocarcinoma↗
PubMed2003

Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.

Our purpose here is to test the hypothesis that Randall's plaques, calcium phosphate deposits in kidneys of patients with calcium renal stones, arise in unique anatomical regions of the kidney, their formation conditioned by specific stone-forming pathophysiologies. To test this hypothesis, we performed intraoperative biopsies of plaques in kidneys of idiopathic-calcium-stone formers and patients with stones due to obesity-related bypass procedures and obtained papillary specimens from non-stone formers after nephrectomy. Plaque originates in the basement membranes of the thin loops of Henle and spreads from there through the interstitium to beneath the urothelium. Patients who have undergone bypass surgery do not produce such plaque but instead form intratubular hydroxyapatite crystals in collecting ducts. Non-stone formers also do not form plaque. Plaque is specific to certain kinds of stone-forming patients and is initiated specifically in thin-limb basement membranes by mechanisms that remain to be elucidated.

Adult↗
PubMed2002

Stone fragmentation during shock wave lithotripsy is improved by slowing the shock wave rate: studies with a new animal model.

PURPOSE: The current trend toward ungated shock wave lithotripsy means that more patients are being treated with shock waves delivered at a rapid rate (120 shock waves per minute or greater). However, no benefit of an increased shock wave rate has been shown and in vitro studies indicate that slowing the shock wave rate actually improves stone fragmentation. We tested the effect of the shock wave rate on stone comminution in a new animal model. MATERIALS AND METHODS: Gypsum model stones were inserted via upper pole percutaneous access into the lower pole calix of the kidneys of female pigs weighing approximately 100 pounds. Shock wave lithotripsy was performed (400 shock waves uninterrupted at 20 kV. and 30 or 120 shock waves per minute) 2 hours later using an unmodified HM3 lithotriptor (Dornier Medical Systems, Marietta, Georgia). After en bloc excision of the urinary tract stone fragments were collected and sieved through 2 mm. mesh. The particles were weighed and surface area was determined. RESULTS: Stones treated at 30 shock waves per minute broke more completely than stones treated at 120 shock waves per minute. The percent of fragments greater than 2 mm. was significantly higher for stones treated at the fast rate of 120 versus the slow rate of 30 shock waves per minute (mean +/- SEM 81% +/- 14% versus 45% +/- 12%, p <0.005). When stone fragmentation was expressed as the percent increase in fragment surface area, significantly greater fragmentation occurred at the slower than at the more rapid rate (327% +/- 63% versus 135% +/- 136%, p <0.02). CONCLUSIONS: Slowing the rate of shock wave administration during shock wave lithotripsy significantly improves the efficiency of stone fragmentation in vivo.

Animals↗
PubMed2002

Multilayered small intestinal submucosa is inferior to autologous bowel for laparoscopic bladder augmentation.

PURPOSE: Bladder augmentation is most commonly performed with ileum. However, porcine small intestinal submucosa has been reported as a substitute for bowel for incorporation into the urinary tract. We assessed the feasibility and long-term 12-month results of laparoscopic bladder augmentation with ileum or multilayered small intestinal submucosa (Cook Biotech, Spencer, Indiana) in a porcine model. MATERIALS AND METHODS: We performed laparoscopically assisted hemicystectomy and bladder augmentation in 24 female Yucatan mini-pigs using an ileal segment (12) or multilayered small intestinal submucosa (12). The followup protocol included anesthetic bladder capacity, renal ultrasonography and serum chemistry. At 3, 6 and 12 months, respectively, 4 animals per group were scheduled for sacrifice and pathological analysis. RESULTS: Despite longer anastomotic time in the multilayered small intestinal submucosa group (120 versus 91 minutes, p = 0.026) total operative time was similar in the 2 groups. In each group bladder capacity increased with time but by 12 months bladder capacity was significantly better in the bowel than in the small intestinal submucosa group (825 versus 431 cc, p = 0.016). At 3 months pathological evaluation revealed that the multilayered regenerated bladder patch had shrunken and by 6 months it was replaced by dense calcified scar tissue. Long-term 6 and 12-month bladder capacity in the small intestinal submucosa group was the result of the regeneration of native bladder with exclusion of the whole multilayered patch in the majority of cases. CONCLUSIONS: Laparoscopic bladder augmentation using multilayered small intestinal submucosa produced functional and pathological results inferior to those of bowel at 12-month followup in a porcine model.

Animals↗
PubMed2002

Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience.

PURPOSE: We assessed the incidence of and analyzed factors that may help prevent major complications and open conversion during laparoscopic nephrectomy at our institutions. MATERIALS AND METHODS: We retrospectively analyzed all laparoscopic nephrectomies performed between August 1, 1999 and July 31, 2001. Data were stratified for nephrectomy type, intraoperative and postoperative complications. Conversion to open surgery was stratified for emergency versus elective procedures. RESULTS: Of the 292 laparoscopic procedures performed at our institutions in 2 years 213 (73%) involved laparoscopic nephrectomy, including 84 live donor nephrectomies, 61 radical nephrectomies, 55 simple nephrectomies and 13 nephroureterectomies. A total of 16 major complications (7.5%) occurred, including access related, intraoperative and postoperative complications in 3, 9 and 4 cases, respectively. The conversion rate was 6.1% (13 patients), the transfusion rate was 1.9% and the mortality rate was 0.5% (1 death). Only 1 complication was related to simple laparoscopic nephrectomy, although this group showed the highest rate of elective conversion (7 of 8 elective conversions). Laparoscopic live donor nephrectomy showed the highest rate for emergency conversion (3 of 5 emergency conversions). CONCLUSIONS: Our results reinforce the importance of thorough preoperative imaging, careful patient selection, surgeon experience and skill maintenance in laparoscopy as well as a low threshold for conversion to open surgery. This series provides additional evidence to support the evolution of laparoscopic nephrectomy into a standard of care.

Adult↗
PubMed2002

Kidney damage and renal functional changes are minimized by waveform control that suppresses cavitation in shock wave lithotripsy.

PURPOSE: In studies to understand better the role of cavitation in kidney trauma associated with shock wave lithotripsy we assessed structural and functional markers of kidney injury when animals were exposed to modified shock waves (pressure release reflector shock pulses) that suppress cavitation. Experiments were also performed in isolated red blood cells, an in vitro test system that is a sensitive indicator of cavitation mediated shock wave damage. MATERIALS AND METHODS: We treated 6-week-old anesthetized pigs with shock wave lithotripsy using an unmodified HM3 lithotriptor (Dornier Medical Systems, Marietta, Georgia) fitted with its standard brass ellipsoidal reflector (rigid reflector) or with a pressure release reflector insert. The pressure release reflector transposes the compressive and tensile phases of the lithotriptor shock pulse without otherwise altering the positive pressure or negative pressure components of the shock wave. Thus, with the pressure release reflector the amplitude of the incident shock wave is not changed but cavitation in the acoustic field is stifled. The lower pole of the right kidney was treated with 2,000 shocks at 24 kV. Glomerular filtration rate, renal plasma flow and tubular extraction of para-aminohippurate were measured in the 2 kidneys 1 hour before and 1 and 4 hours after shock wave lithotripsy, followed by the removal of each kidney for morphological analysis. In vitro studies assessed shock wave induced lysis to red blood cells in response to rigid or pressure release reflector shock pulses. RESULTS: Sham shock wave lithotripsy had no significant effect on kidney morphology, renal hemodynamics or para-aminohippurate extraction. Shock waves administered with the standard rigid reflector induced a characteristic morphological lesion and functional changes that included bilateral reduction in renal plasma flow, and unilateral reduction in the glomerular filtration rate and para-aminohippurate extraction. When the pressure release reflector was used, the morphological lesion was limited to hemorrhage of vasa recta vessels near the tips of renal papillae and the only change in kidney function was a decrease in the glomerular filtration rate at the 1 and 4-hour periods in shock wave treated kidneys. Red blood cell lysis in vitro was significantly lower with the pressure release reflector than with the rigid reflector. CONCLUSIONS: These data demonstrate that shock wave lithotripsy damage to the kidney is reduced when cavitation is suppressed. This finding supports the idea that cavitation has a prominent role in shock wave lithotripsy trauma.

Animals↗
PubMed2002

Urinary calculus containing gas.

The combination of gas in the upper urinary tract along with renal calculi has been reported in the setting of emphysematous renal infections, urinary tract instrumentation, and urinary-gastrointestinal fistulas. We present a case of a 46-year-old nondiabetic man with the isolated finding of a gas-containing renal calculus. The significant history in this case included recurrent urinary tract infections and primary hyperparathyroidism with persistent hypercalcemia despite previous parathyroid explorations. The patient was treated with oral antibiotics and rendered stone and infection free by percutaneous nephrolithotomy. The stone culture was negative, and the stone analysis revealed 100% hydroxyapatite.

Durapatite↗
PubMed2002

One versus two proficient laparoscopic surgeons for laparoscopic live donor nephrectomy.

OBJECTIVES: To compare the laparoscopic donor nephrectomy (LDN) results obtained by two different surgical teams, one consisting of a proficient laparoscopic surgeon assisted by an inexperienced laparoscopic surgeon and another consisting of two proficient laparoscopic surgeons. With more centers embarking on LDN programs, it is important to identify the factors that can improve overall outcomes during the initial learning curve. METHODS: A retrospective review was performed of the initial 70 sequential LDNs performed between October 1998 and March 2001 at our institutions. The procedures were stratified into two groups. Group 1 consisted of LDN cases performed by one proficient laparoscopic surgeon and an inexperienced laparoscopic surgeon (resident, fellow, or faculty) as the first assistant; group 2 consisted of cases performed by two proficient laparoscopic surgeons. RESULTS: Twenty-six LDNs were performed by group 1 and 44 by group 2. The total operative time and estimated blood loss showed a statistically significant decrease in group 2 compared with group 1, 143 +/- 32 minutes versus 218 +/- 38 minutes (P <0.001) and 92 +/- 115 mL versus 158 +/- 148 mL (P = 0.044), respectively. Two major complications occurred in group 1 (7.7%) and two major complications occurred in group 2 (4.5%). The 3-month postoperative recipient creatinine levels were similar for both groups, 1.6 +/- 1.3 versus 1.4 +/- 0.4 (P = 0.408). CONCLUSIONS: A surgical team composed of two proficient laparoscopic surgeons during the early learning curve of LDN may allow safe and efficient development of a laparoscopic live donor renal transplantation program.

Clinical Competence↗
PubMed2002

Laparoscopic treatment for ureteropelvic junction obstruction.

OBJECTIVES: To assess retrospectively the subjective and objective outcomes achieved after laparoscopic treatment for ureteropelvic junction obstruction at our institutions. METHODS: Between August 1999 and July 2001, 19 patients (11 women and 8 men), with a mean age of 31.2 years (range 17 to 67), underwent laparoscopic treatment for ureteropelvic junction obstruction. Of these, 17 patients were eligible for postoperative analysis. Nine of these patients had a history of prior surgical intervention on the affected side. The patients were subjectively assessed by an analog pain scale performed before and at least 6 months after surgery. Preoperatively, patients had a diuretic renal scan to confirm the presence of obstruction. Helical computed tomography was also performed preoperatively to assess for the presence of crossing vessels. The renal scan was repeated at least 12 weeks after surgery to document the relief of obstruction objectively. RESULTS: Helical computed tomography correctly predicted the presence of crossing vessels in 12 patients (63%). The Anderson-Hynes and Fenger pyeloplasty techniques were performed in 16 and 2 patients, respectively. In 1 patient, a small crossing vein over the ureteropelvic junction was identified and divided without complications. The average operative time was 240 minutes (range 128 to 470). The blood loss was minimal, and no open conversions were required. The mean hospital stay was 2.9 days (range 2 to 7). Two postoperative complications occurred (11.7%). The average subjective follow-up was 14.4 months (range 6 to 27), and the average objective follow-up was 7.8 months (range 3 to 12). Of 17 assessable patients, 16 (94%) had subjective and objective success (postoperative improvement in analog pain score and half-life of radiotracer washout). The average split renal function improved from 34.1% to 38.5% (P <0.01). CONCLUSIONS: On the basis of our data, laparoscopic pyeloplasty has a similar success rate compared with the traditional open approach and better results than other minimally invasive techniques. Longer follow-up and further experience are needed to validate these data.

Adolescent↗
PubMed2002

Percutaneous stone implantation in the pig kidney: a new animal model for lithotripsy research.

PURPOSE: This report describes a new animal model for research on the parameters of shockwave delivery and the mechanisms of shockwave action in SWL. MATERIALS AND METHODS: Female pigs (approximately 45 kg) were anesthetized for creation of an upper pole peripheral caliceal access. The tract was dilated with a 30F Nephromax balloon and Amplatz sheath, and a 24F rigid nephroscope was used to guide a gypsum artificial stone into a lower pole calix. An internal ureteral stent was then placed. After a 2-hour recovery period, lithotripsy was performed using an unmodified Dornier HM3 lithotripter. Following SWL, en bloc excision of the urinary tract was performed, and the stone fragments were collected. RESULTS: As observed by nephroscopy, most stones were surrounded by urine that was free of clot or debris. Urine output was >1 mL/kg per minute by the time the animal was positioned for SWL after a 2-hour observation period. When the conditions of shockwave (SW) exposure were 400 SWs, 20 kV, and 120 SW/min, the efficiency of stone fragment recovery was 85% +/- 2% (N = 6 stones). CONCLUSIONS: This procedure provides a minimally invasive method for placement of model stones of clinically relevant size within the pig kidney. Stone implantation is efficient and permits experiments to be conducted in 1 day. Stone fragmentation can be quantitated, and the animal can serve as its own control. Long-term experiments are also feasible. Overall, this new animal model is appropriate for experimentation on the parameters of SW delivery in SWL.

Animals↗