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Biomedical subjects

M O Koch

Publications and source records attributed to M O Koch.

At least 19 recordsLinked to original sources
PubMed1996

Blood loss during radical retropubic prostatectomy: is preoperative autologous blood donation indicated?

PURPOSE: We assessed the requirement for transfusion of allogeneic blood in a contemporary series of patients who did not deposit autologous blood before radical retropubic prostatectomy. MATERIALS AND METHODS: After a policy was adopted in which preoperative autologous blood was not donated, 124 consecutive patients underwent radical retropubic prostatectomy. Type and screen for allogeneic blood were routinely available but neither hemodilation nor a cell saver was used. RESULTS: Mean intraoperative blood loss was 579 cc and mean postoperative serum hematocrit was 33%. Only 3 patients (2.4%) required blood products due to intraoperative blood loss (2) and postoperative bleeding from a duodenal ulcer (1). CONCLUSIONS: Transfusion of blood products was required in a small percentage of our patients even without autologous blood donation. Therefore, the overall cost of care is decreased but, more importantly, the potential risks associated with autologous or allogeneic blood transfusion are eliminated.

Aged↗
PubMed1996

Bropirimine immunotherapy of upper urinary tract carcinoma in situ.

OBJECTIVES: Bropirimine has been shown to be effective in treating approximately 50% of patients with carcinoma in situ (CIS) of the bladder in recent clinical trials. Patients with upper tract CIS were treated with bropirimine to determine whether this oral drug might be effective in that setting. METHODS: Twenty-four patients with negative radiographic findings and positive cytologic evidence for upper tract CIS in one or both ureters received bropirimine (3.0 g/day orally) for 3 consecutive days each week for up to 1 year. Ureteral collection of urine or barbotage for cytologic analysis was performed quarterly thereafter. RESULTS: Ten (48%) of 21 evaluable patients had a negative ureteral cytologic analysis after 12 weeks (5 patients) or 24 weeks (5 patients). Of these 10 patients, 8 continue to have negative cytology for a period of 3 to 30 months (median, more than 9 months). In 2 patients, negative cytology reverted to positive at 6 and 9 months, respectively, during therapy. Twelve (50%) of the 24 patients reported no toxicity. Three patients stopped treatment at 2, 3, and 3 weeks due to pruritic rash, nausea and vomiting, and severe bone pain, respectively. Therapy was stopped in 1 additional patient between 4 and 5 months because of transient liver enzyme elevations, yet this patient has had a continuous negative cytologic analysis for more than 9 months. CONCLUSIONS: Orally administered bropirimine may be effective therapy for CIS of the ureter or renal pelvis, with acceptable toxicity in most patients. Further efforts to better define this activity as well as the possible need for maintenance or intermittent long-term therapy are warranted.

Adjuvants, Immunologic↗
PubMed1996

Impotence and incontinence after immediate realignment of posterior urethral trauma: result of injury or management?

PURPOSE: We examined further whether the injury or method of management is responsible for impotence and incontinence after immediate realignment of prostato-membranous urethral disruptions. MATERIALS AND METHODS: A total of 20 patients with complete urethral disruptions treated with immediate realignment (group 1) was compared to 12 with partial or complete injuries treated with retrograde catheterization alone (group 2). Followup status was obtained by patient questionnaire or telephone interview. RESULTS: Of the patients 83% in group 1 and 80% in group 2 are continent, and 76% and 70%, respectively, regained erections suitable for sexual intercourse. CONCLUSIONS: The results suggest that impotence and incontinence in this setting are the result of the injury and not of attempts at immediate surgical management.

Erectile Dysfunction↗
PubMed1996

Influence of patient age and co-morbidity on outcome of a collaborative care pathway after radical prostatectomy and cystoprostatectomy.

PURPOSE: We determined whether standardized care patterns developed with a collaborative care methodology can be applied successfully across all patient groups with favorable effects on cost and quality. MATERIALS AND METHODS: We retrospectively analyzed financial and clinical outcomes in 109 radical retropubic prostatectomy and 47 radical cystectomy cases. Patients older than 70 years and/or with an American Society of Anethesiology status of 3 or greater were compared to younger, healthier patients undergoing these procedures. RESULTS: Standardized care patterns resulted in favorable financial and clinical outcomes in high and low risk patient groups. The only apparent difference was an increased need for rehospitalization after discharge for patients undergoing radical prostatectomy with a high American Society of Anesthesiology status. CONCLUSIONS: Standardized care patterns developed with a collaborative care methodology provide a high quality, cost-efficient approach to medical care. This methodology is applicable to all patient groups and is highly compatible with current medical practice.

Age Factors↗
PubMed1996

Ureteral replacement with reconfigured colon substitute.

PURPOSE: Upper ureteral defects are often too extensive to repair by direct anastomosis or with use of a bladder flap. Ureteral substitution may be the only remaining alternative to restoring urinary drainage from the kidney to the bladder. This effect is usually achieved by interposing a segment of small bowel between the proximal collecting system and bladder. If ileum is not available other substitution alternatives must be sought. MATERIALS AND METHODS: We report a new technique in which a tube constructed from a small piece of ascending colon was used to replace a large ureteral defect. RESULTS: Excellent short-term results were achieved by replacing the strictured ureteral segment with a reconfigured colon segment as shown by symptomatic and radiographic improvement. CONCLUSIONS: A reconfigured colon segment can be used for ureteral reconstruction in the patient with limited alternatives. This tube has several advantages for ureteral reconstruction over ileal segments.

Colon↗
PubMed1996

The use of an extended spiral bladder flap for treatment of upper ureteral loss.

PURPOSE: We demonstrated the effectiveness of an extended spiral bladder flap procedure for repair of upper ureteral injuries. MATERIALS AND METHODS: Two patients with extensive ureteral loss underwent repair with a modified bladder flap based posterolaterally on the affected side, spiraled anteriorly and inferolaterally toward the contralateral bladder base, and then anastomosed directly to the renal pelvis. RESULTS: With this technique renal function was preserved in both patients without obstruction on followup radiographs. CONCLUSIONS: Using this extended bladder flap technique a well vascularized urothelial repair can be achieved for upper ureteral injury in select patients.

Adult↗
PubMed1995

Femoral neuropathy complicating urologic abdominopelvic procedures.

We report on 3 cases of femoral neuropathy following radical surgery for urologic malignancy. The defect was bilateral in 2 patients. Compression from self-retaining retractors was the presumed mechanism of injury in all patients. Spontaneous improvement was observed in each case although the symptoms did not resolve completely. The pathophysiology contributing to this operative complication as well as measures for prevention and treatment are discussed.

Adult↗
PubMed1995

Morbidity associated with nonoperative management of extraperitoneal bladder injuries.

Foley catheter drainage alone has become routine management for extraperitoneal bladder ruptures in many medical centers, and few reports address treatment failures with this approach. Over the last 10 years, 70 patients with bladder ruptures were managed at our institution. Thirty-six of these had extraperitoneal injuries caused by blunt trauma, and 29 of these were treated by catheter drainage alone. Of those patients managed nonoperatively, 74% had spontaneous healing within 10 to 14 days; however, 26% had significant complications, including delayed healing, vesicocutaneous fistula, septic events, bladder calculi, or death. Although our results confirm previous reports in the literature that most patients with extraperitoneal bladder ruptures do well with nonoperative management, they also point out that a significant subset of patients do not. We were unable to identify presenting features that would predict an unfavorable outcome, although patients with multiple pelvic fractures seem to be at high risk. The maintenance of adequate catheter drainage and use of antibiotic prophylaxis seems to have a significant impact on outcome.

Drainage↗
PubMed1995

Clinical outcomes associated with the implementation of a cost-efficient programme for radical retropubic prostatectomy.

OBJECTIVE: To develop and analyse a cost-containment programme for radical retropubic prostatectomy. PATIENTS AND METHODS: An in-depth analysis of the hospital charges associated with radical retropubic prostatectomy was conducted and a standard programme developed to control patient costs using a collaborative pathway method. The development of this programme and the outcomes of the first 50 patients who underwent radical retropubic prostatectomy while on the collaborative care pathway system are summarized. RESULTS: The programme reduced both overall hospital charges per patient and the duration of hospital stay by 44%. In addition, there was a significant reduction in the duration of surgery, intra-operative blood loss and the need for transfusion. Implementation of this programme had no apparent adverse effects on the rates of major or minor complications or hospital readmissions, and was accepted well by the patients. CONCLUSION: The collaborative care pathway developed for radical prostatectomy provides a system to deliver high quality, cost-efficient care in an environment which is highly acceptable to patients and which allows continued refinements in the care delivered.

Aged↗
PubMed1995

Primary realignment of prostatomembranous urethral disruptions.

Management of prostatomembranous urethral disruptions remains controversial. Advocates of delayed urethral reconstruction suggest that immediate repair provides inferior outcomes in terms of impotence and incontinence. However, review of the literature, provides strong evidence that the injury itself is the most important factor in determining outcome because impotence appears to be the result of injury to the corpora cavernosa. Moreover, techniques for immediate urethral realignment provide outcomes that are equivalent to delayed-repair approaches while eliminating the need for long-term suprapubic catheter drainage and multiple surgical procedures for reconstruction. Techniques for immediate urethral realignment, along with outcomes at the Vanderbilt University Medical Center (Nashville, TN) are presented. Potency and continence rates of 83% and 100% were achieved, with early realignment of complete prostatomembranous urethral disruptions. These results are comparable to or exceed those of delayed-repair approaches.

Erectile Dysfunction↗
PubMed1995

Impact of a collaborative care approach to radical cystectomy and urinary reconstruction.

PURPOSE: We report the results of a collaborative care program that has been developed for radical cystectomy and urinary reconstruction. MATERIALS AND METHODS: All patients undergoing surgery after July 1993 were placed on a collaborative care pathway and were compared to patients undergoing the same procedure before this period. RESULTS: Total adjusted hospital charges decreased from $31,174 to $19,479. Hospital stay decreased from 12.7 to 10.3 days. There were also decreases in duration of surgery, blood loss, intensive care unit use and postoperative morbidity rates. CONCLUSIONS: Collaborative care pathways favorably affect the cost efficiency of care and provide favorable surgical outcomes.

Blood Loss, Surgical↗
PubMed1995

Cost-efficient radical prostatectomy.

Radical retropubic prostatectomy is an easily standardized procedure with reproducible outcomes. Care has been standardized at our institution through the use of a collaborative care approach that defines the optimal care and outcomes for the ideal patient on a daily basis. This approach is based on an objective evaluation of the available medical literature. With this program, hospital charges have been reduced by 41% and hospital stay has been reduced to 2.9 days. Surgical outcomes have been excellent with low morbidity rates and excellent patient acceptance. Collaborative care programs for health care provide a comprehensive approach that allows for the delivery of cost-efficient care, which is supportive of the patient and allows continual refinement in care based on objective analysis of outcomes.

Cost Control↗
PubMed1995

Orthotopic neobladder reconstruction after radical cystectomy.

Urinary diversion with continent urinary reservoirs to the urethra offer major advantages to patients with invasive bladder carcinoma. Multiple configurations for pouch creation have been described, however, there are unifying concepts between all types of continent diversions which should be adhered to in order to optimize outcome. These general concepts are discussed and the author's technique for small and large intestinal neobladder construction is presented. Perioperative management is delivered using a collaborative care critical pathway technique and has resulted in excellent outcomes.

Anastomosis, Surgical↗
PubMed1994

Retrospective analysis of outcome in patients with nodal metastases from transitional cell carcinoma of lower urinary tract.

OBJECTIVE: To determine the outcome in patients with nodal metastases from transitional cell carcinoma (TCC) using currently available surgical and chemotherapeutic techniques. METHODS: A retrospective analysis of all patients with TCC of the lower urinary tract who underwent radical cystectomy or lymph node dissection at our institution since 1980 was performed. Thirty-one patients were identified who had documented pelvic lymph node metastases prior to or at the time of radical cystectomy. These patients' records were reviewed in-depth with regard to treatment approach, presenting features, and outcome. RESULTS: Outcome was poor despite the treatment approach taken, including whether or not chemotherapy was administered prior to or after cystectomy. Median survivals of patients receiving no chemotherapy, adjuvant chemotherapy, and neoadjuvant chemotherapy were 14.5, 9.5, and 15.0 months, respectively. Only 4 of 28 patients survived more than three years, and only one of these received chemotherapy. CONCLUSIONS: Survival of patients with lymph node metastases from transitional cell carcinoma remains poor despite aggressive surgical therapy and the use of adjuvant or neoadjuvant platinum-based chemotherapy.

Actuarial Analysis↗
PubMed1994

The effect of sequential compression devices on intraoperative blood loss during radical prostatectomy.

We reviewed 109 consecutive patients undergoing radical retropubic prostatectomy to determine the effect of intermittent pneumatic compression devices on intraoperative blood loss. Sequential compression devices were used intraoperatively and perioperatively in 86 patients, while 23 underwent surgery without these devices. There were no identifiable selection factors between the 2 groups. Median intraoperative blood loss was 885 cc without sequential compression devices and 800 cc when they were used. These results are at odds with previous reports in the urological literature and suggest that anatomical control of the dorsal vein complex negates any potential influence of sequential compression devices on blood loss during radical prostatectomy.

Bandages↗
PubMed1994

Exposure of intestinal segments to hemiacidrin: analysis of metabolic and histological effects using a rat model.

Using a previously reported rat model, we examined the effects of intestinal perfusion with hemiacidrin on calcium and magnesium homeostasis, and inspected the intestinal segments for histological alterations following exposure to the solution. Intestinal irrigation with hemiacidrin resulted in a significant increase in serum magnesium. Urinary excretion rates of calcium increased 8-fold and magnesium excretion rates increased 5-fold over control values. Hemiacidrin appeared to have detrimental effects on the integrity of the intestinal mucosa, and irrigation should be done with caution in patients whose urinary tract has been reconstructed with intestinal segments.

Animals↗