Biomedical subjects

R Ernest Sosa

Publications and source records attributed to R Ernest Sosa.

At least 19 recordsLinked to original sources

PubMed2006

Renal cell carcinoma sub-typing by histopathology and fluorescence in situ hybridization on a needle-biopsy specimen.

OBJECTIVE: To determine the subtype of renal cell carcinoma (RCC) on needle-core biopsies of renal masses using histopathology and fluorescence in situ hybridization (FISH), and to evaluate the use of interphase FISH to augment the accuracy of needle-core biopsies. PATIENTS AND METHODS: Histology correlates with prognosis in RCC but, historically, biopsies are inaccurate for histological subtype. As histological subtypes of RCC have distinct cytogenetic abnormalities (loss of 3p in clear cell, trisomy 7 or 17 in papillary and widespread chromosomal losses in chromophobe), we hypothesized that FISH would improve the accuracy of biopsies. Forty patients with renal masses underwent nephrectomy, yielding 42 tumours. Needle-core biopsies were taken of the mass immediately after surgery. Interphase FISH was performed on one core for chromosomes 3, 7, 10, 13, 17, and 21 and the locus 3p25-26. Histopathology was performed on a second core. Results were compared in a 'blinded' fashion with final pathology. RESULTS: In all, 36 of 42 masses were RCC or oncocytoma. Histopathology of the biopsy correctly identified the tumour subtype in 27 (75%), while four (11%) were incorrectly classified and five (14%) were inadequate for diagnosis. With the addition of FISH, 31 (86%) were correctly subtyped, while two (6%) were incorrect and three (8%) were inadequate. In cases with adequate tissue, histology alone was 87% accurate, while the combined method was 94% accurate. CONCLUSION: Needle-core biopsy of renal tumours provides adequate material for evaluation of histological subtype. Adding FISH to histopathology might improve the accuracy of kidney tumour biopsies, providing important prognostic information that can guide management decisions.

Adult↗

PubMed2005

Impact of delay to nephroureterectomy for patients undergoing ureteroscopic biopsy and laser tumor ablation of upper tract transitional cell carcinoma.

OBJECTIVES: To investigate whether a delay in nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract owing to ureteroscopic biopsy and/or laser tumor ablation affects postoperative disease status. METHODS: Of 155 patients diagnosed with upper tract transitional cell carcinoma at our institution from 1993 to 2003, 121 underwent nephroureterectomy. We compared the postoperative disease status of patients who underwent nephroureterectomy on the basis of positive cytology findings and filling defect on contrast imaging (no ureteroscopy; n = 34) to patients who underwent nephroureterectomy after ureteroscopic biopsy (n = 75) and patients who underwent nephroureterectomy after ureteroscopic biopsy and laser tumor ablation (n = 12). RESULTS: At a mean follow-up of 38.7 months, 29 (85.3%) of 34 patients who underwent nephroureterectomy on the basis of contrast imaging and urinary cytology alone were disease free compared with 61 (81.3%) of 75 patients who underwent ureteroscopic biopsy before nephroureterectomy (P = 0.18). The mean time from biopsy to nephroureterectomy for these 75 patients was 28 days, and the mean follow-up after nephroureterectomy was 40.1 months. Finally, 10 (83.3%) of 12 patients who underwent ureteroscopic biopsy and laser tumor ablation before nephroureterectomy were disease free at a mean follow-up of 37.2 months. The mean time from ureteroscopic biopsy to nephroureterectomy in this group was 196 days. No significant difference was found in the postoperative disease status between patients undergoing nephroureterectomy after ablation and those who proceeded to nephroureterectomy after endoscopic biopsy or those who did not undergo ureteroscopy before nephroureterectomy (P = 0.16). CONCLUSIONS: Ureteroscopy with biopsy and/or tumor ablation before nephroureterectomy did not adversely affect the postoperative disease status.

Aged↗

PubMed2005

Robot-assisted laparoscopic dismembered pyeloplasty: a combined experience.

BACKGROUND AND PURPOSE: The need for advanced laparoscopic skills limits the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the daVinci Surgical System at three New York City medical centers. PATIENTS AND METHODS: A retrospective review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 18 female and 17 male patients between April 2001 and January 2004 was performed. The average patient age was 39.0 years (range 15-69 years). All patients had symptoms or radiographic evidence of ureteropelvic junction (UPJ) obstruction. Robotic assistance with the daVinci Surgical System was employed after preparation of the UPJ with a standard laparoscopic approach. RESULTS: The mean operative time and suturing time was 216.4 +/- 52.9 minutes and 63.0 +/- 14.2 minutes, respectively. The average estimated blood loss was minimal at 73.9 +/- 58.3 mL. The mean length of hospitalization was 69.4 hours (range 28-310 hours). The average use of intravenous morphine was 28.4 mg (range 0-162 mg). There were no intraoperative complications or open conversions. A mean follow-up of 7.9 months revealed a success rate of 94%, with two patients requiring further treatment. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the daVinci Surgical System is safe and reproducible. These intermediate results appear comparable to those of open and laparoscopic pyeloplasty repairs.

Adolescent↗

PubMed2005

Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience.

OBJECTIVE: To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique. PATIENTS AND METHODS: We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance. RESULTS: Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed. CONCLUSIONS: LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.

Female↗

PubMed2005

Bladder cancer after managing upper urinary tract transitional cell carcinoma: predictive factors and pathology.

OBJECTIVE: To evaluate patients with a history of transitional cell carcinoma (TCC) of the upper urinary tract (UUT) to determine the incidence, pathological distribution, and risk factors for developing subsequent bladder tumours. PATIENTS AND METHODS: Between 1993 and 2003, 103 patients were treated at our institution for UUT-TCC. We reviewed demographic, clinical, surgical, and pathological data from these patients at a median follow-up of 38.7 months, and used univariate and multivariate analyses with logistic regression modelling to determine prognostic variables for bladder recurrences. RESULTS: In all, 51 (49.5%) patients developed bladder tumours after treatment for UUT-TCC, at a mean interval of 13.2 months. Patient age (P = 0.01), UUT tumour size (P = 0.03), UUT tumour multifocality (P = 0.05), a history of bladder tumours (P = 0.03), and the number of previous bladder tumours (P = 0.05) predicted the development of bladder recurrences on univariate analysis. On multivariate analysis, only a previous history of bladder tumours (odds ratio 2.6, P = 0.05) remained significant. Over 90% of the recurrent bladder tumours were superficial, with two-thirds of these being low to moderate grade. Six patients had muscle-invasive disease, and five had a cystectomy. CONCLUSION: Bladder tumours occurred in half the patients after treatment for UUT-TCC; > 60% of these subsequent bladder tumours were superficial, low- to moderate-grade lesions. Neither the pathology of the UUT tumours nor the method of treatment for the UUT disease was associated with recurrent bladder tumours. Only a history of bladder cancer predicted the development of subsequent bladder tumours.

Adult↗

PubMed2004

Right laparoscopic live donor nephrectomy: a single institution experience.

BACKGROUND: Laparoscopic live donor nephrectomy (LLDN) is increasingly used by transplantation centers worldwide. As in open live donor nephrectomy, the left kidney is preferred for LLDN; however, not all potential donors have anatomy conducive to left nephrectomy. The purpose of our study, therefore, was to report on a large, single-institution experience with right LLDN performed using a hand-assisted, transperitoneal approach. METHODS: We performed a retrospective review of 40 consecutive patients who underwent transperitoneal right hand-assisted LLDN at our institution. Information on donor age, relation to recipient, and indication for right-sided donation was collected. Surgical demographics included operative time, warm ischemia time, and estimated blood loss. Recipients were followed for graft loss and for long-term renal allograft function. RESULTS: The indications for right-sided donor nephrectomy were a difference in split renal function of greater than 10%, multiple left renal vessels, and right renal cysts. The mean surgical time in our series was 115.8 min, with a mean estimated blood loss of 85.7 mL and a warm ischemia time of 116.0 seconds. Surgical and postoperative complications were limited. Mean serum creatinine levels in the recipients were 1.6 mg/dL on day 7, 1.4 mg/dL on day 30, and 1.4 mg/dL at 1 year after transplantation. CONCLUSIONS: Right LLDN using a hand-assisted, transperitoneal technique was performed with minimal morbidity and favorable graft function. We believe that offering hand-assisted LLDN to patients with an indication for right-sided donation can safely and effectively increase the pool of donor organs available to patients with end-stage renal disease.

Adult↗

PubMed2004

Treatment of adrenocortical carcinoma: contemporary outcomes.

Adrenocortical carcinoma is a rare cancer that historically has been associated with poor outcome. Throughout the past decades, growing experience has allowed better understanding of the natural history and optimal management of this cancer. Advances in imaging and aggressive surgical therapy have raised the outlook for recently diagnosed patients. Further improvements in survival will require more effective systemic therapy.

Adrenal Cortex Neoplasms↗

PubMed2004

The advantages of hand-assisted laparoscopy.

The technical challenges of performing laparoscopic renal surgery require fellowship training and are associated with a steep learning curve. For the established urologist in practice, fellowship training is not a reality. As a result of these obstacles, in the late 1990s, laparoscopic renal surgery was entering the domain of the general surgeons who had a large number of laparoscopic procedures at their disposal to develop laparoscopic skills. Hand-assisted laparoscopic renal surgery is a hybrid procedure combining the most salient features of open renal surgery and laparoscopic renal surgery. By allowing the surgeons to place their non-dominant hand into the abdominal cavity, palpation and spatial orientation became possible, lessening the learning curve for laparoscopic surgery. Moreover, hand-assisted laparoscopic surgery could be applied to a variety of renal surgeries, extirpative and reconstructive, with results similar to those already achieved by standard laparoscopy. Throughout the past 5 years, hand-assisted laparoscopy has allowed urologists to incorporate laparoscopic renal surgery into their practices to the benefit of their patients and of their specialty. This review article offers a historical review of the development of hand-assisted laparoscopy and describes the procedures commonly performed today using this technique.

Cystectomy↗

PubMed2004

Renal angiomyolipoma with contrast-enhancing elements mimicking renal malignancy: radiographic and pathologic evaluation.

The diagnosis of angiomyolipoma can typically be made on the basis of characteristic computed tomography findings. Varying tissue compositions within an angiomyolipoma can create difficulty in pathologically differentiating benign from malignant lesions. Epithelioid angiomyolipoma is a variant of angiomyolipoma characterized by the presence of epithelioid cells. We report a case of two discrete contrast-enhancing lesions within an enlarging angiomyolipoma that radiographically mimicked malignant elements. This finding presented a diagnostic challenge in terms of selecting medical versus surgical intervention. Surgical excision of the lesions was performed and the pathologic examination revealed a benign angiomyolipoma with epithelioid features.

Angiomyolipoma↗

PubMed2004

Hand-assisted laparoscopic nephroureterectomy for upper urinary-tract transitional-cell carcinoma.

Hand-assisted laparoscopic nephroureterectomy with laparoscopic, cystoscopic, or open management of the distal ureter and bladder cuff allow anyone from the novice to the advanced laparoscopic surgeon to perform en-bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients receive significant benefits in the form of less pain, shorter hospital stay, and rapid convalescence. As more urologic surgeons develop skills with this procedure, a more critical analysis of early and long-term results will be possible. As operative times decrease, hand-assisted laparoscopic nephroureterectomy may become the procedure of choice for upper-tract transitional-cell carcinoma. The techniques and early results are described.

Carcinoma, Transitional Cell↗

PubMed2004

Laparoscopic pyeloplasty: history, evolution, and future.

Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital; however, acquired conditions at the level of the UPJ may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty and endoscopic techniques have been the main surgical options with the intent of complete excision or incision of the obstruction. The introduction of laparoscopy has allowed minimally invasive reconstructive surgery that mirrors open surgical techniques. In the hands of experienced surgeons, laparoscopic pyeloplasty offers a less invasive alternative to open surgery with decreased morbidity, shorter hospital stay, and faster convalescence. During the last decade, laparoscopic pyeloplasty for the treatment of congenital or acquired UPJ obstruction has garnered much interest, but, as this procedure is technically challenging, it is being performed only at selected medical centers by surgeons with advanced laparoscopic training. This review describes the early results, ongoing evaluation, and future role for this novel surgical procedure.

Adult↗

PubMed2004

Abnormal selective cytology results predict recurrence of upper-tract transitional-cell carcinoma treated with ureteroscopic laser ablation.

BACKGROUND AND PURPOSE: Endoscopic management of transitional-cell carcinoma (TCC) of the upper urinary tract remains associated with a significant rate of recurrence. We evaluated the impact of selective upper-tract cytology findings on tumor recurrence and renal salvage rate after ureteroscopic laser tumor ablation. PATIENTS AND METHODS: From 1993 though 2003, 38 patients with upper-tract TCC underwent ureteroscopic laser tumor ablation. Cytology specimens were collected from the upper urinary tract prior to ablation. "Abnormal cytology" was defined as the presence of malignant or atypical cells. Patients with abnormal cytology results were compared with patients with those having negative findings for tumor recurrence and renal salvage rates using the X (2) test. RESULTS: Of the 38 patients, 26 (68.4%) experienced at least one recurrence at a mean follow-up of 37.2 months. Pretreatment upper-tract cytology results were available in 34 of these patients: 17 (50%) were negative, and 17 were abnormal. Sixteen of the patients (94.1%) with abnormal cytology results had tumor recurrence after ablation, compared with 8 of the 17 (47.1%) with negative cytology findings (P = 0.0026). Twelve patients (31.5%) underwent nephroureterectomy during follow-up: 8 of the 17 (47.1%) with abnormal cytology, and 4 of the 17 (23.5%) with negative cytology (P = 0.15). CONCLUSION: Abnormal selective cytology results were associated with a significantly higher rate of tumor recurrence and a trend toward increased renal loss in patients with upper-tract TCC treated with ureteroscopic ablation. These findings suggest a prognostic value for upper-tract cytology analysis in patients undergoing endoscopic therapy.

Adult↗

PubMed2004

Cryosurgery of the adrenal gland.

Adrenalectomy has become the standard of care for the management of hormonally active adrenal masses. Minimally invasive adrenal-sparing surgical techniques have recently been introduced for the treatment of benign adrenal lesions, with the intent of complete excision or destruction. Cryosurgery is one such modality that is focused on reducing patient morbidity and hastening postoperative recovery, while preserving normal tissue. The emerging interest in cryosurgery is attributable to improved delivery systems and advances in radiologic imaging. However, questions remain about the risks and benefits of this technology for adrenal-sparing surgery in terms of safety and effective tissue destruction. We examine our experience and discuss our results with open and laparoscopic adrenal cryosurgery.

Adrenal Gland Neoplasms↗

PubMed2003

Adrenal-preserving minimally invasive surgery: the role of laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation of the adrenal gland.

Adrenalectomy has become the standard of care for the management of hormonally active adrenal masses. Various surgical therapies have been proposed to excise completely or destroy these adrenal lesions, which may be benign or malignant. New minimally invasive, adrenal-sparing procedures have recently been introduced, among them laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation. These procedures focus on reducing patient morbidity and hastening postoperative recovery while preserving normal adrenal tissue. However, questions remain about the risks and benefits associated with routine application of minimally invasive therapies for adrenal-sparing surgery in terms of complete tumor extirpation. Clearly, more experience and longer follow-up is necessary to validate these procedures. Herein we describe the surgical techniques and early results of treatment with adrenal-sparing surgery.

Adrenal Gland Neoplasms↗

PubMed2003

Hand-assisted laparoscopy for large renal specimens: a multi-institutional study.

OBJECTIVES: To present our experience with hand-assisted laparoscopy (HAL) for larger renal specimens. One of the theoretical benefits of HAL is the ability to manage large renal specimens, which we defined as tumors greater than 7 cm, and tumors in obese patients. METHODS: Between March 1998 and October 2000, 106 HAL radical nephrectomies were performed for enhancing renal masses, for which 95 patients had complete preoperative, intraoperative, and postoperative data. Of the 95 patients, 32 underwent HAL for large tumors (7 cm or greater) and 41 had a body mass index of 31 or greater. The demographic and outcome data of these two groups were compared with 63 patients who underwent HAL for tumors less than 7 cm and 54 patients with a body mass index of less than 31. RESULTS: When comparing cohorts by tumor size, the only statistically significant differences were in convalescence and specimen weight. Patients with lesions 7 cm or greater required 21 days to recover compared with 18 days for patients with lesions less than 7 cm. Obese patients had statistically significantly higher American Society of Anesthesiologists classifications, longer operative times (214 versus 176 minutes), and longer convalescences (21 versus 17.5 days) compared with nonobese patients. The estimated blood loss and conversion rate was not different between the groups. Furthermore, no difference was noted between the groups in the incidence of positive margins, local recurrence, or metastatic recurrence at a mean follow-up of 12.2 months. CONCLUSIONS: HAL provides a safe, reproducible, and minimally invasive technique to remove large renal tumors and renal tumors in the obese.

Blood Loss, Surgical↗

PubMed2003

Practice patterns among urologic surgeons treating localized renal cell carcinoma in the laparoscopic age: technology versus oncology.

OBJECTIVES: To evaluate the effect of laparoscopy on practice patterns at a single institution in the treatment of renal cell carcinoma. Many now regard laparoscopic radical nephrectomy (LRN) as a standard of care in the management of localized renal cell carcinoma. As laparoscopy becomes more prevalent in the urologic community, practice patterns are changing. METHODS: We analyzed the renal cancer surgical database at the Weill Medical College of Cornell University from 1997 to 2002. We compared three groups, including open radical nephrectomy (ORN), open partial nephrectomy (OPN), and LRN. RESULTS: A total of 222 consecutive renal surgeries done for presumed malignancy were performed from 1997 to 2002. A total of 194 were assessable. Of these, 63 were OPNs, 51 were ORNs, and 80 were LRNs. When analyzed over time, during the latter half of 2000, 89% of all LRNs were performed on tumors less than 4 cm in size. More recently, in 2002, only 42% of LRNs were performed for tumors 4 cm or less in size. From 1997 to 2000, 30% of all OPNs were done on tumors greater than 4 cm compared with 28% from 2000 to 2002. Of 30 OPNs performed from 1997 to 2000, 21 (70%) were performed on small (4 cm or less) tumors compared with 24 (73%) of 33 from 2000 to 2002. CONCLUSIONS: From 2000 to 2002, the percentage of tumors less than 4 cm that were treated with LRN has increased with time. In the ORN cohort, the percentage of nephrectomies performed on small tumors (less than 4 cm) has decreased with time, and the trends in the OPN group have remained relatively stable. As an institution becomes more comfortable with laparoscopic techniques, technological concerns are likely to play less of a role in determining treatment algorithms among treating urologists.

Aged↗

PubMed2003

Minimally invasive surgical management of ureteropelvic junction obstruction: laparoscopic and robot-assisted laparoscopic pyeloplasty.

Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by an intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty and endoscopic techniques have been the main surgical options, with the intent of complete excision or incision of the obstruction. The introduction of laparoscopy and robot-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. These techniques offer substantial benefits to patients by reducing morbidity, hastening postoperative recovery, and improving cosmetic outcome. During the last decade, laparoscopic pyeloplasty has garnered much interest. However, because of the technically challenging nature of this procedure, it is performed only at select medical centers by surgeons with advanced laparoscopic training. The recent introduction of robotics to the field of minimally invasive surgery may facilitate this procedure and allow for more widespread implementation by surgeons of varying skill levels. This review is limited primarily to the treatment of congenital or acquired UPJ obstruction via laparoscopic and robot-assisted laparoscopic pyeloplasty. Herein, we report the early results, ongoing evolution, and potential future role for these novel surgical procedures.

Humans↗

PubMed2002

Laparoscopic adrenalectomy: the New York-Presbyterian Hospital experience.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland. The advantages of the laparoscopic approach include shorter length of stay (LOS), a decrease in postoperative pain, faster return to preoperative activity level, improved cosmesis, and reduced complications. We report our experience with laparoscopic adrenalectomy via a lateral transperitoneal approach. PATIENTS AND METHODS: Between September 1993 and April 2001, we performed 100 lateral transperitoneal adrenalectomies in 91 patients. In 82 cases, the adrenalectomy was unilateral and in the other 9, it was bilateral. A total of 59 left-sided lesions and 41 right-sided lesions were removed. The indications for surgery were Cushing's syndrome (24), aldosteronoma (34), pheochromocytoma (17), nonfunctioning adenoma (13), Carney's syndrome (1), and a metastasis from colon cancer (1) RESULTS: The overall success rate was 98%. Complications occurred in the two patients who required open conversion. In addition, three patients suffered pneumothoraces because of direct iatrogenic injury to the diaphragm during laparoscopic dissection. One additional patient suffered a splenic laceration. Operative time, blood loss, and intraoperative complications were similar in the laparoscopic and open surgery control group (N = 32). CONCLUSIONS: Laparoscopic adrenalectomy is technically feasible and reproducible. The lateral transperitoneal technique offers distinct advantages to the laparoscopist, including better visibility of familiar anatomic landmarks, easy access to other organ systems, the use of gravity to retract the spleen and liver, and a wide exposure, which allows removal of large adrenal lesions.

Adrenal Cortex Neoplasms↗