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Biomedical subjects

R V Clayman

Publications and source records attributed to R V Clayman.

At least 73 records · Page 4Linked to original sources
PubMed1998

Adult endopyelotomy: impact of etiology and antegrade versus retrograde approach on outcome.

PURPOSE: We evaluate our experience with endopyelotomy for ureteropelvic junction obstruction by stratifying the results of an antegrade versus a retrograde approach for primary, secondary, calculi related, high insertion and impaired renal function related obstruction, individually. MATERIALS AND METHODS: We retrospectively reviewed results of 149 nonrandomized patients treated for ureteropelvic junction obstruction, of whom 83 underwent antegrade percutaneous endopyelotomy using a right angle Greenwald electrode and 66 underwent retrograde endopyelotomy using a cutting balloon device. Subjective results were based on an analog pain scale, objective results on renal scan, excretory urography or Whitaker test and cost-effectiveness analysis on total treatment cost. RESULTS: In both primary and secondary ureteropelvic junction obstruction, retrograde endopyelotomy was related to a significantly shorter operating room time and hospital stay (p < 0.05). When treating noncalculous primary ureteropelvic junction obstruction (92 patients) there was a better objective, albeit not statistically significant, success rate with antegrade endopyelotomy (89 versus 71%) but retrograde endopyelotomy was 20% more cost-effective. When treating secondary ureteropelvic junction obstruction (37 patients) there was a better objective, albeit not statistically significant, success rate (83 versus 77%) with retrograde endopyelotomy, which was 37% more cost-effective. Complication rates were higher with antegrade compared to retrograde endopyelotomy for primary and secondary ureteropelvic junction obstruction (25 versus 14% and 26 versus 0%). In 20 patients with concomitant stones endopyelotomy results were better (93 to 100% success) than for any other categories of ureteropelvic junction obstruction. Of note, endopyelotomy also provided a reasonable outcome among patients with a high insertion primary ureteropelvic junction obstruction (70% success). CONCLUSIONS: Antegrade endopyelotomy is the preferred approach in patients with primary ureteropelvic junction obstruction and concomitant renal calculi (13.4% of cases), and may also be preferable in patients with high insertion obstruction (6.7%). For all other primary and all secondary ureteropelvic junction obstruction, antegrade and retrograde endopyelotomy is effective therapy yet retrograde endopyelotomy results in less operating room time, shorter hospital stay, fewer complications and significantly less expense to achieve the desired outcome.

Adolescent↗
PubMed1998

Retrospective analysis of the effect of crossing vessels on successful retrograde endopyelotomy outcomes using spiral computerized tomography angiography.

PURPOSE: Using spiral computerized tomography (CT) angiography, we sought to evaluate the incidence of a crossing vessel in a group of adults with primary ureteropelvic junction obstruction who had previously undergone successful retrograde endopyelotomy. MATERIALS AND METHODS: A total of 16 patients who had undergone successful Acucise balloon incision endopyelotomy for ureteropelvic junction obstruction, all with followup greater than 2 years, underwent a spiral CT angiogram with intravenous contrast material to identify those with a crossing vessel. Contrast enhanced CT was performed with dual phase technique on a Somatom-Plus-S CT scanner using prototype software. After 180-degree linear interpolation of the projection data, transaxial images of the affected kidney were reconstructed. In addition, at the time of the study all patients completed analog followup pain scales and quality of life assessment questionnaires. RESULTS: Among the 16 patients 6 (38%) had anterior or posterior crossing vessels based on spiral CT angiography. No patient had both types. By analog pain scale patients had 80% mean improvement in pain (range 63 to 100). CONCLUSIONS: In our series nearly 40% of patients with anterior or posterior crossing vessels had a long-term (greater than 2 years) successful outcome with retrograde endopyelotomy. Endopyelotomy continues to be our initial mode of therapy among adults with primary ureteropelvic junction obstruction. In our opinion the adverse influence of the crossing vessel is not sufficient to justify the added expense of preoperative angiography, spinal CT or endoluminal ultrasound.

Adult↗
PubMed1998

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Humans↗
PubMed1998

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience.

OBJECTIVES: Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS: Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS: The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS: The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Adult↗
PubMed1998

Endourologic options for management of ureteropelvic junction obstruction in the pediatric patient.

Endourologic intervention is becoming a more widely accepted modality in the management of pediatric UPJ obstruction. The authors present five factors that are important in selecting patients that will lead to a successful treatment and outline techniques for antegrade and retrograde endopyelotomy and balloon dilation. This article also reviews the recent literature on endourologic interventions in the management of pediatric UPJ obstruction. The authors conclude that pediatric endopyelotomy has an 86% success rate and should be offered as treatment for select pediatric patients with UPJ obstruction.

Adolescent↗
PubMed1998

Lower-pole caliceal stone clearance after shockwave lithotripsy, percutaneous nephrolithotomy, and flexible ureteroscopy: impact of radiographic spatial anatomy.

Spatial anatomy of the lower renal pole, as defined by the infundibulopelvic angle (LIP angle), infundibular length (IL), and infundibular width (IW), plays a significant role in the stone-free rate after shockwave lithotripsy. A wide LIP angle, a short IL, and a broad IW, individually or in combination, favor stone clearance, whereas a LIP <70 degrees, an IL >3 cm, or an IW < or =5 mm are individually unfavorable. When all three unfavorable factors or an unfavorable LIP and IL coexist, the post-SWL stone-free rate falls to 50% or less. Using these criteria, more than one fourth of our patients with a lower-pole calculus might have been better served by an initial percutaneous or perhaps ureteroscopic procedure, neither of which is significantly affected by the lower-pole spatial anatomy.

Adolescent↗
PubMed1998

Endopyelotomy for high-insertion ureteropelvic junction obstruction.

We assessed the results of endourologic treatment of patients with a primary ureteropelvic junction obstruction (UPJO) caused by high insertion of the ureter into the renal pelvis (HIUPJO). A total of 10 patients 15 to 76 years old with preoperatively diagnosed HIUPJO were treated. Acucise retrograde endopyelotomy was performed in eight patients and percutaneous antegrade endopyelotomy in two. A stent was left in place for an average of 5.3 weeks. The subjective success rate, based on patient questionnaire and analog pain scales, was 80% at 27 months' average follow-up. The objective success rate, based on diuretic renal scanning or Whitaker test, was 70% at 26 months' mean follow-up. Overall, 60% of the patients had both an objectively and a subjectively successful outcome. The success rate for endopyelotomy in patients with UPJO caused by high insertion is similar to that reported for endopyelotomy in patients without high insertion. High insertion is not a contraindication to endopyelotomy.

Adolescent↗
PubMed1998

Impact of etiology of secondary ureteropelvic junction obstruction on outcome of endopyelotomy.

Endopyelotomy for secondary ureteropelvic junction obstruction (UPJO) is a highly effective procedure. However, the impact of the etiology of the obstruction on the outcome of an endopyelotomy has not been defined. Herein, we review the success rates with endopyelotomy for secondary UPJO after failure of open pyeloplasty or endopyelotomy. Thirty-five adult patients with both objective and subjective follow-up were identified retrospectively who had endopyelotomy for secondary UPJO. Twenty-four patients had failed a previous open reconstruction (23) or laparoscopic Foley Y-V plasty (1). Eleven patients had failed a prior endopyelotomy. Retrograde endopyelotomy was performed using the Acucise device in 11 patients, and antegrade endopyelotomy was performed in 24 patients. Objective follow-up was obtained with diuretic renal scintigraphy (mean 14.1 months) and subjective follow-up by analog pain scales (mean 27.8 months). Objective success was defined as no obstruction on renal scintigraphy, while subjective success was used to describe a minimum of 50% resolution of symptoms. The subjective success rate of secondary endopyelotomy in the open-pyeloplasty group was 88% v 71% in the prior endopyelotomy group (P = 0.20). The objective success rate in the failed-pyeloplasty group was 71% v 55% in the prior endopyelotomy group (P = 0.40). Endopyelotomy for secondary UPJO has a good success rate. Success rates tend to be higher in patients who have failed an open pyeloplasty; however, a statistically significant difference was not seen between the two groups.

Adult↗
PubMed1998

Laparoscopic ureteroureterostomy using vascular closure staples in porcine model.

The greatest difficulty in performing a laparoscopic pyeloplasty is the suturing of the ureteropelvic junction. The purpose of this study was to evaluate the use of nonperforating titanium vascular closure staple (VCS) clips to perform in laparoscopic ureteroureterostomy in the porcine model. Six female minipigs underwent laparoscopic transection of one of the proximal ureters at the level of the lower pole of the kidney. Ureteroureterostomy was then performed using the titanium VCS clips. The animals were evaluated at 6 and 12 weeks postureteroureterostomy with retrograde pyelography and differential creatinine clearances. At 12 weeks, the animals were euthanized, and the area of ureteroureterostomy was examined grossly and histopathologically. The technique for laparoscopic vascular clipping of the ureteroureterostomy proved to be fast and effective. Follow-up indicated that the method was successful in producing a functionally patent anastomosis. No encrustation, stone formation, or intraluminal clip was noted in any of the ureters or kidneys undergoing the ureteroureterostomy. The area of the ureteroureterostomy showed minimal fibrosis and inflammation on histopathologic examination. In this animal study, the nonperforating titanium clips facilitated the performance of a laparoscopic ureteroureterostomy.

Anastomosis, Surgical↗
PubMed1998

Simultaneous bilateral percutaneous nephrolithotomy with subarachnoid spinal anesthesia.

We report our experience performing simultaneous bilateral percutaneous nephrolithotomy (SBPN) in four patients with large stone burdens in both kidneys. We modified the previously described approach by combining SBPN with subarachnoid Duramorph (preservative-free morphine sulfate) in an effort to decrease postoperative discomfort and shorten the duration of hospitalization. These patients (study group) were then compared with a contemporary group of four patients with similar bilateral stone burdens who underwent staged bilateral percutaneous nephrolithotomies (PCNs) (control group). The comparison showed a marked advantage in hospital stay (4.8 days for the study group v 11 days for the control group) and postoperative narcotic requirement (27.5 mg of meperidine for the study group v 533 mg for the control group). All four patients were rendered stone free. This method of treatment for large bilateral renal calculi with the addition of subarachnoid Duramorph resulted in less postoperative discomfort, less morbidity, and a more rapid recovery than staged PCN or sandwich PCN/SWL/PCN.

Adult↗