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Biomedical subjects

Robert B Nadler

Publications and source records attributed to Robert B Nadler.

At least 19 recordsLinked to original sources
PubMed2007

Does body mass index affect preoperative prostate specific antigen velocity or pathological outcomes after radical prostatectomy?

PURPOSE: Several studies suggest that obesity may be associated with more aggressive prostate cancer. Similarly the rate of serum prostate specific antigen change is associated with adverse tumor features and prostate cancer specific mortality rates after radical prostatectomy and radiation therapy. We examined the associations among obesity, prostate specific antigen velocity and adverse tumor features in men treated with radical prostatectomy. MATERIALS AND METHODS: A total of 587 men with documented preoperative height and weight measurements underwent radical prostatectomy. Prostate specific antigen velocity and other clinicopathological features were compared among men with a body mass index of less than 25, 25 to 29.9 and 30 or greater. RESULTS: Although Gleason score and prostate volume were similar among groups, there was a significantly lower proportion with organ confined disease and fewer low volume tumors as body mass index increased. Of patients with a body mass index of 30 or greater 52% had a preoperative prostate specific antigen velocity of more than 2 ng/ml yearly compared to 34% with a body mass index of 25 to 29.9 and 26% with a body mass index of less than 25 (p = 0.04). Although on univariate analysis body mass index was associated with adverse clinical and pathological tumor features, on multivariate analysis with other preoperative variables body mass index did not add significant independent predictive information concerning pathological stage (OR 1.02, 95% CI 0.96-1.08). CONCLUSIONS: Obesity was significantly associated with several adverse pathological features. However, it did not provide independent predictive information concerning final pathological tumor stage. Nevertheless, obesity was significantly associated with increased preoperative prostate specific antigen velocity. Additional studies are needed to further clarify the links between body mass index, prostate specific antigen velocity and prostate cancer progression, and determine whether weight reduction could lead to improved outcomes.

Adult↗
PubMed2006

Prostate-specific antigen test in diagnostic evaluation of chronic prostatitis/chronic pelvic pain syndrome.

OBJECTIVES: To determine whether prostate-specific antigen (PSA), the percent free PSA, or free PSA isoforms may be used as diagnostic markers for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS; National Institutes of Health category IIIa and IIIb). METHODS: We evaluated 421 patients enrolled in the Chronic Prostatitis Cohort Study and 112 age-matched controls. Subjects were stratified by the number of white blood cells (WBCs) in their expressed prostatic secretions and pain as determined by the National Institutes of Health Chronic Prostatitis Symptom Index. RESULTS: Total PSA, free PSA, and [-2]proPSA ([-2]pPSA) were significantly elevated in those with CP/CPPS compared with controls (mean PSA 1.97 ng/mL versus 1.72 ng/mL, P = 0.03; mean free PSA 0.76 ng/mL versus 0.70 ng/mL, P = 0.01; and [-2]pPSA 2.38 ng/mL versus 1.80 ng/mL, P = 0.04). The percent free PSA was not significantly different between the patients and controls. For those with CP/CPPS, the percent free PSA was significantly lower as the WBC count rose in the expressed prostatic secretions (0 WBCs = 43.29 versus more than 25 WBCs = 26.52; P < .0001). A PSA level of 4.0 ng/mL or greater was found in 10% of patients and 7% of controls (P = 0.03). CONCLUSIONS: Men with elevated PSA values and CP/CPPS should be treated as one would any other patient screened for prostate cancer with an elevated PSA level. Although PSA, free PSA, and [-2]pPSA were slightly elevated in men with CP/CPPS, the low sensitivity and specificity do not warrant using them as biomarkers for CP/CPPS.

Biomarkers↗
PubMed2006

Baseline prostate-specific antigen compared with median prostate-specific antigen for age group as predictor of prostate cancer risk in men younger than 60 years old.

OBJECTIVES: Limited data are available concerning the extent to which the initial prostate-specific antigen (PSA) measurement in men younger than age 60 predicts for the risk of prostate cancer (CaP) and how this compares to other known risk factors. METHODS: From 1991 to 2001, 13,943 men younger than 60 years old participated in a CaP screening study. Men aged 40 to 49 years were eligible for the study if they had a positive family history or African-American heritage, and men older than 50 years were screened without respect to risk factors. The CaP detection rate, PSA velocity, pathologic features, and treatment outcomes were evaluated as a function of the baseline PSA level. RESULTS: The median PSA level was 0.7 ng/mL for men aged 40 to 49 years and 0.9 ng/mL for men aged 50 to 59. A baseline PSA level between the median and 2.5 ng/mL was associated with a 14.6-fold and 7.6-fold increased risk of CaP in men aged 40 to 49 and 50 to 59 years, respectively. A greater baseline PSA value was also associated with a significantly greater PSA velocity, more aggressive tumor features, a greater biochemical progression rate, and a trend toward a greater cancer-specific mortality rate. CONCLUSIONS: In men younger than 60, a baseline PSA value between the age-specific median and 2.5 ng/mL was a significant predictor of later CaP and was associated with a significantly greater PSA velocity. A young man's baseline PSA value was a stronger predictor of CaP than family history, race, or suspicious digital rectal examination findings. A greater baseline PSA level was associated with significantly more adverse pathologic features and biochemical progression.

Adult↗
PubMed2006

Management of the complications of external beam radiotherapy and brachytherapy.

External beam radiation therapy (EBRT) and brachytherapy are common treatment modalities for newly diagnosed prostate cancer. What complications can patients and physicians expect following these therapies? How are these conditions diagnosed and treated? In this article, we examine several of the most common acute and delayed complications of radiation therapy for prostate cancer. In addition, we discuss appropriate follow-up diagnostics for these patients and our suggestions for management of the main complications that may develop.

Acute Disease↗
PubMed2006

Novel technique for management of distal ureter and en block resection of bladder cuff during hand-assisted laparoscopic nephroureterectomy.

OBJECTIVES: To report our experience with a novel flexible cystoscopic approach to excise the en block bladder cuff and juxtavesical ureter during hand-assisted laparoscopic nephroureterectomy. The optimal technique for excising the distal ureter and bladder cuff during nephroureterectomy continues to evolve. METHODS: Hand-assisted laparoscopic nephroureterectomy was performed in 6 patients. A hand-assist device and two 5 to 12-mm ports were placed in the mid and upper abdomen. Two 10-mm clips were placed on the proximal ureter to occlude it, and the kidney was resected in the usual fashion. An additional 5 to 12-mm port was placed in the midline between the umbilicus and symphysis pubis. The ureter was dissected down into the pelvis to the level of the bladder. Without repositioning the patient, a flexible cystoscope was inserted into the bladder and a 2-cm bladder cuff excised using a 5F electrode on cutting current, with coagulating current used as needed. The specimen was removed intact through the hand port. RESULTS: The mean time to resect the distal bladder cuff was 30 minutes (range 22 to 35). The mean estimated blood loss was 254 mL. The mean operating room time was 264 minutes, mean hospital stay 6.3 days, and mean time to a general diet 2.6 days. All patients underwent cystography at 7 to 10 days postoperatively, with no extravasation or diverticula. Cystoscopic and computed tomography follow-up demonstrated no evidence of recurrence. CONCLUSIONS: This technique allows for complete resection of the kidney, distal ureter, and a cuff of bladder, avoiding repositioning.

Carcinoma, Transitional Cell↗
PubMed2006

Use of BioGlue in laparoscopic partial nephrectomy.

Hemostasis during laparoscopic partial nephrectomy continues to be a challenging problem for the laparoscopic surgeon. We have found BioGlue to be highly effective as a hemostatic agent during laparoscopic partial nephrectomy.

Hemostatic Techniques↗
PubMed2006

A prospective study of laparoscopic radical nephrectomy for T1 tumors--is transperitoneal, retroperitoneal or hand assisted the best approach?

PURPOSE: We designed a prospective, randomized clinical trial to compare 3 common approaches to laparoscopic radical nephrectomy, namely transperitoneal, retroperitoneal and hand assisted. MATERIALS AND METHODS: A total of 33 patients with a solid renal mass of 7 cm or less were prospectively enrolled in alternating fashion to a hand assisted procedure, a transperitoneal procedure with morcellation and a retroperitoneal procedure with intact specimen extraction. A single surgeon performed all operations. Preoperative, intraoperative and postoperative criteria were compared among the 3 techniques. RESULTS: A total of 11 patients underwent each type of procedure. There was no significant difference in age, American Society of Anesthesiologists class, body mass index or tumor size among the groups. Mean operative time was significantly lower using the hand assisted approach, whereas estimated blood loss was similar in all 3 groups. Incision size, hospital stay and time to normal daily activity were less using the transperitoneal approach. While not significant, there was a trend toward less narcotic use in the transperitoneal group. Hernia formation was seen with increased frequency in the hand assisted group. CONCLUSIONS: In our series the hand assisted approach had significantly shorter operative time than the transperitoneal or retroperitoneal approach but it had the greatest risk of hernia formation. The transperitoneal approach was associated with a significantly shorter hospital stay and the earliest resumption of normal activity.

Adult↗
PubMed2005

Histopathology of human renal tumors after laparoscopic renal cryosurgery.

PURPOSE: Laparoscopic renal cryoablation is a nephron sparing treatment alternative for selected patients with small renal tumors. The acute tumoricidal effects of cryosurgery on human renal tumors and in experimental models have been reported previously. For cryoablation to be a viable option in the treatment of renal tumors, it must induce not only acute tissue injury but also sustain permanent tissue necrosis and cellular death, in addition to affording an adequate surgical margin free of viable tumor. We report on the longer term effects of in vivo human tumor tissue destruction by cryosurgery and describe the histopathology of a cryoablated renal lesion. MATERIALS AND METHODS: Three patients in our series who were treated with laparoscopic renal cryosurgery subsequently underwent radical nephrectomy of the cryoablated renal unit. RESULTS: All patients underwent uneventful cryosurgery. Two patients were found to have positive post-cryosurgery biopsies, while a new, metachronous lesion developed in 1 patient. All 3 patients elected to undergo radical nephrectomy. Mean time from cryosurgery to nephrectomy was 275 days. The cryoablated lesions demonstrated coagulative necrosis as evidenced by numerous histiocytes, cholesterol crystals and dystrophic calcification. There was no evidence of viable tumor within the cryoablated field. CONCLUSIONS: The longer term tumoricidal effects of laparoscopic renal cryosurgery in human renal tissue have been demonstrated. However, careful patient selection with lesions less than 3.0 cm and vigilant monitoring of the iceball under strict radiographic guidance are imperative to ensure successful oncological outcomes.

Aged↗
PubMed2005

Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less.

PURPOSE: The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial. MATERIALS AND METHODS: A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. RESULTS: A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. CONCLUSIONS: This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.

Adult↗
PubMed2005

Cystine: helical computerized tomography characterization of rough and smooth calculi in vitro.

PURPOSE: The classification of cystine stones into rough and smooth varieties has been suggested as an aid to choosing treatment for these difficult stones. Since the surface of stones is difficult to visualize preoperatively, we tested the hypothesis that the surface morphology of cystine stones correlates with their internal structure, as viewed by helical computerized tomography (CT). MATERIALS AND METHODS: Cystine stones were examined visually and categorized into rough (15 stones) and smooth (16 stones) subpopulations of similar size. Each stone was scanned in a helical CT scanner (GE Quad Scanner) to assess radiological characteristics and to measure attenuation values. Scans were also performed using a microCT 20 high resolution laboratory scanner (Scanco Medical AG, Bassersdorf, Switzerland) at 34 microm voxel size and the percent of internal voids was determined. RESULTS: Mean helical CT attenuation values +/- SD for rough stones were lower than for smooth stones (702 +/- 206 vs 921 +/- 51 HU, p <0.002) and the radiological appearance of rough stones suggested radiolucent voids. Internal voids in rough stones were confirmed using micro CT. Rough cystine stones contained a higher percent of internal voids (0.30% vs 0.06%, p <0.0001). CONCLUSIONS: Rough cystine stones can be distinguished from smooth stones using helical CT in vitro, suggesting that it may be possible to distinguish these stones preoperatively. Since rough cystine stones have been reported to be susceptible to shock wave lithotripsy, the identification of this morphology of cystine stones in the patient using attenuation values and appearance on helical CT could be valuable for planning treatment.

Cysteine↗
PubMed2005

Intravesical holmium laser fragmentation and removal of detached resectoscope sheath tip.

PURPOSE: We describe a case in which the tip of a resectoscope sheath broke off in the bladder during transurethral resection of the prostate. MATERIALS AND METHODS: A holmium laser was used to fragment a detached ceramic 26Fr resectoscope sheath tip, which was dislodged into the bladder during transurethral resection of the prostate. The fragments were then retrieved using grasping forceps. RESULTS: This procedure caused minimal trauma. CONCLUSIONS: The procedure represents a novel and safe approach to the intravesical fragmentation and subsequent removal of an iatrogenic foreign body from the bladder.

Aged↗
PubMed2005

Use of 2.6 ng/ml prostate specific antigen prompt for biopsy in men older than 60 years.

PURPOSE: Since the United States Food and Drug Administration approved the prostate specific antigen (PSA) blood test as an aid to early prostate cancer detection, using a cutoff of 4.0 ng/ml in 1994, this cutoff has been widely adopted to recommend prostate biopsy. There has been recent investigation into lowering the PSA prompt for biopsy, especially in men younger than 60 years. We determined how a lower cutoff would perform in men older than 60 years. MATERIALS AND METHODS: From a prostate cancer screening study we studied 782 consecutive men who underwent prostate biopsy for PSA greater than 2.5 ng/ml or suspicious digital rectal examination. Biopsy results were evaluated as a function of patient age. RESULTS: Clinical and pathological characteristics of cancers detected in the PSA range 2.6 to 4.0 ng/ml were similar regardless of patient age. Overall PSA between 2.6 and 4.0 ng/ml was associated with a cancer detection rate of 16.2% using a sextant biopsy technique. PSA velocity was similar in men with prostate cancer in all age groups. CONCLUSIONS: More than 15% of men with PSA 2.6 to 4.0 ng/ml who are 40 years or older have prostate cancer detected with sextant needle biopsies. PSA velocity, tumor stage, Gleason grade and tumor volume were similar in all age groups.

Age Factors↗
PubMed2004

Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is principally defined by pain in the pelvic region lasting more than 3 months. No cause of the disease has been established, and therapies are empirical and mostly untested. Antimicrobial agents and alpha-adrenergic receptor blockers are frequently used. OBJECTIVE: To determine whether 6-week therapy with ciprofloxacin or tamsulosin is more effective than placebo at improving symptoms in men with refractory, long-standing CP/CPPS. DESIGN: Randomized, double-blind trial with a 2 x 2 factorial design comparing 6 weeks of therapy with ciprofloxacin, tamsulosin, both drugs, or placebo. SETTING: Urology outpatient clinics at 10 tertiary care medical centers in North America. PATIENTS: Patients were identified from referral-based practices of urologists. One hundred ninety-six men with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score of at least 15 and a mean of 6.2 years of symptoms were enrolled. Patients had received substantial previous treatment. MEASUREMENTS: The authors evaluated NIH-CPSI total score and subscores, patient-reported global response assessment, a generic measure of quality of life, and adverse events. INTERVENTIONS: Ciprofloxacin, 500 mg twice daily; tamsulosin, 0.4 mg once daily; a combination of the 2 drugs; or placebo. RESULTS: The NIH-CPSI total score decreased modestly in all treatment groups. No statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin (P = 0.15) or tamsulosin versus no tamsulosin (P > 0.2). Treatments also did not differ significantly for any of the secondary outcomes. LIMITATIONS: Treatment lasting longer than 6 weeks was not tested. Patients who had received less pretreatment may have responded differently. CONCLUSION: Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms.

Adrenergic alpha-Antagonists↗
PubMed2004

Safety and efficacy of percutaneous nephrolithotomy in patients with neurogenic bladder dysfunction.

OBJECTIVES: To review our experience performing percutaneous nephrolithotomy (PNL) on patients with neurogenic bladder dysfunction with special attention paid to the risks of surgical complications and stone recurrence. Patients with neurogenic bladder dysfunction with or without urinary diversion are at increased risk of urolithiasis, surgical complications, and recurrent stone disease. METHODS: We retrospectively reviewed the 23 patients with neurogenic bladder dysfunction who underwent PNL at our institution. Neurologic lesions included spina bifida, traumatic spinal cord injury, exstrophy/epispadias, neonatal meningitis, stroke, and spine chondrosarcoma. Bladder management included ileal conduit (n = 8), intermittent catheterization (n = 7), indwelling catheter (n = 7), and ureterosigmoidostomy (n = 1). RESULTS: We performed 100 procedures on 47 renal units (17 bilateral, 7 with recurrent stones). Urinary tract infection/colonization was seen in 21 of 23 patients, most of whom had more than one organism. The stone-free rate was 96%. Six patients required three or more procedures, each had a complete staghorn calculus. In an average of 36 months of follow-up, 10 patients (46%) had recurrent stone disease requiring intervention, and 5 patients (23%) underwent repeat PNL. The stone composition analysis revealed mainly infection-related stones. CONCLUSIONS: PNL in patients with neurogenic voiding dysfunction is safe and effective, with outcomes comparable to that of patients without such lesions. The complication rate is small but statistically significant. It is important to obtain adequate urine cultures, because renal pelvis and bladder culture data may differ and affect the outcome. Risk factors for recurrent stone disease include a high spinal cord lesion, indwelling urinary catheter, and ureterosigmoidostomy.

Adolescent↗
PubMed2004

Preperitoneal laparoscopic simple prostatectomy.

Simple prostatectomy has been a mainstay of therapy for patients with benign prostatic hyperplasia. We describe a preperitoneal laparoscopic approach for resection of large prostatic adenomas. We believe this is a viable and less invasive alternative to the traditional open approaches used for simple prostatectomy.

Aged↗
PubMed2004

Pneumothorax masked by subcutaneous emphysema after laparoscopic nephrectomy.

An 81-year-old man with an enhancing upper-pole renal mass underwent laparoscopic nephrectomy via a retroperitoneal approach. Postoperatively, his systolic blood pressure declined to 72 mm Hg, and arterial blood gas analysis suggested acute respiratory acidosis. Chest radiography suggested subcutaneous emphysema, but a CT scan showed tension pneumothorax. This case illustrates the difficulties in interpretation of chest films caused by the subcutaneous air that is routinely present after laparoscopic procedures.

Aged↗