Biomedical subjects

Stephen E Strup

Publications and source records attributed to Stephen E Strup.

12 recordsLinked to original sources

PubMed2005

Detection of prostate carcinoma with contrast-enhanced sonography using intermittent harmonic imaging.

BACKGROUND: The purpose of this study was to assess prostate carcinoma detection and discrimination of benign from malignant prostate tissue with contrast-enhanced ultrasonography. METHODS: In all, 301 subjects referred for prostate biopsy were evaluated with contrast-enhanced sonography using continuous harmonic imaging (CHI) and intermittent harmonic imaging (IHI) with interscan delay times of 0.2, 0.5, 1.0, 2.0 seconds, as well as continuous color and power Doppler. Targeted biopsy cores were obtained from sites of greatest enhancement, followed by spatially distributed cores in a modified sextant distribution. RESULTS: Carcinoma was detected in 363 biopsy cores from 104 of 301 subjects (35%). Carcinoma was found in 15.5% (175 of 1133) of targeted cores and 10.4% (188 of 1806) of sextant cores (P < 0.01). Among subjects with carcinoma, targeted cores were twice as likely to be positive (odds ratio [OR] = 2.0, P < 0.001). Clustered receiver operating characteristic (ROC) analysis of imaging findings at sextant biopsy sites yielded the following Az values: precontrast gray scale: 0.58; precontrast color Doppler: 0.53; precontrast power Doppler: 0.58; CHI: 0.62; IHI (0.2 sec): 0.64; IHI (0.5 sec): 0.63; IHI (1.0 sec): 0.65; IHI (2.0 sec): 0.61; contrast-enhanced color Doppler: 0.60; contrast-enhanced power Doppler: 0.62. A statistically significant benefit was found for IHI over baseline imaging (P < 0.05). CONCLUSIONS: The carcinoma detection rate of contrast-enhanced targeted cores is significantly higher when compared with sextant cores. Contrast-enhanced transrectal sonography with IHI provides a statistically significant improvement in discrimination between benign and malignant biopsy sites. However, given the relatively low ROC areas, this technique may not be sufficient to predict which patients have benign versus malignant disease.

Aged↗

PubMed2005

Hand-assisted laparoscopic nephroureterectomy: analysis of distal ureterectomy technique, margin status, and surgical outcomes.

OBJECTIVES: To review our experience with various techniques used to manage the distal ureter during hand-assisted laparoscopic nephroureterectomy and to evaluate the surgical outcomes, including pathologic margin status and the incidence of disease recurrence. METHODS: We retrospectively analyzed 55 hand-assisted laparoscopic nephroureterectomies performed to treat transitional cell carcinoma (TCC), with the distal ureter managed as follows: cystoscopic disarticulation in 16 patients, stapled division in 7, open distal ureterectomy in 3, and hand-assisted laparoscopic extravesical en bloc distal ureterectomy with bladder cuff in 29. The cystotomy was not closed in 7 patients. RESULTS: The coexistence of renal pelvic and ureteral tumors was common but in 27% of cases was not recognized preoperatively. One outer and four distal ureteral margins were positive for tumor (n = 2) or carcinoma in situ (n = 3). Two (29%) of the seven cystotomies that were not closed and only 1 (2%) of the 42 that were closed demonstrated extravasation. The operative time was 60 to 90 minutes longer and the estimated blood loss, open conversion rate, and indwelling catheterization time were two to three times greater for the cystoscopic ureteral disarticulation cohort. The stapled division cohort had a greater positive margin rate (29%) than the other cohorts (10% or less). With a mean follow-up of 24 months, 19 patients had developed bladder cancer, 1 prostate cancer, 1 an extravesical malignancy with synchronous liver metastasis, and 4 distant recurrence (lung in 2 and the retroperitoneum and spine in 1 each). CONCLUSIONS: The results of our study have shown that distal ureteral tumors have the greatest likelihood for a positive margin. Cystoscopic ureteral disarticulation increased the operative time and estimated blood loss. Cystotomy closure reduced the extravasation rate. We favor hand-assisted laparoscopic en bloc distal ureterectomy followed by cystotomy closure to minimize the risk of distal ureteral or extravesical recurrence.

Aged↗

PubMed2004

Laparoscopic radical prostatectomy: a multi-institutional study of conversion to open surgery.

OBJECTIVES: To perform a multi-institutional review of the incidence and factors contributing to conversion from laparoscopic radical prostatectomy (LRP) to open radical retropubic prostatectomy (RRP) among eight surgeons. METHODS: The medical records from all patients undergoing LRP at seven institutions were reviewed to assess the incidence of open conversion to RRP. The clinical, operative, pathologic, and functional outcomes of patients who required conversion were compiled and analyzed. RESULTS: Of 670 operations, 13 (1.9%) were converted from LRP to RRP. The most common steps at which conversion occurred were the apical dissection (38%) and the posterior seminal vesicle dissection (31%). Failure to progress was the most common cause of conversion, followed by injury to adjacent structures and hypercarbia. Comorbidities associated with conversion were prior pelvic surgery and obesity (body mass index greater than 30). Six of the 13 conversions occurred in the surgeons' first 5 cases. Despite open conversion, patients were continent (no pads) (92%) and potent (44%) with at least 6 months of follow-up. CONCLUSIONS: Open conversion from LRP to RRP is an uncommon event, but is more likely to occur during a surgeon's early experience. Surgeons beginning their experience with LRP are advised to select their patients carefully to minimize the need for conversion to open surgery. Obese patients and those at risk of periprostatic adhesions should initially not be considered for LRP. Despite open conversion, the functional outcomes did not appear to be adversely affected.

Adenocarcinoma↗

PubMed2004

Hand-assisted laparoscopic partial nephrectomy.

The resurgence of nephron-sparing surgery for selected renal masses has fueled interest in minimally invasive approaches. Several authors have shown that laparoscopic partial nephrectomy is feasible if two goals are met: resection of the mass with negative margins and control of bleeding. The latter is a particular challenge, but numerous options are available. The authors describe the operative technique and the available results of hand-assisted laparoscopic partial nephrectomy.

Humans↗

PubMed2004

Laparoscopic radical prostatectomy after neoadjuvant hormonal therapy: an apparently safe and effective procedure.

OBJECTIVE: In an effort to determine the safety and efficacy of laparoscopic radical prostatectomy (LRP) in patients who have received neoadjuvant hormonal therapy (NHT), our initial series of 65 patients undergoing successful LRP was analyzed, specifically comparing 5 patients who received neoadjuvant hormonal therapy to 60 who did not. METHODS: From March 2000 to March 2002, 68 patients were scheduled for LRP. Three cases, none post-NHT, were converted to open radical retropubic prostatectomy (RRP). Clinical and pathologic data were recorded on the remaining 65 patients, 5 of who had received NHT. Forty-two bilateral and 16 unilateral nerve sparing LRP were performed in the non-NHT cohort, and 3 bilateral and 1 unilateral nerve sparing LRP in the NHT cohort. RESULTS: The mean patient age, preoperative prostate specific antigen (PSA), clinical stage, and biopsy grade were similar for the NHT and the non-NHT LRP cohorts. The mean estimated blood loss (EBL) and serum hemoglobin decrease (preoperative to postoperative day 1) were lower in the NHT cohort than the non-NHT cohort: 160 mL and 2.4 g/dL vs. 317 mL and 3.1 g/dL, respectively. The mean operative time and hospital stay were similar: 5.7 hours and 2.4 days for the NHT cohort and 5.8 hours and 2.8 days for the non-NHT cohorts. As expected, the mean prostate weight was lower for the NHT cohort: 36.8 g vs. 46.5 g. All NHT cohort tumors were pathologic stage pT2, with negative margins. Eleven (18%) of the non-NHT cohort had pathologic T3 (10 patients) or T4 (1 patient) tumors and 10 (17%) specimens had a positive surgical margin. Four of 5 (80%) NHT cohort and 21 of 25 (84%) non-NHT cohort patients are continent (no pad use) 3 to 6 months postsurgery. One NHT cohort patient (20%) and 20 (33%) non-NHT cohort patients had an elevated drain fluid creatinine 24 hours postoperatively. There were no other complications in the NHT cohort. All 5 NHT cohort patients have no evidence of recurrent disease, whereas 2 non-NHT cohort patients (3.3%) have developed PSA recurrence. No NHT patient and only 1 non-NHT patient received a blood transfusion postoperatively. CONCLUSION: LRP appears to be a safe and efficacious procedure in patients who have received NHT. Perioperative morbidity of NHT patients undergoing LRP appears equivalent to non-NHT patients, with slightly lower EBL, hemoglobin decrease, urinary extravasation, positive margin, and complication rates.

Antineoplastic Agents, Hormonal↗

PubMed2004

The 3-port laparoscopic pyeloplasty.

PURPOSE: We describe our technique of a 3 port approach for transperitoneal laparoscopic pyeloplasty and its evolution. MATERIALS AND METHODS: Between August 1999 and February 2003, 56 patients underwent laparoscopic transperitoneal pyeloplasty. The operative procedure, including patient positioning, surgical technique and postoperative care, is described in detail. For analysis patients were divided into 2 groups, namely an initial 4 port approach and a later 3 port approach. The number of additional ports placed and the reasons why were determined. RESULTS: In the initial 14 patients a 4 port plan was used and 1 (7.2%) required a fifth port. In the subsequent 42 patients surgery was initiated with a 3 port plan and 8 (19%) required 1 additional port, while 2 (4.8%) required 2 additional ports. Of the extra ports used 50% were necessary for liver retraction in procedures on the right side. In patients with greater than 10 renal calculi a retrieval pouch was used, necessitating an additional port. A planned 3 port approach was feasible in 32 of the 42 cases (76.2%) and even initially a 4 port approach was sufficient in 13 of 14 (92.9%). CONCLUSIONS: We believe that our 3 port, transabdominal laparoscopic pyeloplasty technique is an efficient one with the least number of incisions and morbidity to the patient. It has proved to be feasible in more than 75% of our cases. Additional ports can easily be added but usually they are not required.

Adult↗

PubMed2004

Hand assisted laparoscopic partial nephrectomy for peripheral and central lesions: a review of 30 consecutive cases.

PURPOSE: We reviewed our first 30 hand assisted laparoscopic partial nephrectomies and compared the results of 8 centrally located vs 22 peripherally located tumors. MATERIALS AND METHODS: Tumors were classified by computerized tomography as central (less than 5 mm from the pelvicaliceal system or hilar vessels) or peripheral. The hand assisted technique consisted of mobilization and manual parenchymal compression without vascular occlusion or ureteral stent placement. Argon beam coagulation and a fibrin glue bandage were used for hemostasis. RESULTS: Mean tumor size was 2.6 cm (range 1.0 to 4.7). Mean operative time was 199 and 271 minutes, and estimated blood loss was 240 and 894 ml for peripheral and central lesions, respectively. No case required open conversion. The final diagnoses were renal cell carcinoma in 21 patients, angiomyolipoma in 4, benign or hemorrhagic cyst in 3 and oncocytoma in 2. Initial positive margins were found in 5 of 30 specimens (16.7%) (1 central and 4 peripheral) and all final resection margins were negative. Four central (50%) and 2 peripheral (9.1%) tumor cases required transfusion. Drain creatinine was elevated in 6 patients (20%) postoperatively, of whom 3 had a central and 3 had a peripheral lesion. All responded to conservative management except 1 patient (3.3%) who required stent placement. Postoperative bleeding in a central tumor case required transfusion of 4 units. There were no short-term local recurrences and 1 patient had an asynchronous tumor. CONCLUSIONS: Hand assisted laparoscopic partial nephrectomy is safe with excellent immediate cancer control. Careful dissection and frozen section analysis are mandatory to ensure a negative tumor margin. Blood loss and transfusion rates were higher in patients with centrally located tumors and renal hilar vascular control should be considered for central lesions.

Carcinoma, Renal Cell↗

PubMed2003

Retroperitoneal laparoscopic cryoablation of small renal tumors: intermediate results.

OBJECTIVES: To present our experience with laparoscopic renal cryoablation with up to 3 years of follow-up. Laparoscopic renal cryoablation remains a viable option for the treatment of small peripheral renal masses in patients with significant comorbidities. Although partial nephrectomy has been shown to be a safe and reliable method of renal parenchymal preservation, laparoscopic cryoablation still requires longer term data to prove its efficacy. METHODS: Twenty patients with small renal masses (1.4 to 4.5 cm) underwent laparoscopic renal cryosurgery at our institution. A retroperitoneal laparoscopic approach was used to expose the kidney. Intraoperative ultrasound guidance was used to localize the lesions and monitor iceball formation. A double-freeze technique was used. Needle biopsies of solid masses were performed intraoperatively. RESULTS: Renal biopsies revealed renal cell carcinoma in 11 of the 20 patients. Of these 11 patients, none had evidence of recurrent disease at last follow-up, and follow-up scans showed no enhancement of any lesions. Of the 8 patients with follow-up of 2 years or greater, 4 had complete resolution of the renal lesions. The remainder had lesions that were reduced and stable in size. Complications included surgical re-exploration to evaluate pancreatic injury in 1 patient and failure to ablate a lesion in another. CONCLUSIONS: Laparoscopic renal cryoablation appears to be an effective tool for ablation of small renal lesions. A moderate length of follow-up continues to demonstrate efficacy because no patients had growth of treated pathologic lesions or developed metastasis to date. Continued maturation of data is necessary to determine the long-term efficacy.

Adult↗

PubMed2003

Pathologic comparison of laparoscopic versus open radical retropubic prostatectomy specimens.

OBJECTIVES: To compare the pathologic evaluation of 60 sequential laparoscopic radical prostatectomy (LRP) specimens with 60 sequential and 60 stage and grade-matched open radical retropubic prostatectomy (RRP) cohort specimens. METHODS: Of 68 patients undergoing LRP, 3 requiring open conversion and 5 receiving neoadjuvant hormonal therapy were excluded, leaving 60 for analysis. Among 72 sequential open RRP specimens, 60 from patients not receiving neoadjuvant hormonal therapy and without nodal metastases were analyzed. A third cohort of 60 RRP specimens matched with the LRP specimens for clinical stage and biopsy grade was also evaluated. RESULTS: The specimen weight and preoperative serum prostate-specific antigen level were similar for each cohort, and approximately 75% of patients from each cohort were clinical Stage T1c. Forty-six LRP and matched open RRP (76.7%) and 39 sequential open RRP (65%) specimens were biopsy Gleason sum 6, and the remainder were primarily Gleason sum 7. The pathologic grade and stage distribution were similar for each cohort. Ten LRP (16.9%) and 12 open RRP (20%) specimens from each cohort had positive inked margins (P > 0.10). Positive apex margins were noted in 3, 7, and 7 and multiple positive margin sites in 0, 5, and 6 of the LRP, matched open RRP, and sequential open RRP specimens (P < 0.05), respectively. CONCLUSIONS: Pathologic evaluation of the LRP and open RRP specimens from patients not receiving neoadjuvant hormonal therapy demonstrated similar overall positive margin rates, but LRP had a lower rate of apex and multiple-site positive margins.

Biopsy, Needle↗

PubMed2002

High-frequency Doppler US of the prostate: effect of patient position.

PURPOSE: To evaluate cancer detection with directed biopsy of the prostate on the basis of high-frequency Doppler ultrasonographic (US) findings, and to determine the effect of patient position on the observed flow pattern. MATERIALS AND METHODS: Thirty-two patients were evaluated in the left lateral decubitus position with gray-scale, color Doppler, and power Doppler transrectal US. Up to four directed biopsy specimens were obtained on the basis of gray-scale and Doppler US findings, and modified sextant biopsy followed. Analysis of variance and the Wilcoxon signed rank test were used to evaluate the distribution of Doppler signals within the prostate. Three healthy volunteers with no known prostate disease were also examined in supine and both decubitus positions. RESULTS: In the patient group, both color and power Doppler US demonstrated increased flow on the left side of the prostate, with greater flow toward the base of the gland (P <.002). Consequently, 62 of 90 directed-biopsy cores were obtained in the left base and mid-gland. The positive biopsy rate for directed biopsy was not significantly different from that of sextant biopsy (P =.4). Seven patients had cancer that was identified with sextant biopsy, but only four cancers were identified with directed biopsy. Each of the three healthy volunteers demonstrated increased Doppler flow on the dependent side when the subject was in the lateral decubitus position. CONCLUSION: The positive yield of directed biopsy was similar to the yield of sextant biopsy. On the basis of observations made in healthy volunteers, the authors conclude that flow asymmetry in patients who underwent biopsy may have been related to patient position.

Adult↗

PubMed2002

Prostate: high-frequency Doppler US imaging for cancer detection.

PURPOSE: To evaluate cancer detection with targeted biopsy of the prostate performed on the basis of high-frequency Doppler ultrasonographic (US) imaging findings versus cancer detection with a modified sextant biopsy approach with laterally directed cores. MATERIALS AND METHODS: Sixty-two patients were prospectively evaluated with gray-scale, color, and power Doppler transrectal US performed with patients in the lithotomy position. Gray-scale and Doppler findings within each sextant were rated on a five-point scale. Up to four targeted biopsy specimens were obtained from each patient on the basis of Doppler findings; this was followed by a modified sextant biopsy. Conditional logistic regression analysis was performed to compare the positive yields for targeted and sextant biopsy specimens. Clustered receiver operating characteristic analysis was performed to compare gray-scale, color, and power Doppler detection of cancer at sextant biopsy sites. RESULTS: Cancer was detected in 18 (29%) of 62 patients, including 11 patients in whom cancer was detected with both sextant and targeted biopsy, six in whom cancer was detected only with sextant biopsy, and one in whom cancer was detected only with targeted biopsy. The positive biopsy rate for targeted biopsy (24 [13%] of 185 cores) was slightly higher than that for sextant biopsy (36 [9.7%] of 372 cores; P =.1). The odds ratio for cancer detection with targeted versus sextant cores was 1.8 (95% CI: 0.9, 3.7). Receiver operating characteristic analysis demonstrated that overall identification of positive sextant biopsy sites was close to random chance for gray-scale (area under the curve, 0.53), color Doppler (area under the curve, 0.50), and power Doppler (area under the curve, 0.47) imaging. CONCLUSION: Targeted biopsy performed on the basis of high-frequency color or power Doppler findings will miss a substantial number of cancers detected with sextant biopsy.

Aged↗

PubMedDate not supplied

Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy.

The objective of the study was to compare the perioperative complication rates of our initial 60 laparoscopic radical prostatectomy (LRP) patients and our most recent 60 sequential open radical retropubic prostatectomy (RRP) patients. Sixty sequential LRP and 60 sequential RRP patients treated between March 2000 and March 2002 were retrospectively evaluated. Patients who received neo-adjuvant hormonal therapy or had metastatic disease and 3 LRP patients converted to open RRP were excluded. Estimated blood loss (EBL), transfusion rates, hemoglobin level, serum and drain fluid creatinine levels, hospital stay and complication rates were analyzed. There were 15 (25%) and 11 (18.3%) complications in the LRP and RRP cohorts, respectively. There were 3 (ulnar neuropathy, ureteral stricture, anastomotic leak with ureteral obstruction requiring reoperation), and 4 [2 bladder neck contractures (BNC) and 2 deep venous thromboses (DVT)] major complications, respectively. Minor complications included rectus hematoma, superficial wound infections, ileus and anastomotic urine leaks. A higher incidence of the latter (10 patients) was noted in the LRP cohort. One (1.7%) LRP and 31 (52%) RRP cohort patients received intraoperative or postoperative transfusions. The mean (median) EBL was 317 (250) and 1355 (1100) for the LRP and RRP cohorts, respectively. A transient, insignificant increase in serum creatinine from a median of 1.0 to 1.2 mg/dL was observed only in the LRP cohort. We concluded that our initial 60 LRP patients had a similar, but not improved, rate of perioperative complications when compared with 60 sequential open RRP patients of nearly identical age, preoperative PSA and prostate size. The types of complications differed between the LRP and RRP cohorts.

Blood Loss, Surgical↗