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Biomedical subjects

D G Skinner

Publications and source records attributed to D G Skinner.

At least 145 records · Page 8Linked to original sources
PubMed1989

Vena caval resection in bulky metastatic germ cell tumors.

We describe the operative management and followup of vena caval resection in 12 patients with thrombosis of the inferior vena cava secondary to bulky metastatic (stage B3 or IIC) germ cell tumors. All patients received induction chemotherapy (10 platinum-based) followed by retroperitoneal lymph node dissection. The inferior vena cava was resected from just below the renal veins to the bifurcation of the iliac veins. Complete resection of retroperitoneal disease was accomplished in all patients. Five patients had postoperative complications, including 2 small bowel obstructions, 1 prolonged ileus and 2 persistent lymphatic leaks. Mean hospital stay was 37 days (range 27 to 49 days) versus 12 days (range 8 to 16 days) for noncomplicated recoveries. No long-term sequelae related to the vena caval resection have occurred with followup of 24 to 80 months. Seven patients are without disease, with a mean followup of 36 months (range 24 to 60 months). We conclude that en bloc vena caval resection for thrombosis of the vena cava allows for complete resection and simplifies the procedure with acceptable morbidity.

Adolescent↗
PubMed1989

Continent urinary diversion.

From August 1982 through March 1988, 531 patients have undergone continent urinary diversion using an ileal reservoir constructed according to the method of Kock. For the last 18 months we have used the principle of Kock reservoir construction for primary lower urinary tract reconstruction after cystectomy in 39 highly selected male patients by means of a ureteroileal urethrostomy. Early complications occurred in 86 of 531 patients (16.2 per cent), resulting in an operative mortality rate of 1.9 per cent (10 of 531). The early complication rate was 16.5 per cent among patients undergoing 1-stage cystectomy and Kock pouch construction, and 15.2 per cent among patients undergoing Kock pouch conversion. Late complications have been analyzed in 489 patients who have undergone Kock cutaneous diversion. The complications unique to continent urinary diversion, their incidence and the effect of technical modifications in reducing the number of late complications are shown. Note that since the last modification in July 1985 the over-all incidence of late complication has decreased to 22 per cent. Based on this ongoing experience we conclude that the continent ileal reservoir, as conceived by Kock, remains the ideal internal reservoir for bladder replacement in terms of volume accommodation with the lowest internal pressures, and the intussuscepted ileal nipple valve mechanism is a reproducible, highly effective mechanism that prevents reflux and pyelonephritis in greater than 95 per cent of the patients and produces excellent continence. Our enthusiasm remains tempered by the need for reoperation in approximately 10 to 15 per cent of the patients, usually due to a pinhole fistula or false passage at the base of the efferent nipple valve mechanism. Electrolyte abnormalities rarely occur and in the absence of radiation gastrointestinal dysfunction is unusual. Continent urinary diversion is a viable concept that provides a real alternative in terms of quality of life and self-image for the patient who requires urinary diversion for any reason.

Adolescent↗
PubMed1989

Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival.

In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.

Actuarial Analysis↗
PubMed1989

[The Kock continent urinary diversion].

The continent ileal reservoir as conceived by Kock produces a low-pressure, high-capacity reservoir with continent and nonrefluxing valves constructed from ileum. From August 1982 through March 1988, 531 patients underwent continent urinary diversion via a Kock reservoir at our institution. Of these, 39 males had a Kock bladder substitution, while the rest underwent cutaneous Kock diversion. Early complications occurred in 16% of all patients, and there was an operative mortality rate of 1.9%. Surgical modifications of nipple fixation, which are discussed in detail in this paper, help to reduce late complications to less than 10%. Patient satisfaction with both procedures remains excellent.

Adolescent↗
PubMed1988

The hemi-Kock augmentation ileocystoplasty: a low pressure anti-refluxing system.

Experiences with various methods of using intestinal segments for bladder augmentation and urinary undiversion, as well as with clinical applications of the Kock continent ileostomy for urinary diversion have led us to develop the hemi-Kock augmentation ileocystoplasty for selected patients requiring a nonrefluxing bladder augmentation. In 6 of 7 patients this bladder augmentation technique fulfilled the requirement for a low pressure nonrefluxing reservoir. Renal function has been preserved and electrolyte problems have not occurred. Nocturnal incontinence has been eliminated. Although 2 of 7 patients required surgical revision patient acceptance has been excellent. Prerequisites to implementing this approach are appropriate patient selection and familiarity with the surgical principles of the continent ileal reservoir.

Adult↗
PubMed1988

Management of adult sarcomas of the bladder and prostate.

Historically, survival of patients with adult pelvic sarcoma of the bladder and prostate has been poor. Between November 1974 and November 1984 we treated 11 patients with leiomyosarcoma: 7 with primary bladder and 4 with prostate tumors. Patients with nonbulky disease underwent surgical resection and were observed if the margins and nodes were negative. Patients with positive surgical margins or nodes were treated adjunctively with external beam radiotherapy, 4,500 to 5,000 rad, and chemotherapy. Patients with bulky disease were treated with preoperative chemotherapy with or without radiotherapy followed by an exenterative operation. Of the 11 patients 9 are without evidence of disease with a mean followup of 61 months (range 35 to 96 months). One patient was lost to followup after 4 months and 1 died of disease after 11 months. Three patients with rhabdomyosarcoma were treated and 1 had no evidence of disease 24 months after therapy. Two patients died at 4 and 18 months.

Adolescent↗
PubMed1988

The potency-sparing radical cystectomy: does it compromise the completeness of the cancer resection?

Anatomical radical cystectomies with en bloc pelvic lymph node dissections were performed post mortem on 10 male cadavers. The traditional technique of radical cystectomy was used on 1 side and the potency-sparing technique was used on the opposite side. The tissue responsible for the differences in the surgical margins with the 2 procedures was examined by routine surgical pathological techniques to determine if it contained lymph nodes. Lymph nodes were identified in the bundle of tissue left in the pelvis with the nerve-sparing radical cystectomy in 6 of the 10 dissections (60 per cent). Because these lymph nodes may represent the potential first site of metastatic disease leaving the bladder, the reader is cautioned about adopting the nerve-sparing radical cystectomy as part of the management of invasive bladder cancer until the long-term sequelae of the procedure are known.

Erectile Dysfunction↗
PubMed1988

A comparative study of perioperative complications with Kock pouch urinary diversion in highly irradiated versus nonirradiated patients.

To define the nature and risk of complications associated with Kock pouch urinary diversion after high dose radiation (more than 4,500 rad), we analyzed the clinical course of 44 irradiated patients and a comparable group of 42 selected retrospectively from the nonirradiated patient cohort. Of the 42 patients in the irradiated group 18 had received 4,500 to 5,700 rad and 24 had received 6,000 to 8,700 rad. With standard statistical methods we found no difference between the irradiated and control groups when compared for age, sex ratio, followup interval, surgical procedure, operative time or estimated blood loss. There were 2 operative mortalities in the irradiated and 1 in the control groups. In the immediate postoperative period there was no difference between the irradiated and control groups when compared for hospital stay, incidence of urine leak or fascial dehiscence. The irradiated group had 8 urine leaks (20 per cent) and 3 patients (7.5 per cent) required surgical repair. The control group had 5 urine leaks and 1 patient (2.3 per cent) required repair. Diarrhea severe enough to require further hospitalization or medication was significantly more frequent in the irradiated group (18 versus 2 per cent) but the postoperative stay was not significantly different (13 versus 11 days). We conclude that Kock pouch urinary diversion may be performed safely in highly irradiated patients.

Combined Modality Therapy↗
PubMed1988

Unsuspected prostatic adenocarcinoma in patients who have undergone radical cystoprostatectomy for transitional cell carcinoma of the bladder.

In 45 of 165 male cystectomy patients with bladder cancer (27 per cent) incidental adenocarcinoma of the prostate was found during the diagnostic evaluation or histological examination of the cystoprostatectomy specimens. Of the patients 37 had stage A1 or A2 and 8 had stage C or D1 prostate cancer. Clinical presentation, stage and grade distributions for each primary and prognostic variable are reviewed. Over-all, 67 per cent of the patients currently are alive with a 3-year actuarial survival rate of 60 per cent. The presence of incidental stage C or D1 prostate cancer in the surgical specimen implies incomplete surgical excision and it may warrant additional postoperative treatment. However, a significantly increased mortality rate among these patients has not been identified during the limited median followup of 25 months.

Adenocarcinoma↗
PubMed1988

Continent urinary diversion. A 5 1/2 year experience.

From August 1982 through March 1988, 531 patients have undergone continent urinary diversion using an ileal reservoir constructed according to the method of Kock. For the past year, the Division of Urology at the USC School of Medicine in Los Angeles has used the principle of Kock reservoir construction for primary lower urinary tract reconstruction after cystectomy in 39 highly selected male patients by means of a ureteroileal urethrostomy. Early complications occurred in 86 of 531 patients (16.2%), resulting in an operative mortality rate of 1.9% (ten of 531). The early complication rate was 16.5% in patients undergoing single stage cystectomy and Kock pouch construction and 15.2% among patients undergoing Kock pouch conversion. Late complications have been analyzed in a group of 489 patients who have undergone Kock cutaneous diversion. The complications unique to continent urinary diversion, their incidence, and the effect of technical modifications in reducing the number of late complications are discussed. Since the time of the last modification, in July 1985, the overall incidence of late complication has dropped to 22%. Based on this ongoing experience, the authors conclude that: 1) the continent ileal reservoir as conceived by Kock remains the best internal reservoir for bladder replacement in terms of volume, accommodation with the lowest internal pressures compared with other alternative reservoir construction, 2) the intussuscepted ileal nipple valve mechanism is a reproducible, highly effective mechanism that prevents reflux in 95% of patients and produces excellent continence, 3) our enthusiasm remains tempered by the need for reoperation in approximately 10-15% of patients, usually due to a pinhole fistula or false passage at the base of the efferent nipple valve mechanism, 4) electrolyte abnormalities rarely occur and gastrointestinal dysfunction is unusual in the absence of radiation, and 5) continent urinary diversion is a viable long-term concept that provides a real alternative in terms of quality of life and self-image for the patient undergoing urinary diversion.

Adolescent↗
PubMed1988

Complications of the Kock pouch.

Over the past 41/2 years, 395 consecutive Kock pouch procedures have been performed by the urology faculty at the University of Southern California School of Medicine as an alternative to conventional cutaneous urinary diversion. This article reviews the early and late complications experienced in the 386 patients surviving the operation and describes in detail modifications in surgical technique designed to reduce the complication rate and the subsequent need for re-operation. We remain convinced that construction from ileum of a low-pressure, high-capacity internal reservoir with continent and nonrefluxing valves as originally described by Kock remains the ultimate technique for patients requiring permanent urinary diversion or for those requiring conversion from a pre-existing form of diversion.

Adolescent↗
PubMed1987

The incidence and significance of seminal vesicle invasion in patients with adenocarcinoma of the prostate.

The incidence and significance of seminal vesicle invasion in patients with adenocarcinoma of the prostate were determined in 139 patients who underwent radical prostatectomy. Of the 36 patients who had seminal vesicle invasion, 27 (75%) also had capsular invasion and 13 (43%) had lymph node metastases. Disease progression rates were 31% and 58% at 5 and 8 years, respectively. Survival rate at 5 years was 90.6% and at 8 years it was 83.7%. Of the 103 patients without seminal vesicle invasion, 21 (20.4%) also had capsular invasion and 11 (12%) had lymph node metastases. Disease progression rates were 2.5% and 15.7% at 5 and 8 years, respectively. Survival rate at both 5 and 8 years was 98.4%. These data suggest that the majority of patients with seminal invasion do not have lymph node metastases on presentation and thus they cannot be detected by lymph node dissection before radical prostatectomy. Improved techniques for preoperative detection of seminal vesicle invasion can assist in patient selection for surgery and improve the results of radical prostatectomy.

Adenocarcinoma↗
PubMed1987

Preoperative magnetic resonance imaging of vena caval tumor thrombi: experience with 5 cases.

Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical removal of renal or adrenal tumors with direct extension of the tumor into the vena cava. Of the patients 4 had renal cell carcinoma and 1 had adrenocortical carcinoma. Magnetic resonance imaging staged correctly the level of vena caval tumor thrombus involvement in 4 patients and missed the presence of right atrial tumor extension in 1. This noninvasive imaging modality can be used instead of contrast venography in most patients to assess the presence and extent of vena caval tumor involvement by renal cell carcinoma. Contrast venography should be used for those patients with suspected cardiac involvement and for those whose tumor thrombus extent remains unclear after magnetic resonance imaging.

Adrenal Cortex Neoplasms↗
PubMed1987

Quality of life survey of urinary diversion patients: comparison of ileal conduits versus continent Kock ileal reservoirs.

There has been a recent marked increase in interest in continent urinary diversions. While considerable time has been spent on the technical aspects of these diversions the psychological impact has not yet been fully explored. We describe an extensive survey that was conducted among 100 consecutive adults (87 respondents) who had undergone urinary diversion via an ileal conduit and 100 consecutive adults (85 respondents) in whom a continent Kock ileal reservoir was created during the last 3 to 5 years at our university by the same surgeons. The Kock pouch patients were stratified further into 63 with primary diversion and 22 who underwent conversion from previous conduit diversions. The survey consisted of a questionnaire that included a social and sexual survey, the Beck Depressive Inventory, the Profile of Mood States and a physical impact study. The results revealed that all patients surveyed generally were satisfied with the diversions and they had adapted reasonably socially, physically and psychologically. The key to adaptation seemed to be a detailed, realistic preoperative education about the type of diversion used. Patients with ileal conduit diversions had the lowest expectations of the form of diversion as defined by the preoperative awareness of the need to wear an external ostomy appliance with its associated inconveniences and change in the external body image. Postoperatively, ileal conduit patients also had the poorest self images as defined by a decrease in sexual desire and in all forms of physical contact (sexual and nonsexual). The subset of patients who underwent conversion from conduit diversions to Kock pouches, however, were statistically the most satisfied, and they were the most physically and sexually active. We conclude that the Kock continent urostomy offers an important alternative to noncontinent forms of diversion.

Adaptation, Psychological↗