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Biomedical subjects

G S Gerber

Publications and source records attributed to G S Gerber.

At least 73 records · Page 4Linked to original sources
PubMed1994

Results of conservative management of clinically localized prostate cancer.

BACKGROUND: The selection of treatment for patients with localized prostate cancer requires reliable information about the outcome of conservative management. Previous studies of this question are generally considered unreliable because they were uncontrolled and nonrandomized. METHODS: We performed a pooled analysis of 828 case records from six nonrandomized studies, published since 1985, of men treated conservatively (with observation and delayed hormone therapy but no radical surgery or irradiation) for clinically localized prostate cancer. A Cox regression analysis was performed to determine which factors influenced survival among patients who did not die of causes other than prostate cancer (disease-specific survival). Kaplan-Meier curves for overall and metastasis-free survival among such patients were compared with use of the log-rank method and the Mantel-Haenszel test. RESULTS: Factors that had a significant effect on disease-specific survival were grade 3 tumors (risk ratio, 10.04), residence in Israel (risk ratio, 2.48) or New York (risk ratio, 0.37), and age under 61 years (risk ratio, 0.32). Ten years after diagnosis, disease-specific survival (with data on men who died from causes other than prostate cancer censored) was 87 percent for men with grade 1 or 2 tumors and 34 percent for those with grade 3 tumors; metastasis-free survival among men who had not died of other causes was 81 percent for grade 1, 58 percent for grade 2, and 26 percent for grade 3 disease. These findings were not affected by the inclusion of men who had early-stage cancer, were older, had worse-than-average health, or underwent delayed radiation therapy or radical prostatectomy. CONCLUSIONS: The strategy of initial conservative management and delayed hormone therapy is a reasonable choice for some men with grade 1 or 2 clinically localized prostate cancer, particularly for those who have an average life expectancy of 10 years or less. New treatment strategies are needed for men with grade 3 prostate cancer.

Aged↗
PubMed1994

Laparoscopic retroperitoneal lymphadenectomy: multi-institutional analysis.

Modified unilateral laparoscopic retroperitoneal lymph node dissection was attempted in 20 patients with nonseminomatous testicular cancer. The procedure was completed in 18 men at a median operative length of 6 hours. Median estimated blood loss was 250 cc and median number of lymph nodes removed was 14.5. Nodal disease spread was noted in 3 of 18 patients (17%). Most patients were hospitalized for 3 days or less and had returned to normal activity levels within 2 to 3 weeks. Antegrade ejaculation was preserved in all 20 patients. Significant complications occurred in 6 of 20 patients (30%), with bleeding being the most common adverse event encountered. In 2 patients an abdominal incision and completion of the procedure by open retroperitoneal lymph node dissection were required due to significant bleeding following injury to the gonadal vessels. With a median followup of 10 months (range 2 to 25), 2 men had pulmonary disease recurrence and none had abdominal recurrence. Laparoscopic retroperitoneal lymph node dissection can be completed successfully in patients with stage I testicular cancer and may be most appropriate in those with limited risk of metastatic disease spread. The morbidity may be largely attributed to a steep learning curve. The efficacy of laparoscopic retroperitoneal lymph node dissection compared with standard techniques and determination of its role in patients with testicular cancer will require longer followup in larger groups of patients.

Adolescent↗
PubMed1994

Laparoscopic pelvic lymph node dissection: a review of 103 consecutive cases.

Laparoscopic pelvic lymph node dissection is a recently introduced technique for the surgical evaluation of the regional pelvic lymph nodes in genitourinary malignancies. We report the results of a laparoscopic pelvic lymph node dissection performed on 103 consecutive patients for staging of clinically localized prostatic, bladder and penile carcinomas. In 20 patients (group 1) the adequacy of the laparoscopic pelvic lymph node dissection was evaluated with a subsequent open dissection. In this group 87 to 95% of the lymph nodes within a modified template could be reliably removed laparoscopically. In 73 patients (group 2) laparoscopic pelvic lymph node dissection was performed as a solitary operation. Mean hospitalization was 1.6 +/- 2.4 days, while postoperative narcotic requirements were minimal. Mean operative time for bilateral laparoscopic pelvic lymph node dissection was 156 +/- 41.2 minutes. The overall complication rate in these 2 groups was 13.5%. Group 3 includes 10 patients (9.7% of the total) in whom laparoscopic pelvic lymph node dissection was unsuccessful. The minimally invasive surgical techniques of laparoscopic pelvic lymph node dissection seem to provide adequate staging accuracy in patients with genitourinary neoplasms. The complication rate and recovery period appear to be decreased relative to those for open surgical lymphadenectomy.

Adenocarcinoma↗
PubMed1994

Carcinoma in situ of the penis.

Bowen's disease, erythroplasia of Queyrat and bowenoid papulosis are uncommon disorders of the anogenital skin that may be confused with a variety of other lesions. While all appear histologically as carcinoma in situ and are strongly associated with human papillomavirus infection, only Bowen's disease and erythroplasia of Queyrat have been demonstrated to lead to the development of invasive squamous cell carcinoma. In contrast, bowenoid papulosis has a completely benign course with no present evidence suggesting the potential for malignant degeneration. The standard treatment for all 3 lesions in surgical excision, although use of the carbon dioxide or neodymium:YAG laser appears to be effective at obtaining local control of disease while achieving an excellent cosmetic result. Alternative treatments with micrographic surgery, topical 5-fluorouracil or radiotherapy have a more limited role. It is important to remember that adequate biopsies are always necessary to ensure a complete and accurate diagnosis, and allow for proper treatment and followup, as well as appropriate counseling of sexual partners.

Bowen's Disease↗
PubMed1994

Fournier's gangrene secondary to intra-abdominal processes.

We report 2 cases of necrotizing fasciitis of the perineum, perianal area, and male genitalia (Fournier's gangrene) that arose secondary to intra-abdominal infectious processes (ruptured appendicitis and diverticulitis). Management consisted of immediate debridement of necrotic tissue, exploratory laparotomy, and diverting colostomy. The presence of an acute abdominal process was not immediately evident on initial evaluation of either patient. This demonstrates the critical importance of considering intra-abdominal infection in patients with Fournier's gangrene when the more commonly seen urinary tract, perirectal, and traumatic causes are not readily apparent.

Aged↗
PubMed1994

Endopyelotomy: patient selection, results, and complications.

The popularity of minimally invasive surgical techniques, such as endopyelotomy, has increased markedly among urologists in recent years. While it was initially thought that this procedure was best utilized in patients with secondary UPJ obstruction, recent evidence suggests that endopyelotomy should be considered in the majority of cases. The primary contraindication to endoscopic incision of the UPJ is a long stricture, although a large redundant renal pelvis and the presence of crossing lower pole vessels are considered by some to be relative contraindications as well. Although the majority of surgeons have used a percutaneous, antegrade approach to endopyelotomy, successful results also have been reported with a ureteroscopic, retrograde technique. With the development of modified ureterotomes and balloon-cutting devices, the retrograde approach eventually may become the preferred method since no skin incision or external drainage are needed. The role of endopyelotomy in children remains undefined. While successful results have been reported in infants, the relative morbidity and long-term success of open pyeloplasty in this age group are excellent, thus limiting the relative advantage of an endoscopic approach. However, there may be a role for endopyelotomy in older children and in those patients with secondary obstruction who have failed open surgery. From a technical standpoint, there are several minor variations in surgical technique and postoperative management that are important. The success rate of endopyelotomy using a cold knife or small electrocautery probe appears to be comparable, and the use of cautery may allow for precise control of minor bleeding thus decreasing the risk of complications. However, larger electrodes may induce greater tissue reaction leading to fibrosis and should be avoided. Postoperatively, most authors prefer a tapered double-pigtail stent which allows for adequate internal drainage while avoiding excessive pressure within the distal ureter. While successful results have been reported with stenting intervals of only four days, it is generally recommended that the stent be left in place for a minimum of six weeks following endoscopic incision of the UPJ. Overall, endopyelotomy is associated with shortened hospitalization, more rapid return to normal activity levels, and decreased morbidity compared with open pyeloplasty. The success rates reported with endopyelotomy approach those achieved with open surgery, and it is likely that an endoscopic approach to UPJ obstruction will assume an increasingly greater role in the future.

Adolescent↗
PubMed1994

Conservative approach to the management of prostate cancer. A critical review.

Conservative management of patients with early prostate cancer has received increased attention in recent years. While this approach allows patients to avoid the potential side effects associated with radiation therapy and radical prostatectomy, many men who live 10 years or longer will develop advanced disease with watchful waiting. These patients are likely to suffer significant morbidity due to local or distant cancer progression. Conversely, some patients who receive aggressive initial treatment for localized prostate cancer will also experience morbidity secondary to recurrent or progressive disease despite early attempts at curative therapy. Therefore, the need for further prospective study to evaluate the relative effectiveness and morbidity of conservative management in comparison with radiation therapy and radical prostatectomy is evident.

Adenocarcinoma↗
PubMed1993

Disease-specific survival following routine prostate cancer screening by digital rectal examination.

OBJECTIVE: To assess prostate cancer mortality in men undergoing routine screening by routine digital rectal examination. DESIGN: Cohort study with a median follow-up period of 75 months. SETTING: Population consisted of volunteers at a university clinic and men in an institutional health maintenance clinic. PATIENTS: Fifty-six men with a mean age of 65 years (range, 52 to 79 years) diagnosed with prostate cancer. INTERVENTIONS: Patients treated initially by observation, external or interstitial radiotherapy, radical prostatectomy, hormone therapy, or combination. MAIN OUTCOME MEASURES: Kaplan-Meier analysis of time to local progression, distant metastases, death from all causes, and death from prostate cancer. Mantel-Haenszel log-rank statistic was used to compare outcome in men diagnosed on initial examination with those diagnosed on subsequent examinations. RESULTS: Clinically localized prostate cancer was diagnosed in 73% during an initial examination and 83% on subsequent examinations and (P.35). Grade distribution of tumors was similar in both groups. Overall 5 and 10 year survival of all cancer patients was 85% and 67%, respectively. Death from prostate cancer was 8% (3/38) in men diagnosed on initial examination and 33% (6/18) during subsequent examinations. Five- and 10-year disease-specific survival was 97% and 86%, respectively, for men diagnosed during the first rectal examination compared with only 81% and 57%, respectively, for men diagnosed on subsequent rectal examinations (P = .02). CONCLUSION: Routine screening for prostate cancer by annual digital rectal examination alone may be insufficiently frequent and/or sensitive to prevent significant mortality from this disease [corrected].

Aged↗
PubMed1993

Current and future roles of laparoscopic surgery in urology.

There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.

Biomarkers, Tumor↗
PubMed1993

Buschke-Lowenstein tumor: therapeutic options including systemic chemotherapy.

Verrucous carcinoma of the penis (Buschke-Lowenstein tumor) is a rare variant of squamous cell carcinoma which has been reported to have limited potential for metastatic disease. We report on 2 patients who presented with locally advanced disease after prolonged intervals of neglect. In both cases, the disease was locally aggressive with extensive tissue destruction. In 1 patient, after failure to achieve tumor control with repeated aggressive surgical excision, systemic chemotherapy using bleomycin, cisplatin, methotrexate, and leucovorin led to a complete pathologic response. We believe this is the first reported case in which systemic chemotherapy has been used to successfully treat verrucous carcinoma of the penis. Surgical excision alone was successful in achieving local disease control in the second patient.

Adult↗
PubMed1993

Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents.

Of 6,275 pregnancies seen at our institution over a two-year period, 5 patients required operative intervention for acute urinary obstruction unresponsive to medical management. Ultrasonography was able to definitively diagnose the presence of an obstructing calculus in 4 of 5 patients. Using ultrasound guidance, 7 indwelling ureteral stents were successfully placed with local anesthesia supplemented by intravenous sedation. Complications consisted of distal stent migration in 1 patient. This method of management was successful for symptomatic nephrolithiasis in a pregnant renal transplant patient. Endoscopic placement of ureteral stents under ultrasound guidance is an effective, safe method of urinary decompression, with no radiation risks imparted to the mother or fetus. Definitive therapy then can be safely deferred to the post-partum period.

Acute Disease↗
PubMed1993

Endourological management of upper tract urothelial tumors.

Advances in ureteroscopic and percutaneous techniques have made it possible to treat many upper tract malignancies by conservative, parenchyma sparing surgery. Percutaneous techniques generally allow for easier and better access to the renal pelvis and improved tumor resection. However, concerns for tumor spillage and nephrostomy tract seeding make the ureteroscopic approach best for initial management of accessible renal pelvic lesions, particularly when the diagnosis is unclear. Ureteral tumors, especially those arising in the lower third of the ureter, are technically easier to treat endoscopically than are renal pelvic tumors. Fulguration or laser photocoagulation may be used to ablate the tumor following cold-cup biopsy for histological diagnosis. Supplemental therapy using laser treatment of the tumor base, and postoperative instillation of BCG and mitomycin C offer great potential benefit in terms of improved tumor control. Confirmation of such benefit awaits the results of larger trials. Presently, standard nephroureterectomy remains the procedure of choice for most transitional cell carcinomas of the upper urinary tract in patients with a normal contralateral kidney. For those with a solitary kidney, renal insufficiency, bilateral tumors or severe intercurrent disease preventing a major open operation conservative management using endoscopic techniques is a viable alternative. Overall, it appears that grade and stage are far more important determinants of long-term out-come than the type of operation in those with transitional cell carcinoma of the upper urinary tract. For this reason, some physicians have recommended conservative management of low grade, noninvasive lesions even in the face of a normal opposite kidney. However, the majority of patients with upper tract urothelial tumors are best treated by nephroureterectomy, which leads to a low risk of local recurrence and obviates the need for rigorous postoperative upper tract surveillance.

Carcinoma, Transitional Cell↗
PubMed1993

Female urinary tract fistulas.

Urinary tract fistulas in women are an uncommon complication of a variety of surgical procedures. However, such fistulas lead to significant patient and physician distress, and have important medicolegal implications. Successful repair of urinary tract fistulas requires careful preoperative evaluation and adherence to basic surgical principles. A variety of approaches and techniques may be used, and the choice of procedure is less important than achieving adequate resection of fibrosis with watertight, tension-free closure of well vascularized tissues in layers. Interposition grafts of omentum, muscle, peritoneum and labial fat may be used in recurrent, complicated or radiated fistulas, and add significantly to the rate of success. Overall, successful repair of urinary tract fistulas can be achieved in the majority of cases.

Female↗
PubMed1993

Value of prostate cancer screening.

The challenge for the future is to establish whether screening will lead to a decrease in prostate cancer mortality. This issue can only be settled by the performance of a properly controlled, randomized, prospective study. Due to the generally slow progression rate of prostate cancer, such a study will require an at least 15-year follow-up of a large number of men. Because of the increasing widespread use of prostate-specific antigen in the United States, finding a large control population who will not be screened for an extended period of time may no longer be possible. Nevertheless, such a study is clearly needed and is being undertaken by the National Institutes of Health. In the meantime, it is important that physicians counsel patients regarding the relative benefits and risks of screening so that they can make their own judgments regarding the aggressiveness with which the diagnosis of prostate cancer should be pursued.

Humans↗
PubMed1993

The role of laparoscopic lymphadenectomy in staging and treatment of urological tumours.

Laparoscopic lymphadenectomy for managing a variety of urological malignancies is likely to continue to increase in popularity. It is essential that the role of these procedures be critically evaluated to ensure that they offer significant benefit without added morbidity as compared with standard techniques. The challenge for the future is to better define selection criteria for laparoscopic surgery, particularly in men with clinically localized prostate cancer, so that both staging methods and therapy can be tailored to the individual patient.

Carcinoma, Transitional Cell↗
PubMed1993

Early diagnosis of prostate cancer.

Prostate cancer continues to be a leading cause of cancer death in American men. Since no studies have yet been reported that demonstrate a reduction in prostate cancer mortality, widespread prostate cancer screening by any modality must be considered experimental. Although, for an individual patient, screening may appear to have great potential benefit, when applied on a large scale, both the expense and potential morbidity could have a substantially negative impact on health care. These issues are too often ignored by enthusiasts of screening, but inevitably they will need to be addressed. Can society afford the expense of screening even if it does lead to reduced mortality? In addition, if health care resources are limited, is prostate cancer screening the best use of these funds? Finally, until the efficacy of prostate cancer screening is demonstrated by properly performed studies, it is essential that patients be told of both the potential risks and benefits of screening so that a fully informed decision can be made. Alternatively, should patients only be told that screening is clearly in their best interest? Currently, these questions have not been adequately addressed.

Biomarkers, Tumor↗
PubMed1993

The application of laparoscopy to retroperitoneal surgery in urology.

The application of minimally invasive laparoscopic surgical techniques has provided the urologist with access to retroperitoneal structures previously available only through an abdominal incision. The enhanced visualization provided by video-imaging as well as the ease of access to the retroperitoneum through an incision in the posterior peritoneal envelope has facilitated the manipulation of many retroperitoneal organs. In particular these techniques have been applied to the clinical management of several urologic malignancies, such as adenocarcinoma of the prostate, transitional cell carcinoma of the bladder, and squamous cell carcinoma of the penis. A transperitoneal laparoscopic pelvic lymphadenectomy appears to provide adequate surgical staging of regional pelvic lymph nodes in these malignancies, while providing the patients with reduced morbidity. Additionally, transperitoneal access may be accomplished for an internal spermatic vein ligation, as well as approaches to the kidney, ureter and retroperitoneal lymph nodes. The surgical options are limited only by the availability of the instrumentation and the creativity of the surgeon. However, the indications for these procedures remain unclear and must await further information regarding actual benefits in the form of reduced patient morbidity and cost. The challenge for the future is to more completely define the indications and selection criteria for laparoscopic surgery.

Humans↗