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Biomedical subjects

H N Winfield

Publications and source records attributed to H N Winfield.

At least 37 records · Page 2Linked to original sources
PubMed1997

Hip and knee replacement as a relative contraindication to laparoscopic pelvic lymph node dissection.

PURPOSE: We investigated the effect of lower extremity joint prostheses on subsequent laparoscopic pelvic lymph node dissection. MATERIALS AND METHODS: We reviewed the records and pathology studies of 5 patients who underwent laparoscopic pelvic lymph node dissection subsequent to total hip or knee replacement from 1990 through 1995. RESULTS: Four of the 5 laparoscopic operations were complicated, 3 were unsuccessful in obtaining bilateral pelvic lymph nodes and 2 required conversion to an open procedure. Examination of the lymph nodes revealed sinus histiocytosis in the 4 cases in which nodal tissue was removed. CONCLUSIONS: The increased risk of complications in certain patients with lower extremity joint prostheses may contraindicate attempted laparoscopic pelvic lymph node dissection.

Aged↗
PubMed1997

Laparoscopic pelvic lymph node dissection following definitive radiotherapy for carcinoma of the prostate.

PURPOSE: Laparoscopic pelvic lymph node dissection is an effective and minimally invasive approach to the clinical staging of adenocarcinoma of the prostate. We report our experience with this technique in patients in whom full course pelvic radiotherapy had failed and who were being considered for salvage local therapy. MATERIALS AND METHODS: In 14 patients disease was staged by transperitoneal laparoscopic pelvic lymph node dissection performed for persistent adenocarcinoma of the prostate at least 20 months (average 49.5) following external beam radiotherapy and/or brachytherapy. All patients were healthy, had no evidence of metastatic disease and were considered to be candidates for salvage therapy. RESULTS: A total of 13 patients underwent successful laparoscopic pelvic lymph node dissection while 1 sustained an enterotomy requiring conversion to open surgery. The normal surgical planes were more difficult to dissect, with the obturator lymph node packets appearing smaller and more fibrotic than in nonirradiated patients, yielding an average of 7.1 total nodes. Average operative time was 167 minutes and postoperative hospitalization was comparable to reported series of nonirradiated patients. Four patients (28%) with metastatic pelvic lymph nodes underwent subsequent orchiectomy. Nine patients with negative lymph nodes underwent ultrasound guided transperineal placement of radioactive gold or palladium seeds. One patient underwent salvage radical retropubic prostatectomy. CONCLUSIONS: Laparoscopic pelvic lymph node dissection following full course pelvic irradiation is technically feasible, albeit more difficult than in nonirradiated patients. This approach appears to be an excellent minimally invasive technique for the clinical restaging of persistent adenocarcinoma of the prostate in patients being considered for salvage therapy.

Adenocarcinoma↗
PubMed1997

Role of laparoscopic surgery in pediatric urology.

OBJECTIVES: In our clinic, laparoscopy was introduced in 1987 for the exploration of non-palpable testes and since 1991 it has also been applied with therapeutic aims. We present our experience with this minimally invasive technique in pediatric patients. PATIENTS AND METHODS: Between May 1987 and September 1996, 219 laparoscopic procedures were performed in children. All children received general anesthesia. Positioning of the patient on a rotatable and tiltable operating table is very important. RESULTS: All laparoscopic interventions were well tolerated in children. The operative time for exploration of a nonpalpable testis ranged from 10 to 30 min, and for varix ligation from 15 to 30 min. In nephrectomy and nephroureterectomy cases 80-150 min were required. The excision of the urachal remnant and the drainage of lymphocele took between 30 and 70 min. No immediate postoperative complications were observed. Mobilization and oral intake were routinely carried out on the day of surgery. The children required little or no postoperative pain medication. CONCLUSION: Laparoscopy has been found to be the most reliable diagnostic tool in evaluating nonpalpable testes within the pediatric population. This approach enables subsequent therapy of laparoscopic orchiectomy, primary laparoendoscopic orchidopexy, or laparoscopically assisted two-stage Fowler-Stephens maneuver. Laparoscopic varix ligation is a simple and highly effective treatment modality for the pubescent male with a symptomatic varicocele. To date, the recurrence rate is 1.8% based on 80 patients followed for over 1 year. Fenestration of lymphoceles following renal transplantation has been found to be as efficaciously treated with laparoscopy as with open surgery. Laparoscopic nephrectomy and/or nephroureterectomy are technically demanding procedures and should only be performed by an experienced laparoscopic surgical team to minimize the complication rate. At the present time, the intraoperative costs of laparoscopic surgery are greater than with open surgery due to the use of disposable instrumentation and longer operating room times. However, minimally invasive surgery continues to gain a greater and more important role in the field of pediatric urology.

Adolescent↗
PubMed1996

Laparoscopic urethral sling for treatment of intrinsic sphincter deficiency.

The surgical treatment of intrinsic sphincter deficiency, or Type III genuine stress urinary incontinence, has traditionally been accomplished by sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. We developed a laparoscopic approach for the performance of a sling cystourethropexy as an alternative to the open approach and herein describe our experience. We have found that a laparoscopic sling cystourethropexy is feasible, but at the present time, we have been unable to demonstrate any significant advantages to the patient in terms of decreased cost or convalescence compared with the open vaginal sling cystourethropexy.

Female↗
PubMed1996

Carbon dioxide homeostasis during transperitoneal or extraperitoneal laparoscopic pelvic lymphadenectomy: a real-time intraoperative comparison.

The primary goal of this study was to evaluate differences in carbon dioxide metabolism between patients undergoing transperitoneal or extraperitoneal laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (CaP). Eighteen candidates undergoing L-PLND were divided between the transperitoneal (N = 12) and extraperitoneal (N = 6) approaches. End-tidal partial pressure of CO2 (PeCO2) and minute volume of expired CO2 (VCO2) were considered indicators of CO2 absorption. These two parameters were monitored intraoperatively utilizing a metabolic cart and Ohmeda Rascal-II. The cardiostimulatory effect of increasing serum CO2 and the ventilatory countermeasures used to correct the iatrogenic hypercapnia associated with CO2 insufflation were also measured. With the exception of the region of CO2 insufflation, the operative procedure and perioperative care were identical for the two groups. Preoperative patient characteristics were similar. The mean time of CO2 insufflation was 136 minutes for the transperitoneal group and 120 minutes for the extraperitoneal group. The absorption of CO2 was significantly greater and more rapid during extraperitoneal L-PLND. This may be attributable to more profound CO2 absorption from the parietal peritoneal surface compounded by subcutaneous CO2 emphysema. Disruption of microvascular and lymphatic channels during the development of the extraperitoneal working space facilitates direct CO2 absorption into the intravascular space. A minor increase in heart rate and systolic blood pressure was noted during CO2 insufflation. In all but one patient (extraperitoneal group), hypercarbia and acidemia were prevented by an increased ventilatory rate. The potential dysrhythmogenicity of hypercarbia may contraindicate the extraperitoneal approach in patients with cardiopulmonary disease.

Adenocarcinoma↗
PubMed1996

Comparative financial analysis of laparoscopic pelvic lymph node dissection performed in 1990-1992 v 1993-1994.

In 1994, it was reported that laparoscopic pelvic lymph node dissection (L-PLND) was US $1350 more expensive than open pelvic lymph node dissection (O-PLND) for the staging of prostate cancer. Despite the lower postoperative expenses associated with L-PLND, the intraoperative expenditures were 52% higher, primarily because of the prolonged operating time and the cost of disposable instrumentation. The objective of the present study was to determine if, with increasing laparoscopic experience and a more competitive surgical supply market, the intraoperative as well as the overall hospital expenses would diminish. The study population consisted of 105 men who underwent staging L-PLND for cancer of the prostate. Group I was composed of 50 patients who underwent surgery between 1990 and 1992, and Group II consisted of 55 patients operated on in 1993 and 1994. All hospital-related expenses were reorganized into preoperative, intraoperative, and postoperative and subsequently corrected for inflationary changes to a base year of 1993-1994. The total overall expenses of the two groups were similar, differing by only $65. Despite a lowering of preoperative and postoperative expenses in the 1993-1994 group by 112% and 31%, respectively, the intraoperative expenses were still $571 higher. The operative time decreased by 19 minutes in the contemporary group, but the expense of surgical supplies continued to increase up to $910 (104%) more than the 1990-1992 group. It is hoped that the use of "laparoscopic kits" as well hospital equipment consortiums will help slow the escalating costs of surgical care. However, it is the responsibility of the laparoscopic surgeon to demonstrate that these procedures are as safe, efficient, and cost-effective as their open counterpart.

Aged↗
PubMed1996

Sequential laparoscopic bladder diverticulectomy and transurethral resection of the prostate.

The surgical treatment of prostatic obstruction associated with a clinically significant bladder diverticulum has classically combined open diverticulectomy with relief of the bladder outlet obstruction. This report demonstrates that this result may be efficiently achieved by performing transurethral surgery followed immediately by laparoscopic excision of the diverticulum. As assessed by a retrospective comparison with four open bladder diverticulectomies combined with transurethral resection of the prostate, laparoscopic diverticulectomy markedly reduces the postoperative and convalescence period. The overall financial saving that ensues may benefit both the patient and the healthcare system. Sequential laparoscopic bladder diverticulectomy and transurethral resection of the prostate illustrates the increasing possibilities of minimally invasive surgery.

Aged↗
PubMed1996

Laparoscopic marsupialization of pelvic lymphoceles.

Pelvic lymphoceles are a known complication of urologic surgery. Often, these are small and asymptomatic and require no specific therapy. When large or symptomatic, the treatment of choice is controversial, but includes needle aspiration, percutaneous drainage, sclerotherapy, open surgical marsupialization or, most recently, laparoscopic marsupialization. The laparoscopic technique described herein has been performed successfully by many urologists and is accepted as a standard laparoscopic procedure. Because of its efficacy and its low morbidity, laparoscopic marsupialization may be considered a first-line treatment for pelvic lymphoceles.

Humans↗
PubMed1995

Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach.

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Adult↗
PubMed1995

Laparoscopically assisted penile revascularization for vasculogenic impotence.

Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.

Adult↗
PubMed1995

Laparoscopic urologic surgery. The financial realities.

Since 1990, laparoscopic surgery has gained an important role in the specialty of urology. This article provides a financial analysis of the three most common urolaparoscopic procedures compared with their open surgical counterpart. The intraoperative costs of laparoscopic surgery are more expensive, but the postoperative expenses are less compared with open surgery. The financial ramifications of a shorter period of convalescence following laparoscopic surgery must be considered.

Cost of Illness↗
PubMed1994

Comparative financial analysis of laparoscopic versus open pelvic lymph node dissection for men with cancer of the prostate.

Laparoscopic pelvic lymph node dissection has been applied as a minimally invasive staging technique for men with prostate cancer. This procedure has been shown to shorten markedly postoperative hospitalization, decrease analgesic requirements and shorten convalescence period compared to open pelvic node dissection. However, the laparoscopic procedure takes longer to perform and many disposable instruments are used, thus increasing the cost. We determine the overall cost of laparoscopic versus open pelvic lymph node dissection. Between January 1989 and April 1992, 61 men underwent only staging pelvic lymph node dissection for cancer of the prostate at a single university teaching hospital. Of these patients 11 and 50 underwent open and laparoscopic pelvic lymph node dissection, respectively. Information from the hospital business office was reorganized into preoperative, intraoperative and postoperative expenses. All individual charges were transformed up or down to the dollar amounts of the 1990 to 1991 fiscal year so as to correct for inflationary changes. Preoperative costs were not significantly different between the 2 operative approaches. Intraoperative expenses were 52% greater if laparoscopic pelvic lymph node dissection was performed and can be explained by the longer operative times and use of disposable instrumentation. However, the postoperative period lasted an average of 1.61 days following laparoscopic pelvic lymph node dissection. Postoperative nursing and analgesic requirements were significantly more for patients undergoing open pelvic lymph node dissection. The overall postoperative costs following open pelvic lymph node dissection were 280% more expensive than for the laparoscopic procedure. The overall total costs were approximately $1,250 more for laparoscopic pelvic lymph node dissection. Wages lost or earned during this period and rapid return to normal activity following laparoscopic pelvic lymph node dissection would, in our opinion, justify this additional cost.

Aged↗
PubMed1994

Laparoscopic excision of urachal cyst.

The treatment of choice for persistent urachal anomaly is radical surgical excision intended to prevent complications, notably malignancy in a retained remnant. We report a case of the radical laparoscopic excision of an infected urachal cyst. This effective alternative to an open technique has the advantages inherent in minimally invasive surgery.

Adolescent↗
PubMed1994

Laparoscopic approaches to the treatment of intrinsic urethral weakness (type III stress urinary incontinence).

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

Animals↗