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Biomedical subjects

J Stuart Wolf

Publications and source records attributed to J Stuart Wolf.

At least 37 records · Page 2Linked to original sources
PubMed2005

Retroperitoneoscopic radical and partial nephrectomy in the patient with cirrhosis.

PURPOSE: In patients with cirrhosis and a renal mass options may be limited by medical disease and the surgical difficulties associated with portal hypertension. We describe a retrospective review of patients with cirrhosis with renal masses who underwent radical or partial nephrectomy through a retroperitoneoscopic approach. MATERIALS AND METHODS: Ten consecutive patients, including 4 men and 6 women, with cirrhosis, of whom 2 had undergone liver transplantation, underwent radical (7) or partial (3) nephrectomy for a total of 5 right and 5 left renal neoplasms via the retroperitoneoscopic approach at our institution from March 2002 to February 2004. Recovery data were prospectively obtained and other information was gathered retrospectively from the medical record. RESULTS: Average patient age was 58 years and average American Society of Anesthesiology score was 2.8. Average renal tumor size for radical and partial nephrectomy was 4.6 (range 2.9 to 7) and 1.8 cm (range 1.3 to 2.3), respectively. Operative time was 140 to 315 minutes (median 172) and estimated blood loss was 100 to 5,000 ml (median 225). One patient required open conversion due to hemorrhage from left portosystemic venous communications. Mean postoperative hospitalization was 1.5 days (range 1 to 6). CONCLUSIONS: Although retroperitoneoscopic surgery avoids many surgical dangers associated with portal hypertension and it is our preferred approach to renal surgery in patients with cirrhosis, significant portosystemic venous communications exist in the retroperitoneum, especially on the left side, and they still lead to substantial blood loss in some patients.

Blood Loss, Surgical↗
PubMed2005

Intermediate followup of hand assisted laparoscopic nephroureterectomy for urothelial carcinoma: factors associated with outcomes.

PURPOSE: We report our experience with hand assisted laparoscopic (HALS) nephroureterectomy and describe the associations of preoperative, operative and pathological factors with outcome. MATERIALS AND METHODS: HALS nephroureterectomy was performed in 54 consecutive patients using modified transurethral resection of the ureteral orifice (TURUO) or a 1 port transvesical endoscopic cuff technique for the distal ureter in all except 8. Data were collected prospectively and retrospectively, and followup was distinguished for bladder, contralateral upper tract and nonurothelial (local recurrence and distant metastases) sites. RESULTS: The endoscopic cuff was associated with significantly shorter mean operative time than the transurethral resection of the ureteral orifice method (234 vs 295 minutes, p = 0.002) but the comparison was confounded by the effect of experience. With 28% of patients having stage II or greater tumors and 49% having high grade bladder disease, contralateral upper tract and nonurothelial recurrences developed in 55%, 11% and 25% of evaluable patients at a median followup of 25.1, 24.4 and 24.9 months, respectively, in those without recurrence. At a median followup of 25.0 months cancer specific survival was 94%, 86% and 80% at 1 to 3 years, respectively. Three-year cancer specific survival was 100% in patents with grade 1 or 2, or stage 0 or I tumors but only 57% and 36% in patients with grade 3 and stage II or IV tumors, respectively. CONCLUSIONS: HALS nephroureterectomy is associated with 3-year outcomes that are strongly associated with stage and grade. We prefer the endoscopic cuff method for the distal ureter because it is performed after nephrectomy, does not require patient repositioning and is expedient.

Aged↗
PubMed2005

Venous thrombosis prophylaxis for urological laparoscopy: fractionated heparin versus sequential compression devices.

PURPOSE: Venous thromboembolism (VTE) is a significant postoperative complication. Common methods of VTE prophylaxis include subcutaneous fractionated heparin (FH) and lower extremity sequential compression devices (SCD). There is no conclusive evidence supporting 1 method compared to the other for urological laparoscopy. We examined the rates of postoperative hemorrhagic and thrombotic complications after laparoscopic urological procedures in patients treated with FH or SCD as VTE prophylaxis. MATERIALS AND METHODS: A prospective database augmented by retrospective chart review included all patients who underwent urological laparoscopic surgery of the upper retroperitoneum at our institution from June 2000 to December 2002. Patients nonrandomly received FH or SCD as VTE prophylaxis beginning on the day of surgery. RESULTS: A total of 344 patients were included in this study, 172 in the FH group and 172 in the SCD group. Thrombotic complications included VTE and/or pulmonary embolism. Hemorrhagic complications were minor or major, the latter requiring transfusion or other intervention. In both groups the rate of thrombotic complication was 2 of 172 (1.2%). The rate of hemorrhagic complication was 16 of 172 (9.3%) in the FH group, of which 12 of 172 (7.0%) were major. The hemorrhagic complication rate was 6 of 172 (3.5%), with 5 of 172 (2.9%) being major in the SCD group. CONCLUSIONS: After urological laparoscopy of the upper retroperitoneum, subcutaneous fractionated heparin is associated with increased hemorrhagic complications (p = 0.045), without a reduction in thrombotic complications (p >0.999), compared with sequential compression devices.

Bandages↗
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

Fibrin glue v sutured bolster: lessons learned during 100 laparoscopic partial nephrectomies.

PURPOSE: Laparoscopic partial nephrectomy (LPN) is performed with marked technical variations. We defined the limits of sutureless LPN and determined which closure technique is best in a particular situation. MATERIALS AND METHODS: During 100 consecutive LPNs fibrin glue products were used for closure in the first 75 (group 1) and sutured bolsters were applied when the collecting system (CS) or renal sinus was entered in the final 25 (group 2). RESULTS: In groups 1 and 2 hand assisted laparoscopy was used in 72% vs 40% of cases and hilar clamping was used in 27% vs 92%, respectively. Mean tumor size was 25 vs 26 mm, tumor depth was 11 vs 13 mm, distance to the renal sinus was 9 vs 5 mm, operating room time was 185 vs 210 minutes, estimated blood loss was 398 vs 247 cc and hospital stay was 2.9 vs 2.6 days in groups 1 and 2, respectively. Overall postoperative hemorrhage and urine leakage occurred in 9% and 2% of patients, respectively. Tumors associated with postoperative hemorrhage/leakage tended to be larger (35 vs 24 mm, p = 0.007) and closer to the renal sinus (0.5 vs 8.2 mm, p = 0.02). Postoperative hemorrhage or urine leakage occurred in 41% of the 17 patients in group 1 with CS or renal sinus entry but in only 2 of the 58 (3.4%) without entry (p <0.0001). In group 2 hemorrhage/leakage occurred in 11% of the 18 patients with CS or renal sinus entry (vs same subset in group 1, p = 0.04). CONCLUSIONS: LPN with closure using fibrin glue products provides adequate hemostasis when the CS or renal sinus is not entered. When the CS or renal sinus is entered, a sutured bolster is recommended.

Decision Trees↗
PubMed2005

Wound complications after hand assisted laparoscopic surgery.

PURPOSE: Hand assisted laparoscopic surgery (HALS) provides benefits similar to standard laparoscopy but generally requires a larger incision. We assessed the nature of and risk factors for incisional complications after HALS. MATERIALS AND METHODS: All patients who underwent HALS at our institution from February 1997 through December 2003 were included in a prospective and retrospective review to assess postoperative wound complications. Literature regarding wound complications associated with open surgery and standard laparoscopy was reviewed. RESULTS: A total of 424 consecutive procedures performed on 422 patients were evaluated. Postoperative HALS incision site complications included 29 infections (6.8%), 15 hernias (3.5%) and 2 dehiscences (0.5%). Multivariate logistic regression models revealed that HALS incision site hernias were associated with current or past tobacco smoking (6.0%, p = 0.04), with a trend toward significance for diabetes mellitus (14%, p = 0.07), male gender (5.3%, p = 0.08) and renal failure (16%, p = 0.08). HALS incision site infections were associated with omission of perioperative antibiotics (13%, p = 0.007), obesity (12%, p = 0.03) and increased operative time (252 vs 222 minutes in patients with and without infection, respectively, p = 0.001). CONCLUSIONS: Our findings suggest that wound infections and hernias occur less frequently with HALS than with open surgery, but more often than with standard laparoscopy. Certain patient comorbidities (eg obesity), modifiable risk factors (eg smoking status) and procedural variables (eg omission of perioperative antibiotics or length of procedure) may adversely influence HALS wound complications. This information can be used to decide between HALS and standard laparoscopic approaches in particular patients.

Adult↗
PubMed2005

Devices for hand-assisted laparoscopic surgery.

A number of tools have been introduced to make laparoscopy easier. Some, such as 3D video systems, are interesting, and may add a modicum of benefit in some situations, but overall, have not had substantial impact. Others, such as robotic surgery, clearly have great potential, but are simply too expensive for widespread use. A few, such as the argon beam coagulator, are helpful only in particular situations. One technique has lived up to its billing and moreover, can be applied in almost any laparoscopic procedure, it is cost effective and actually does make laparoscopy easier. Hand-assisted laparoscopic surgery is a useful adjunct to the laparoscopic surgeon, and should be considered by all interested in this endeavor. This review summarizes the current hand-assistance devices and their use.

Equipment Design↗
PubMed2004

En bloc stapling of renal hilum during laparoscopic nephrectomy and nephroureterectomy.

OBJECTIVES: To evaluate the safety and advisability of en bloc mass stapling of the renal pedicle during difficult laparoscopic nephrectomy to avoid conversion to an open procedure. METHODS: A retrospective chart review was performed of 433 consecutive patients undergoing laparoscopic simple or radical nephrectomy or laparoscopic nephroureterectomy between August 1998 and July 2003 by two surgeons. In all cases of en bloc hilar ligation, a stapler was deployed across the renal hilum without individual dissection of the renal artery and vein. RESULTS: The overall incidence of en bloc ligation was 6.0% (26 of 433 patients). The reasons for en bloc ligation were a difficult hilar dissection and/or the appearance of the renal hilum in 21 cases and urgent ligation secondary to bleeding in 5 cases. No correlation was found between surgeon experience and the frequency of en bloc ligation. No immediate or short-term complications related to this method of hilar division were observed with a mean follow-up of 26 months. CONCLUSIONS: In this study, no cases of arteriovenous fistula development occurred after en bloc stapling of the renal pedicle. Long-term follow-up is needed, because arteriovenous fistula development may be a late complication of nephrectomy. Although we do not advocate the generalized use of en bloc division of the renal pedicle, early data suggest that en bloc stapling can be performed to avoid conversion to an open procedure with no related short-term complications.

Arteriovenous Fistula↗
PubMed2004

Selection of patients for hand-assisted laparoscopic surgery.

Each of the well-established approaches to laparoscopy-standard transperitoneal, standard retroperitoneal, and transperitoneal hand-assisted-has its advantages and disadvantages. In order to maximize efficiency and patient benefit, each approach should be used selectively. This paper offers recommendations for the selective use of the hand-assisted technique, which is particularly useful when intact specimen removal is required, the surgeon has limited experience, the situation is expected to be difficult (e.g., prior surgery, fibrosis, inflammation), or the patient's other medical comorbidities mandate a rapid procedure.

Humans↗
PubMed2004

Laparoscopic nephron-sparing surgery for a renal mass: 1-year minimum follow-up.

BACKGROUND AND PURPOSE: Because of the explosion of laparoscopy in urology coinciding with the excellent results of open nephron-sparing surgery (NSS) for small renal masses, laparoscopic NSS has become an alternative to an open surgical approach. We report our results with laparoscopic NSS in patients who have had a minimum of 1 year of follow-up. PATIENTS AND METHODS: All consecutive laparoscopic partial nephrectomies from November 1998 through February 2002 were assessed. The mean patient age, body mass index, and American Society of Anesthesiology score were 57.1 years, 28.5 cm/kg2, and 2.0, respectively. The procedures were performed using hand-assisted (N = 28) or standard (N = 12) laparoscopic techniques. Hospital records were reviewed in order to obtain operative, perioperative, and follow-up data. RESULTS: The median operating room time, estimated blood loss, and hospital stay were 184 minutes, 300 mL, and 2.0 days, respectively. No patients were converted to an open surgical procedure. Four patients (10%) required a blood transfusion, and one (2.5%) had a postoperative urinoma. The mean tumor size was 2.3 cm. Twenty-nine lesions were renal-cell carcinoma, and 11 were benign. With a mean CT scan follow-up of 100.0 weeks, there has not been any recurrence of renal-cell carcinoma. CONCLUSION: Laparoscopic NSS can be performed with acceptable complication rates, which will continue to decrease as newer methods of controlling hemostasis are developed. Although follow-up is fairly short, no renal-cell carcinoma recurrences have appeared. At this point in time, the oncologic efficacy of a laparoscopic approach appears to mirror that of the open surgical technique.

Carcinoma, Renal Cell↗
PubMed2004

Clinical skills acquisition for hand-assisted laparoscopic donor nephrectomy.

PURPOSE: The learning curve associated with laparoscopic surgery may be associated with higher patient risk, and in the setting of kidney donation such risk may be unacceptable. We characterize the learning curve for hand-assisted laparoscopic donor nephrectomy in the context of a urology training program, and establish a case volume threshold after which improvements in laparoscopic skill can be demonstrated. MATERIALS AND METHODS: The study included 245 consecutive laparoscopic cases, including 111 donor nephrectomies, performed in 2 (1/2) years to characterize various measures of experience. Documentation of resident involvement in each case was made by a single surgeon and collected prospectively. Outcomes assessed included operative time, blood loss and intraoperative complications. RESULTS: Of the 111 hand-assisted donor nephrectomies the resident was surgeon in 47%. Operative time proved a reliable and sensitive measure of surgeon experience. Increasing laparoscopic experience, as measured by several parameters, was associated with decreasing operative time (each p <0.02). Measurable improvements in laparoscopic skill were realized after participating in 13 (p = 0.007) or serving as surgeon in as few as 6 (p = 0.02) hand-assisted donor nephrectomies. Conversion (2%) and intraoperative complication rates (3%) were low. CONCLUSIONS: Skills for hand-assisted laparoscopic donor nephrectomy can be safely taught in the context of a urology training program independent of resident training level. We documented measurable improvements in laparoscopic skill as gauged by operative time. Our findings provide a basis by which expectations can be set for laparoscopic skill acquisition in the context of a residency program and for the laparoscopically naïve surgeon.

Clinical Competence↗
PubMed2004

Ex vivo ureteroscopic treatment of calculi in donor kidneys at renal transplantation.

PURPOSE: We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) as a means of rendering the donated kidney stone-free at live donor renal transplantation. MATERIALS AND METHODS: A total of 10 suitable kidney donors with small, unilateral nonobstructive calculi underwent live donor nephrectomy (8 open flank, 2 hand assisted transperitoneal). Immediately after cold perfusion, ExURS was performed in an iced saline solution. Access to the collecting system was via the ureteral stump. Calculi were either removed with endoscopic baskets and/or completely fragmented with Holmium laser lithotripsy. RESULTS: Access to the renal collecting system was technically successful in all cases. A total of 10 stones, ranging in largest diameter from 1 to 8 mm (average 5.2) were visualized. Of the kidneys 6 had solitary stones, 2 had 2 stones and 1 had no stone. Of 10 stones 9 were successfully removed and/or fragmented with an average procedure time of 6.5 minutes (range 3 to 28). Indwelling ureteral stents were placed at transplantation in 5 of 10 kidneys. There were no intra-operative or postoperative ureteral complications. At 1 month after transplant serum creatinine ranged from 0.9 to 2.7 mg/dl (average 1.5). At a mean followup of 33.2 months new stones have not formed in any recipients and at mean 36.4-month followup no new calculi have formed in the remaining kidney of any donors. CONCLUSIONS: ExURS is a technically feasible means of rendering a stone bearing kidney stone-free without compromising ureteral integrity or renal allograft function.

Adolescent↗
PubMed2004

Long-term outcome of laparoscopic decortication of peripheral and peripelvic renal and adrenal cysts.

PURPOSE: We determined the perioperative course of laparoscopic decortication of renal/adrenal cysts, and the association among cyst location, radiographic assessment and long-term symptom relief. MATERIALS AND METHODS: Laparoscopic cyst decortication was performed 18 times in 17 patients for pain relief (1 patient had bilateral cysts) at our institution between August 1996 and June 1999. Of these patients 13 had single and 5 had multiple cysts, and 9 each had peripelvic and peripheral (includes 2 adrenal) cysts. Questionnaires were prospectively distributed to these patients preoperatively, 2 and 6 weeks postoperatively, and annually thereafter. Preoperative and postoperative radiographs were reviewed. RESULTS: Perioperative morbidity measures were similar to those previously published with minimal complications and a rapid recovery. Cyst location had no significant perioperative impact. Symptom relief occurred in 78% of cases overall. Median final symptomatic followup was 52 months. Radiographic success (complete absence of cyst) was 89% for the peripheral cyst group and 55% for the peripelvic cyst group (p = 0.29). Median radiographic followup was 23 months. Symptomatic failure occurred in 40% of the 5 radiographic failures and 15% of the 13 radiographic successes (p = 0.53). CONCLUSIONS: Laparoscopic decortication is a safe, minimally invasive and effective treatment for symptomatic renal cysts with durable response. Although peripelvic cyst location can make certain cases more difficult or even technically not feasible, perioperative measures and long-term outcome are generally equivalent. Symptomatic failure after complete cyst resection, as measured radiographically, is likely due to a misdiagnosis of the cause of symptoms.

Adrenal Gland Diseases↗
PubMed2004

Intraoperative local anesthesia decreases postoperative parenteral opioid requirements for transperitoneal laparoscopic renal and adrenal surgery: a randomized, double-blind, placebo controlled investigation.

PURPOSE: To determine if local anesthesia decreases discomfort following laparoscopic upper retroperitoneal surgery, we performed a randomized, double-blind, placebo controlled study in which the port sites and hand assist incision were infiltrated with bupivacaine or placebo prior to surgery. MATERIALS AND METHODS: A total of 72 patients undergoing transperitoneal laparoscopic renal or adrenal surgery were randomly assigned to the treatment (0.5% bupivacaine) or placebo (0.9% normal saline) arm. Port and hand assist port sites were infiltrated at the outset of the procedure. Postoperative pain and opioid use were measured at consistent intervals. RESULTS: A total of 37 individuals were treated with placebo (standard laparoscopy [SL] in 15 and hand assisted laparoscopy [HALS] in 22) and 35 were treated with bupivacaine (SL in 16 and HALS in 19). Mean parenteral morphine equivalents use for the placebo vs bupivacaine groups were 29.6 vs 20.0 mg at 12 hours, 50.2 vs 34.5 mg at 24 hours and 57.1 vs 36.6 mg for the total hospital stay (all p <0.05). Parenteral opioid use was decreased in the bupivacaine group in the SL and HALS subgroups with a significant effect at 12 hours in the latter subgroup. On multivariate ANOVA bupivacaine use but not SL vs HALS was associated with decreased parenteral opioid use at all time points (p <0.05). CONCLUSIONS: At the outset of transperitoneal laparoscopic urological surgery in the upper retroperitoneum, port site and other incision infiltration with long acting local anesthesia decreases postoperative parenteral opioid requirements compared with placebo controls. The effect was seen with SL and HALS and it was greater than any effect of SL vs HALS.

Adrenal Glands↗