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Biomedical subjects

R Bihrle

Publications and source records attributed to R Bihrle.

At least 55 records · Page 3Linked to original sources
PubMed1995

Adaptations of the Mitrofanoff principle in adult continent urinary reservoirs.

Among the different techniques to develop a continence mechanism in continent urinary diversion, the Mitrofanoff principle of creating a submucosal tunnel for implantation of a catheterizable tube has gained in popularity. Early experience in the pediatric population focused on use of the appendix and ureter as the efferent limb, while bladder served as the reservoir. Recent developments have demonstrated that any segment of bowel can be tapered and implanted to achieve continence. Colonic teniae serve as an ideal site for implantation of the tube. The continence achieved with implantation of a supple straight tube beneath a tenia of colon is excellent. Success with this form of continence has made it our preference when converting an ileal or colon conduit to a continent reservoir.

Adult↗
PubMed1994

Stage I nonseminomatous germ-cell testicular cancer--management options and risk-benefit considerations.

The results obtained with primary retroperitoneal lymph-node dissection (RPLND) in 464 patients with clinical stage A nonseminomatous germ-cell (NSGC) testicular cancer over a period of 25 years (1965-1989) were reviewed. Results were analyzed in clinical terms and subdivided into early (1965-1978) and contemporary (1979-1989) findings so as to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients), the overall relapse rate of 15% (n = 13) was similar to that obtained in radiotherapy series but the survival (98.8% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A cases had primary RPLND, of whom 29% (n = 111) had cancerous nodes. The relapse rate for pathological stage A patients (n = 267) was 11% and two patients died. The rate of relapse for pathological stage B patients who did not receive adjuvant chemotherapy was 32%. No relapse was seen among 46 pathological stage B patients given postoperative adjuvant chemotherapy. The mortality of 0.7% observed among 378 clinical stage A RPLND cases was lower than the 2% value reported in surveillance series. Although not statistically significant, these consistent results reported for two eras (pre- and postplatinum) spanning a period of 25 years suggest a sound basis for the surgical approach. The anatomic and medical principles in oncology, which have supported this approach, remain cogent today. They are discussed herein. Now that nerve-sparing techniques have been developed, the one long-term morbidity of RPLND (i.e., anejaculation) can be avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part I--Vena cava.

A total of 42 patients underwent inferior vena cava resection (n = 40) or intraluminal tumor thrombectomy (n = 2) during retroperitoneal lymph-node dissection (RPLND) for bulky abdominal metastatic nonseminomatous germ-cell cancer (7% of all postchemotherapy RPLND cases). The three indications for caval resection included tumor clearance (38%), caval scar occlusion (14%), and caval tumor thrombus (48%). En bloc caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of specimens, teratoma in 31% specimens). Caval resection in the presence of scar occlusion was required de facto by virtue of its incorporation in the specimen. Caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer, 35%; teratoma, 45%; fibrosis, 20%) reflected nodal pathology in 71% of cancer cases, 78% of teratoma cases, and 100% of fibrosis cases. The complications of caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapeutic options.

Adolescent↗
PubMed1994

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part II.

A total of 710 patients underwent postchemotherapy retroperitoneal lymph-node dissection (RPLND) from 1965 to 1992. Ten patients, all with bulky disease, required aortic replacement either postoperatively (n = 3) or during RPLND (n = 7). The principal risk factor for aortic rupture after RPLND was an extended subadventitial aortic dissection made necessary by tumor fixation. Also, duodenal enterotomy or extensive violation of the bowel serosa was a further risk for aortoenteric fistula. Prospective aortic grafting may be indicated in the presence of these risk factors. In our four elective cases, there was no further vascular or bowel complication. Omental interposition further protects against fistula formation. Although rarely indicated except under the most extenuating circumstances, the exposure requirements of RPLND permit aortic grafting as a relatively straightforward procedure that is feasible and well tolerated in this small subset of patients.

Aorta↗
PubMed1994

Fertility considerations in nerve-sparing retroperitoneal lymph-node dissection.

Nerve-sparing retroperitoneal lymph-node dissection (RPLND) maintains the patient's ability to ejaculate postoperatively. However, since testicular cancer patients sometimes have diminished spermatogenesis, questions have been raised as to the advisability of nerve preservation relative to ultimate fertility. Fertility status was assessed in clinical stage A patients by two methods. These included standard semen analysis and a post-RPLND survey. The results show that approximately 75% of non-seminomatous testicular cancer patients who present in clinical stage A have fertility potential as based on semen analysis. Additionally, of those patients responding to the post-RPLND survey who had attempted pregnancy following RPLND, 76% reported attainment of pregnancy. Nerve-sparing RPLND maintains fertility potential in clinical stage I patients; furthermore, this fertility potential appears to be worth preserving as many patients will be capable of impregnating their partners.

Ejaculation↗
PubMed1994

Complications of primary retroperitoneal lymph-node dissection for low-stage testicular cancer.

The surgical complications encountered in 478 patients who underwent primary retroperitoneal lymph-node dissection for clinical stage A and B nonseminomatous testicular cancer during the period ranging from 1982 to 1992 were reviewed. There were 54 complications in 51 patients (10.6%), and there was no surgery-related mortality. There were 16 minor complications and 38 major complications. The most frequent complication encountered was superficial wound infection, and many of the major complications were related to small-bowel obstruction and atelectasis. The incidence of complications was significantly lower in patients operated on during the last 6 years of the study (1987-1992). The complication rate was lower in patients who underwent modified unilateral procedures than in those who had bilateral dissections. The ejaculation rate of patients undergoing nerve-sparing procedures was 98%. This study reinforces the conclusion that primary retroperitoneal lymph-node dissection is an operation yielding minimal morbidity and no long-standing effect.

Ejaculation↗
PubMed1994

Stage II nonseminomatous germ-cell testicular tumors--the Indiana experience and risk-benefit analysis.

Controversy exists in the appropriate management of patients with nonseminomatous testicular cancer presenting as clinical stage B disease. Traditional treatment in the United States has included retroperitoneal lymph-node dissection (RPLND). Conversely, in Europe and other places some of these patients have been managed with primary chemotherapy. The experience with RPLND in clinical stage B disease at Indiana University from 1965 to 1989 was reviewed. A total of 174 patients were considered to be in clinical stage B prior to RPLND. After RPLND, 23% of these patients (n = 41) were found to have pathological stage A disease. In all, 77% (n = 133) were determined to be in pathological stage B. Of those pathological stage B patients who did not receive adjuvant chemotherapy, 65% were cured by RPLND alone. The pathological stage B patients who went on the receive postoperative adjuvant chemotherapy displayed an overall 14% chance of relapse. (Patients treated early in the series did not receive cisplatin-based chemotherapy.) The overall survival over the entire period was 96%. In the more modern era, during which cisplatin-based chemotherapy was available, the overall survival was 98%. RPLND is an effective procedure for the management of clinical stage B nonseminomatous testicular cancer. It provides excellent survival in patients found to have pathological stage B disease; additionally, it avoids the unnecessary toxicity of chemotherapy in the 23% of patients who in fact are in pathological stage A.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

High-intensity focused ultrasound in the treatment of prostatic tissue.

OBJECTIVE: Beginning in 1987, high-intensity focused ultrasound was investigated in the canine model to determine the feasibility of destroying prostate tissue. After demonstrating the ability to ablate prostate tissue reliably in a canine model, a 15-patient pilot clinical study was undertaken at Indiana University in the fall of 1992. This pilot study was undertaken to assess the safety in the human clinical situation, as well as to give some early efficacy results. METHODS: The early canine feasibility studies were conducted via a suprapubic extracorporeal approach using two separate transducers, one for imaging and the other for therapy. Subsequent to this, a transrectal probe, which had the dual capability of both imaging and therapy, was developed and used to treat canine prostates in a formal, "good laboratory practice" study to determine the safety of this technology prior to beginning treatment of human benign prostatic hypertrophy. RESULTS: The formal canine studies demonstrated that prostatic tissue could be reliably ablated in the therapy zone. The dosimetry and duty cycle required to ablate canine prostatic tissue effectively was also determined in this study. The study also demonstrated that the prostatic tissue could be ablated without injury to the intervening rectal tissue or periprostatic tissue. The human pilot study has also demonstrated safety of high-intensity focused ultrasound, as well as early efficacy. CONCLUSIONS: These early clinical results are encouraging, but assessment of efficacy will require a randomized study comparing high-intensity focused ultrasound to sham and to transurethral prostatectomy. This multicenter trial is currently planned.

Animals↗
PubMed1994

The fertility of patients with clinical stage I testis cancer managed by nerve sparing retroperitoneal lymph node dissection.

Nerve sparing retroperitoneal lymph node dissection reliably preserves emission and ejaculation in patients with clinical stage I nonseminoma. The fertility of 51 patients who underwent nerve sparing retroperitoneal lymph node dissection was assessed by 3 different methods: standard semen analysis, analysis of chromatin content by deoxyribonucleic acid histogram and assessment of ultimate fertility status by a questionnaire. Approximately 75% of these patients have semen analyses generally considered to be in the normal range. Virtually all patients who underwent deoxyribonucleic acid histogram analysis had histograms similar to controls. A retrospective analysis of fertility was performed in 201 patients who had previously undergone nerve sparing retroperitoneal lymph node dissection. Of these patients who attempted pregnancy after nerve sparing retroperitoneal lymph node dissection 76% have been successful. Approximately 75% of patients who present with clinical stage I nonseminoma are potentially fertile. Nerve sparing retroperitoneal lymph node dissection is capable of preserving this potential in allowing these patients to father children.

Female↗
PubMed1994

Nerve sparing retroperitoneal lymphadenectomy after primary chemotherapy for metastatic testicular carcinoma.

Initial success with nerve sparing retroperitoneal lymph node dissections in patients with low stage nonseminomatous germ cell tumors of the testis has led to the application of these techniques to a select group of 40 patients treated after chemotherapy at our institution between March 1988 and November 1991. A minimum 1-year followup was available for 38 patients. There have been no abdominal relapses, and 34 of the 38 patients report normal ejaculation postoperatively. Nerve sparing techniques are applicable to select patients undergoing retroperitoneal lymph node dissection after primary chemotherapy for metastatic disease without increasing the chance of local recurrence. Emission and ejaculation are preserved in the majority of patients.

Adult↗
PubMed1994

Splenic rupture during occlusion of the porta hepatis in resection of tumors with vena caval extension.

The surgical management of renal cell carcinoma with intraluminal extension into the vena cava is technically demanding. Although the curative merit of the procedure is well established, extension of tumor above the hepatic veins may cause potentially life threatening complications, including pulmonary embolus and exsanguination. To our knowledge we report the first 2 cases in which intraoperative splenic rupture occurred and discuss possible causes of this complication.

Constriction↗
PubMed1994

High intensity focused ultrasound for the treatment of benign prostatic hyperplasia: early United States clinical experience.

High intensity focused ultrasound via a transrectal approach was used to treat 15 patients with symptomatic benign prostatic hyperplasia. The first 10 of these 15 patients underwent continuous temperature monitoring of the periprostatic region throughout the treatment. Patients undergoing transperineal thermocouple placement for the purpose of thermometry were treated while under general or spinal anesthesia, whereas 4 of the 5 remaining patients were successfully treated using intravenous sedation alone. Of the 10 patients 9 did not demonstrate a significant temperature elevation. One patient with a small prostatic anteroposterior diameter had a transient elevation of 17C. No patient experienced a complication related to periprostatic heating. Followup was available at 90 days in all patients. At 90 days the symptom scores decreased from a pretreatment value (American Urological Association questions 1 to 7) of 31.2 (range 22 to 38) to 15.8 (range 8 to 31). Peak flow rate increased by a mean of 4.7 ml per second from 9.3 ml per second before treatment to 14.0 ml per second at 90 days. The most frequent complication was that of transient urinary retention in 11 of 15 patients (73.3%) and hematospermia in 7 (46.7%). No adverse reactions persisted at 90 days. This study represents an initial attempt using high intensity focused ultrasound to treat symptomatic benign prostatic hyperplasia. Overall, the safety and effectiveness of high intensity focused ultrasound demonstrated in this pilot study are encouraging.

Aged↗
PubMed1994

Complications of primary retroperitoneal lymph node dissection.

The surgical morbidity in 478 patients who underwent primary retroperitoneal lymphadenectomy for clinical stages I and II nonseminomatous testicular cancer from 1982 to 1992 was reviewed. There were 54 complications in 51 patients (10.6%) and no operative related mortality. Superficial wound infection was the most frequent complication, comprising 45% of the total number of complications. Most major complications were related to small bowel obstruction and atelectasis. No complications caused permanent disability. The complication rate was less in patients who underwent a modified unilateral procedure (9.4%) than in those who underwent bilateral dissection (19.3%). Complications were significantly less with procedures done during the latter 6 years of the study (1987 to 1992). The ejaculation rate of patients undergoing a nerve sparing procedure was 98%, which reflects the increase in experience gained with the technique of nerve sparing modified unilateral dissection for early stage testicular cancer. This study reinforces the view that primary retroperitoneal lymph node dissection is an operation with minimal morbidity and no long-term effects. Furthermore, this study serves as the basis for cost-benefit and risk-benefit analyses of primary retroperitoneal lymph node dissection in low stage testicular cancer, which can be set against surveillance and primary chemotherapy programs.

Humans↗
PubMed1993

Vascular surgery-associated ureteral injury: zebras do exist.

This report describes a case of direct ureteral injury sustained during retroperitoneal vascular surgery. The diagnosis was delayed and treatment was complicated by infection. To address the patient's problem initially and then to consolidate our impressions, a literature review was undertaken. The conclusions from this review suggest that direct ureteral injury during vascular surgery is rare but most common during redo surgery, is just as likely to be missed as discovered during surgery, and when missed may be so for months. The diagnostic delay is caused by a varied and often misleading presentation, and a ureteral contrast study is the ultimate diagnostic tool. In these delayed cases the typical ureteral treatment is a stented ureteroureterostomy or nephrectomy. In the present case the patient was otherwise healthy; therefore an aggressive attitude to renal salvage was taken. This is a unique case of ileal conduit replacement of the damaged ureter for this specific situation. Five years after repair, renal function is stable without infectious complications. The current literature would suggest that the vascular graft may be left undisturbed if the urine is sterile. If infection is present, graft removal appears the standard of care and was successful in the present case.

Aorta, Abdominal↗
PubMed1993

Evaluation of diagnostic tests in the differential diagnosis of primary aldosteronism: unilateral adenoma versus bilateral micronodular hyperplasia.

Effective management of primary aldosteronism is dependent upon correct localization of excessive aldosterone production. We report our results of localization studies in patients with biochemically and pathologically confirmed primary aldosteronism. Retrospective chart review identified 69 patients with unilateral adrenal adenoma and 11 with adrenal hyperplasia. Correct unilateral versus bilateral localization of excessive aldosterone production was predicted in 70% versus 71%, respectively, by adrenal venography, 100% versus 63% by adrenal vein hormone sampling, 46% versus 56% by adrenal nuclear scanning and 69% versus 13% by anomalous postural decline of aldosterone. Adrenal computerized tomography appeared to localize correctly 86% versus 80% of the lesions. Unilateral adrenalectomy normalized blood pressure in 79% of the patients with unilateral adenomas versus only 18% of those with adrenal hyperplasia. Once primary aldosteronism is confirmed, localization by adrenal vein sampling, adrenal venography and adrenal computerized tomography is most effective in directing antihypertensive therapy.

Adenoma↗
PubMed1993

Management of chylous ascites after retroperitoneal lymph node dissection for testicular cancer.

Iatrogenic ascites is an uncommon complication of surgery of the retroperitoneum, the base of the mesentery or mediastinum. We treated 18 patients with chylous ascites occurring after retroperitoneal dissection for testicular cancer. Patients were diagnosed by paracentesis or on clinical grounds (increasing abdominal girth). Of interest, 6 patients underwent resection of the inferior vena cava as part of the procedure, and this appears to be a high risk group for this complication. Management options include dietary restriction of fat, administration of medium chain triglycerides and diuretics, hyperalimentation, peritoneovenous shunt or surgery. The majority of patients were managed successfully by dietary treatment.

Adolescent↗