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Biomedical subjects

Richard E Link

Publications and source records attributed to Richard E Link.

29 records · Page 2Linked to original sources
PubMed2005

Laparoscopic radical prostatectomy in obese patients: feasible or foolhardy?

More than 70% of men who are candidates for radical prostatectomy can be classified as either overweight or obese by body mass index. The role for laparoscopic radical prostatectomy (LRP) in treating these patients remains to be defined. A wealth of experience from bariatric surgery confirms that laparoscopic procedures can be performed successfully, even in the setting of morbid obesity, despite well-defined derangements in respiratory dynamics. Using the technical modifications outlined here, LRP can be performed safely and effectively in obese patients. Obesity raises the degree of difficulty for LRP, however, resulting in longer operative times and possibly a higher rate of open conversion. For this reason, surgeons early in their LRP experience are advised to avoid obese patients until they have become facile in the performance of LRP in normal-weight individuals.

Journal Article↗
PubMed2004

Nerve-sparing laparoscopic radical prostatectomy: replicating the open surgical technique.

OBJECTIVES: To present a detailed demonstration of a nerve-sparing laparoscopic radical prostatectomy (LRP) technique that replicates anatomic nerve-sparing radical retropubic prostatectomy (RRP). Techniques for neurovascular bundle preservation during open RRP have undergone several decades of careful refinement. Identifying pre-existing anatomic planes and the avoidance of thermal injury near the nerves are principles considered paramount during nerve-sparing RRP. During LRP and robotic-assisted radical prostatectomy, the use of cautery for hemostasis during nerve dissection is common despite its unknown effects on cavernous nerve function. METHODS: We describe a combined antegrade and retrograde laparoscopic approach to neurovascular bundle dissection. The technique is demonstrated in the accompanying video segments. The use of specialized laparoscopic instrumentation, including a fine-tipped right-angle clamp and curved dissector, is discussed. The principles of meticulous tissue handling and avoidance of electrocautery are stressed. The preliminary outcomes are presented using data obtained using an abridged version of the International Index of Erectile Function and the Expanded Prostate Cancer Index Composite questionnaires. RESULTS: To date, our technique has been applied to LRP in more than 177 patients. Blood loss has been minimal (less than 300 mL), and intraoperative anatomic nerve preservation appeared excellent. On the basis of our early experience, 76% of patients engaging in sexual intercourse preoperatively who underwent bilateral nerve preservation (n = 21) reported the ability to engage in sexual intercourse 1 year after LRP. CONCLUSIONS: Our nerve-sparing LRP technique replicates established open surgical principles of anatomic nerve-sparing RRP. The techniques described here minimize the potential for cavernous nerve damage from electrical energy or heat. Early functional outcomes appear comparable to the results obtained with open RRP performed at our institution.

Adenocarcinoma↗
PubMed2004

Laparoscopic partial nephrectomy in patients with neoplasia in a solitary kidney.

OBJECTIVES: To assess the renal function and describe our operative experience with laparoscopic partial nephrectomy (LPN) in patients with solitary kidneys. METHODS: The medical records were analyzed to find patients with a solitary kidney and renal neoplasms who underwent LPN. Demographic, operative, pathologic, and follow-up data were obtained. RESULTS: Four patients were identified with solitary kidneys who had undergone LPN. The mean operative time was 251 minutes, mean warm ischemic time 15 minutes, mean estimated blood loss 395 mL, and mean hospitalization stay 3 days. The mean preoperative creatinine was 1.5 mg/dL and the mean peak creatinine 2.0 mg/dL. All patients returned to their baseline creatinine levels in the follow-up period. The final pathologic finding was Stage pT1 in 1, pT3a in 2, and angiomyolipoma in 1 patient. All surgical margins were negative. No cancer recurrence developed in the patients, with a mean follow-up of 17 months (range 3 to 35). CONCLUSIONS: LPN in patients with a solitary kidney is feasible and a reasonable treatment alternative to open partial nephrectomy.

Blood Loss, Surgical↗
PubMed2004

Variation in prostate specific antigen results from 2 different assay platforms: clinical impact on 2304 patients undergoing prostate cancer screening.

PURPOSE: Urologists must contend with fluctuating prostate specific antigen (PSA) results from different assay platforms when deciding whether prostate biopsy is indicated. The contribution of cross-platform variation to these fluctuations is not well understood. To address this question we performed a cross-sectional study comparing 2 popular PSA assays during prostate cancer screening. MATERIALS AND METHODS: The Baylor College of Medicine Prostate Cancer Screening Program is a community outreach program providing free screening to Houston residents. From September 18th to 23, 2000, 2,304 patients underwent digital rectal examination and parallel serum PSA assay by the Hybritech Access (Beckman Coulter, Inc., Chaska, Minnesota) and Centaur (Bayer Diagnostics, Tarrytown, New York) systems. The Wilcoxon signed ranks test was used to compare results. RESULTS: Median PSA was low for the 2 assays (Centaur 0.99 ng/ml and Access 1.09 ng/ml) and Access results were significantly higher (1.23 times) than those obtained with Centaur (p <0.001). Frozen serum from 50 patients with PSA greater than 2.5 were then re-assayed using a third methodology (third Generation Immulite, Diagnostic Products Corp., Los Angeles, California). These data were consistent with Centaur results and significantly lower than Access results (p <0.001). Using a cutoff of PSA greater than 4.0 ng/ml 55 of the 288 patients (19%) with PSA greater than 2.5 ng/ml on the 2 platforms would have been candidates for prostate biopsy based on Access but not on Centaur data. CONCLUSIONS: In a large screening population the Access system measured consistently higher PSA than the Centaur system. These findings provide a basis for interpreting PSA results obtained from 2 commonly used clinical assays.

Adult↗
PubMed2004

Making ends meet: a cost comparison of laparoscopic and open radical retropubic prostatectomy.

PURPOSE: We compared the perioperative costs of laparoscopic radical prostatectomy (LRP) and open radical retropubic prostatectomy (RRP) at a metropolitan hospital by developing a detailed computer model. MATERIALS AND METHODS: Our predictive model incorporates institutional cost centers for operative time, operating room consumables, professional fees, hospital room and board, oral analgesics, autologous blood banking, blood transfusion and cystography. Versions with and without pelvic lymphadenectomy (PLND) were evaluated using 1 and 2-way sensitivity analyses. Operative times, lengths of stay and transfusion rates were derived from published series. We also reviewed individual hospital charges for 172 consecutive prostatectomy cases for comparison and validation of model predictions. RESULTS: The model predicted cost premiums for LRP of 14.4% (without PLND) and 17.5% (with PLND). The actual hospital charge premium for LRP and PLND was 18.4%, which differed from the predicted cost premium by less than 1%. The most significant cost centers in order of importance were operative time, length of stay and consumables. To achieve cost equivalence with RRP, operative times would need to average 159 minutes (LRP and PLND) and 174 minutes (LRP alone) holding other factors constant. Cost equivalence could not be achieved by shortening hospital stay alone unless LRP were performed as an outpatient procedure. CONCLUSIONS: Our model predicts the perioperative costs of LRP to be greater than RRP by a factor of less than 1.2x. If disposable instruments and trocars are eliminated, and patients undergoing LRP and PLND are discharged on postoperative day 2, cost equivalence with RRP and PLND can be achieved with operative times of 3.4 hours.

Computer Simulation↗
PubMed2004

Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome.

PURPOSE: Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative to open surgery for renal tumors less than 4 cm. We present oncological followup of patients treated with laparoscopic nephron sparing surgery at our institution. MATERIALS AND METHODS: Between September 1996 and December 2001, 48 patients who underwent LPN for clinically localized tumors were found to have pathologically proven renal cell carcinoma. Medical and operative records were reviewed for clinical characteristics, pathological findings and followup information. RESULTS: Mean patient age was 59.7 years (range 32 to 81) and mean followup was 37.7 months (range 22 to 84). Mean tumor size was 2.4 cm (range 1.0 to 4.0). Final pathological stage was pT1 in 42 patients (87.5%) and pT3a in 6 (12.5%). Histology revealed clear cell in 32 patients (66.7%), papillary in 10 (20.8%), chromophobe in 3 (6.3%), collecting duct in 1 (2.1%) and unclassified in 2 (4.2%). Intraoperative frozen section biopsies revealed negative margins in all cases. Final surgical margins were positive in 1 patient (2.1%). Followup evaluation consisting of physical examination and yearly cross-sectional imaging, which revealed no recurrences in 46 of 48 patients (95.8%). One patient with von Hippel-Lindau disease was found to have local recurrence 18 months after LPN and observation was elected. The second patient had recurrence in the same kidney away from the original tumor site approximately 4 years later. CONCLUSIONS: LPN is an effective treatment modality for clinically localized renal cell carcinoma. Oncological outcomes at a mean followup of 3 years are promising, although the durability of oncological outcomes must be determined.

Adult↗
PubMed2004

Trends in urology graduate medical education: a brief update from the Urology Residency Review Committee.

PURPOSE: This communication clarifies recent trends with regard to the number and configuration of urology training programs, and more precisely describes recent variations in the number of urology residents in training. MATERIALS AND METHODS: We reviewed and analyzed longitudinal data from the Accreditation Council for Graduate Medical Education regarding the number of urology resident positions as well as the number and format of urology training programs in the United States. Several publications related to general and urological graduate medical education were also reviewed. RESULTS: In response to various accreditation and demographic forces the total number of urology residency training programs has decreased by more than 20% since 1982. Coincident with this decrease was a transition in urology resident education away from smaller preceptor based programs and toward the current model of larger, broad based training programs anchored by academic medical centers. The educational format of most residency programs has also evolved, such that in 2003 all except 1 accredited program required 4 years of education in the clinical and basic urological sciences. For most programs this shift coincided with a decrease in the duration of pre-urological general surgical training. The number of first year urology residents decreased progressively between 1994 and 1998 before stabilizing at the current level of approximately 250 first year positions. In 2003 the total number of urologists in training was actually higher than it had been for most of the last decade. CONCLUSIONS: We describe recent trends in urological graduate medical education. The observations reported suggest that our specialty has maintained its focus on training a consistent number of high quality urological surgeons.

Education, Medical, Graduate↗
PubMed2004

Nerve sparing radical prostatectomy: effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model.

PURPOSE: To preserve sexual function following radical prostatectomy, one must avoid injury to the neurovascular bundles (NVBs). In the conventional open surgical technique, the use of energy sources for hemostasis is avoided to prevent damage to the cavernous nerves. In contrast, during laparoscopic radical prostatectomy, electrosurgical and ultrasonic energy sources are frequently used for hemostasis during dissection of the prostate. In this study, we evaluated the acute and chronic physiological effects of various hemostatic energy sources on cavernous nerve function in the canine model. MATERIALS AND METHODS: A total of 12 dogs were divided into 4 groups based on the type of energy source used for hemostasis during unilateral dissection of the NVB. The groups included conventional dissection with suture ligatures (group 1), monopolar (group 2) or bipolar (group 3) electrosurgery and ultrasonic shears (group 4). The contralateral NVB was left undissected as a control. Erectile function was assessed acutely and after 2 weeks of survival by measuring peak intracavernous pressures in response to cavernous nerve stimulation. RESULTS: Following conventional techniques of nerve sparing, the erectile response to nerve stimulation was unaffected. In contrast, the use of energy sources in proximity to the NVB during nerve preservation was associated with a substantial decrease in erectile response both acutely (74% to 91% decrease compared to controls) and after 2 weeks (93% to 96% decrease). CONCLUSIONS: In the chronic canine model, use of hemostatic energy sources in proximity to the prostate during dissection of the neurovascular bundle is associated with a significantly decreased erectile response to cavernous nerve stimulation.

Animals↗
PubMedDate not supplied

Laparoscopic radical nephrectomy: long-term outcomes.

BACKGROUND: Although more than a decade of experience with laparoscopic radical nephrectomy indicates it is an alternative to open surgery for localized renal-cell carcinoma (RCC), the long-term oncologic effectiveness of this procedure remains to be established. MATERIALS AND METHODS: A thorough MEDLINE and PubMed literature research on long-term outcomes of laparoscopic radical nephrectomy was performed, and all pertinent articles were reviewed in detail. This review was formulated on the current cancer indication, the oncologic basis, the oncologic efficacy, and the longterm oncologic effectiveness of the procedure, including laparoscopic cytoreductive nephrectomy, with regard to metastasis, port-site tumor recurrence, and the relation to laparoscopic partial nephrectomy. Furthermore, the authors' previous report on the intermediate-term efficacy of laparoscopic radical nephrectomy was updated. RESULTS: With increasing experience, the indications for laparoscopic radical nephrectomy continue to expand. There were many reports of intermediate-term, two reports of long-term, and our up-to-date outcomes analyzing the management of localized RCC that showed effective cancer control with no statistically significant difference between laparoscopic and open radical nephrectomy in the true 5- and 10-year survival analysis. CONCLUSION: Long-term data, critical in the evaluation of any treatment for cancer, are currently available with respect to laparoscopic radical nephrectomy for localized RCC.

Adult↗