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S Duke Herrell

Publications and source records attributed to S Duke Herrell.

24 records · Page 2Linked to original sources
PubMed2004

Techniques of ureteroscopy.

The flexible ureteroscope has revolutionized the diagnosis and treatment of the entire upper urinary tract. Endoscopic tools have evolved, providing the surgeon with the armamentarium necessary to treat many different pathologic processes. Almost all renal calculi can be treated with retrograde ureteroscopy. The fragility of these new endoscopes is a concern, and great care must be taken when using them. With good technique and proper use of instruments, their working life can be extended.

Equipment Design↗
PubMed2004

Laparoscopic partial nephrectomy techniques: developments and translation.

PURPOSE: Laparoscopic partial nephrectomy has recently emerged as a potential surgical option for select renal masses. Several new techniques and devices that may aid in laparoscopic partial nephrectomy are reviewed. MATERIALS AND METHODS: I review several techniques studied and/or developed in our laboratory. Each technique was evaluated for effectiveness in the porcine model and is in translation to clinical practice. RESULTS: Three techniques are reviewed. A hand assisted approach incorporating renal hilar clamping with hypothermia has proven successful for complex and multifocal lesions. Recent clinical studies, and our laboratory and clinical experience have shown a saline cooled monopolar dissector to be a valuable adjunct. A new and simple technique of achieving rapid hypothermia using a pure laparoscopic approach is described. CONCLUSIONS: Laparoscopic partial nephrectomy continues to develop as a standard of care for select renal masses. New devices and techniques will continue to make the procedure safer and reproducible.

Animals↗
PubMed2003

Single-center comparison of purely laparoscopic, hand-assisted laparoscopic, and open radical nephrectomy in patients at high anesthetic risk.

BACKGROUND AND PURPOSE: The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications. PATIENTS AND METHODS: All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons. RESULTS: The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12). CONCLUSIONS: Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.

Adult↗
PubMed2003

Simplified laparoscopic radical cystectomy with orthotopic ileal neobladder creation in a porcine model.

BACKGROUND AND PURPOSE: Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model. MATERIALS AND METHODS: Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed. RESULTS: Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals. CONCLUSIONS: Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.

Anastomosis, Surgical↗
PubMed2002

Flank position ureterorenoscopy: new positional approach to aid in retrograde caliceal stone treatment.

BACKGROUND AND PURPOSE: Clearance of lower pole stones and complex maneuvers such as basket repositioning remain challenging in ureteroscopic treatment of caliceal stone burdens. We describe the initial use of flank position ureteroscopy (FPU) with modifications to aid in the treatment of complex caliceal urolithiasis. We hypothesized that gravitational force acting on caliceal stones and fragments during holmium laser treatment would result in fragments being repositioned into the dependent renal pelvis, allowing enhanced treatment. PATIENTS AND METHODS: Eleven patients with complex upper tract stone disease (aggregate stone burden 1.5-5 cm) were treated using FPU. Patients were positioned with the stone-containing side superior. Flexible cystoscopy followed by flexible ureterorenoscopy and intracorporeal lithotripsy were performed. We utilized several modifications of the technique, including a radiolucent table and rotational C-arm fluoroscopy unit. Once all stones and particles fell into the dependent renal pelvis, additional laser fragmentation was simple. RESULTS: We observed the expected advantage of gravitational drainage of particles and stone into the renal pelvis during procedures. In many cases, fragments passed partially down the ureter during treatment. Basket repositioning of stones was not necessary. One complication, collecting system perforation during access, was treated with stent placement and successful delayed FPU. Seven patients were stone free at follow-up. Four patients with stone burdens >3 cm had approximately 80% stone burden reduction, but residual asymptomatic lower-pole particles (2-6 mm) remained, with several clearing with a secondary procedure. CONCLUSIONS: The use of FPU for the performance of complex renal stone treatment is a useful aid. Further refinement and comparison with standard technique is ongoing.

Gravitation↗