Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the fem... more Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the femoral arteries of 54 patients. The main factors that might affect the results were reviewed: associated diseases, severity of ischemic symptoms, location and type of lesions (stenosis or occlusion and their length), and presence of disease distal to the site dilated. The vascular status of the patients in our series was more severe than in most others. Improvement at follow-up (average 15 months) was maintained in 74% of 66 radiographically successful PTAs. Poor nmoff was the only factor found to affect the outcome deleteriously. Intra-arterial pressure measurements performed during the procedure and vascular laboratory studies were most valuable in assessing immediate and long-term results. Wide variations in results of PTA published in the literature are due to differences in methods of selection, evaluation, and reporting. A plea is made for future presentations of PTA series in an analyzable and comparable way, including and correlating all relevant variables as in the model suggested by the present study. (J VAse SFRG 1986; 3:583-90.) Transluminal treatment of arteriosclerotic occlusive disease with use of a percutaneously introduced catheter was first reported by Dotter and Judldns 1 in 1964. Gruntzig and Hopff 2 introduced the balloon catheter in 1974 for percutaneous transluminal angioplasty (PTA). Since then it has been widely used for dilatation of vascular stenosis or recanalization of o-zcluded arteries. Tlv " purpose of this article is to present our experieffce with I~A with special emphasis on a comprehensive evaluation of all clinical, arteriographic, and hemodynamic data obtained before, during, and following the procedure. This form of reporting could serve as a model for analysis and comparison of results of PTA in different series.
Superficial transitional cell carcinoma (TCC) has significant rates of recurrence and progression... more Superficial transitional cell carcinoma (TCC) has significant rates of recurrence and progression, therefore accurate urinary makers for early diagnosis and follow-up are essential. Urine cytology is the oldest marker, constantly used clinically and considered the "gold standard". In this review we will summarize the properties of different molecular markers for TCC and their yield compared to cytology. Briefly, the older markers--BTA stat, BTA TRAK and NMP22 are more sensitive than cytology, but their specificity is lower, especially in patients with underlying urologic pathologies. FDP (fibrinogen degradation products) analysis is rapid and the test is available clinically. It's sensitivity is higher than cytology for low grade tumors, but specificity is low. Of the newer markers, telomerase has a high sensitivity, and a specificity similar to urine cytology, but also has an increased rate of false positive results. HA-HAase (Hyaluronidase) and CK20 have promising sensitivity and specificity, but are still unavailable for clinical use. CK20 has the additional advantage of being able to detect premalignant conditions as well as predicting recurrence. The role of urinary markers in replacing cystoscopy and urine sediment cytology in the follow-up of TCC and in hematuria work up is still uncertain. It is possible that urinary markers in different panel arrays will have a role in the future for those indications and perhaps in the screening of populations at risk, such as smokers and workers exposed to occupational hazards.
Objective: This study was carried out to determine whether ejaculation may modify the serum prost... more Objective: This study was carried out to determine whether ejaculation may modify the serum prostate-specific antigen (PSA) level and to investigate whether postejaculation serum PSA may play a role in male hypofertility work-up. Methods: Serum PSA concentration was determined before and 1 h after ejaculation in 18 healthy men (group A) and in 16 men with male-factor infertility (group B). PSA change (delta) was recorded and analyzed. Results: Postejaculation serum PSA differed significantly from basal levels (p = 0.0037 by the Wilcoxon signed rank test). Following ejaculation, a rise was noticed in 74% of subjects. The median relative change in PSA concentration was 54%. No difference in respect to mean, median and relative change was observed between study groups. In two cases (6%), PSA rose from normal level to more than 4 ng/ml. Conclusion: A significant postejaculation serum PSA elevation does occur, it is thus recommended that men abstain from ejaculation for 24 h prior to PSA sampling. Postejaculation PSA was not found to significantly correlate with hypofertility.
Recent advances in laparoscopic surgery have allowed urologists to perform laparoscopic bladder s... more Recent advances in laparoscopic surgery have allowed urologists to perform laparoscopic bladder suspension; however, laparoscopic suturing techniques have a steep learning curve and make the procedure more difficult and time consuming. We describe a new technique that combines extraperitoneal laparoscopic bladder neck mobilization through a single port with the ease of a needle suspension urethropexy in order to avoid the need for vaginal incisions and the use of laparoscopic suturing techniques. The procedure has been performed in four patients, all of whom are continent and voiding with complete bladder emptying. Postoperative pain was minimal, allowing most patients to be discharged the day after surgery. In the future, the procedure may be performed on an outpatient basis.
Complete metabolic evaluation was performed in 21 patients with infected renal lithiasis. Patient... more Complete metabolic evaluation was performed in 21 patients with infected renal lithiasis. Patients with pure struvite stones (struvite +/- carbonate apatite) were significantly less likely to have metabolic abnormalities than patients who had struvite +/- carbonate apatite+calcium oxalate (2 of 14 v 7 of 7, P = 0.0003). Urine calcium excretion was markedly higher in the mixed stone group than the pure struvite group (342 +/- 98 mg/24 h v 136 +/- 82 mg/24 h; P < 0.0001). The differing opinions among researchers regarding the likelihood of finding metabolic abnormalities in patients with urolithiasis and infection probably reflect differences in the definitions of the populations studied. If patients with calculi containing only struvite +/- carbonate apatite are evaluated, we believe that few significant metabolic abnormalities will be identified.
Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the fem... more Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the femoral arteries of 54 patients. The main factors that might affect the results were reviewed: associated diseases, severity of ischemic symptoms, location and type of lesions (stenosis or occlusion and their length), and presence of disease distal to the site dilated. The vascular status of the patients in our series was more severe than in most others. Improvement at follow-up (average 15 months) was maintained in 74% of 66 radiographically successful PTAs. Poor runoff was the only factor found to affect the outcome deleteriously. Intra-arterial pressure measurements performed during the procedure and vascular laboratory studies were most valuable in assessing immediate and long-term results. Wide variations in results of PTA published in the literature are due to differences in methods of selection, evaluation, and reporting. A plea is made for future presentations of PTA series in an analyzable and comparable way, including and correlating all relevant variables as in the model suggested by the present study.
Local hyperthermia to the prostate has initially been found to be of considerable beneficial valu... more Local hyperthermia to the prostate has initially been found to be of considerable beneficial value in cancer of the gland and later also in benign prostatic hypertrophy (BPH) and in chronic prostatitis. The Prostathermer has been especially developed and used for this purpose. 124 patients with BPH, who have been treated by this method, were reevaluated after 1 year. This thermotherapy was well tolerated, and no noticeable complications were encountered. A sustained definite improvement in objective and subjective obstructive symptoms and signs was seen in 51% of the cases. Such definite and persistent improvement was best obtained when treatments were performed twice weekly for 60 min over a period of 3 weeks. Those patients with the more severe obstructive symptoms fared best. A full explanation for the effectiveness of this treatment of BPH has yet to be found. Although local hyperthermia cannot, at this stage, be considered as a radical form of treatment of BPH, it may offer definite relief to about 50% of the cases, particularly to those unwilling or unsuitable for surgery.
Purpose: We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on ... more Purpose: We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on patient well-being. Materials and Methods: We enrolled 211 consecutive men who underwent a total of 218 biopsy events in a questionnaire based survey focusing on pain, anxiety and erectile dysfunction risk factors. Surveys were administered before, and immediately, 1 week and 1 month after biopsy. Quantitative information on the intensity of symptoms and signs was obtained using a uniform grading system. Results: Intraoperative pain considered severe in 20% of the biopsy events was associated with pain in the first 24 hours postoperatively, leading to analgesic use in 10%. Inflammatory infiltrate in the biopsy core and younger patient age correlated with persistent pain on days 2 and 7 after biopsy, respectively. Preoperative anxiety was reported in 64% of biopsy events and predictive of intraoperative pain. Anxiety peaked before result disclosure. Erectile dysfunction attributed to anxiety in anticipation of biopsy was reported in 7% of cases. At days 7 and 30, 15% of previously potent patients reported erectile dysfunction. Conclusions: The impact of prostate biopsy on patient well-being begins while waiting for the scheduled procedure. Shortening the anticipation period before results are disclosed and administering pre-biopsy anxiety decreasing measures may benefit patients. Analgesic therapy is recommended in younger patients, those reporting moderate to severe intraoperative pain and those with known prostatic inflammatory infiltrate. The risk of acute erectile dysfunction should be discussed cautiously with patients who are potent before biopsy.
Purpose: We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones ... more Purpose: We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones not alleviated by shock wave lithotripsy (SWL). Materials and Methods: A total of 28 females and 53 males with a mean age of 53 years (range 18 to 86) were studied. They had been treated with a mean of 3.2 previous SWLs. Mean stone size was 9.2 mm (range 4 to 22) and the mean number of stones per patient was 1.27 (range 1 to 5) for a total of 103 stones overall. In 70 patients there was 1 stone. Rigid and flexible ureteroscopes were used in 8 and 67 cases, respectively, while a combined approach was used in 6. A holmium:YAG laser was used for fragmentation in 52 patients. Success was defined as stone-free status or residual fragments less than 3 mm. Results: The overall success rate was 67%. RIRL yielded a 46% stone-free rate. Of the 44 patients 17 (39%) had residual stones less than 3 mm, while 13 required ancillary procedures. There were no residual ureteral stones. Original stone size correlated inversely with the success rate. Most failures involved lower pole stones, in that laser fiber deflection prevented reaching them in 9 cases. The procedure was interrupted due to extravasation or bleeding in 5 patients and 6 had postoperative urinary tract infections (16% overall complication rate). Conclusions: RIRL effectively and safely alleviated upper tract stones unresponsive to earlier SWL. It can be considered salvage therapy in such cases. RIRL is well suited for treating stones less than 2 cm with better stone-free rates than SWL in the same circumstances. Residual stones were more likely in lower pole cases.
Bleeding during retropubic radical prostatectomy arises from venous structures in the majority of... more Bleeding during retropubic radical prostatectomy arises from venous structures in the majority of cases. Since its introduction two decades ago, the nerve-sparing procedure with surgical control of the dorsal venous complex has led to a reduction in blood loss and blood transfusion rate. The reducton in blood loss is a result of better understanding of the prostatic blood vessel anatomy, extensive surgical experience over time, and reduction in transfusion triggers with an acceptance of lower postoperative hemoglobin values. Increased blood loss during RRP is associated with poorer outcomes most probably due to surgical difficulties. But as for now, there are no decisive risk factors for clinically significant bleeding during RRP although newer technologies for hemostasis of the dorsal vein complex are being utilized.
A case of crossed fused renal ectopia with urosepsis due to multiple struvite calculi in the left... more A case of crossed fused renal ectopia with urosepsis due to multiple struvite calculi in the left lower pole of the orthotopic renal unit is presented. The patient had a neurogenic bladder secondary to myelodysplasia, bilateral ureteral reflux, and had undergone multiple orthopedic operations previously, including posterior iliopsoas transplantation through the iliac bone (Sharrard procedure). After controlling the infection, nephrostolithotomy was performed. Three percutaneous accesses including one through the opening in the left iliac bone were required to gain access to all the stones. The patient was rendered stone free and subsequently underwent bladder augmentation and ureteral reimplantation. The management of complicated renal units is reviewed with respect to crossed renal fusion.
We determined the efficacy of anesthesia for prostate biopsy by periprostatic lidocaine injection... more We determined the efficacy of anesthesia for prostate biopsy by periprostatic lidocaine injection. A total of 90 consecutive patients undergoing prostate biopsies were randomized into lidocaine and placebo groups of 45 each in double-blind fashion. A 5 ml. dose of 1% lidocaine or 0.9% sodium chloride was injected via 23 gauge needles inserted through the transrectal ultrasound probe working channel and aimed at the prostatic neurovascular bundles bilaterally. Patients completed a symptom questionnaire applying a visual analog scale of 0-none to 10-maximal addressing pre-procedure anxiety, overall pain and discomfort throughout the procedure, pain during biopsy punctures and patient tolerance, as judged by the operator. Student's t test was used to analyze continuous variables and the chi-square test was applied for categorical data. Linear regression was done to determine intervariable influences. The average pain level throughout the procedure was 3.06 in the lidocaine group versus 4.15 in the control group (p = 0.04), while the pain level during biopsy punctures was 1.51 versus 3.98 (p = 0.0001) and patient tolerance was 1.06 versus 1.93 (p = 0.018). The level of discomfort throughout the procedure was lower in the lidocaine group with borderline significance (4.31 versus 5.24, p = 0.077). The lidocaine and control groups were comparable regarding average patient age (65 and 66 years, respectively). Prostate volume was similar in the 2 groups (68.5 versus 63 ml.). The median number of biopsy punctures was 7 and 8, respectively. Cancer was identified in 10 patients (22.2%) per group. Periprostatic lidocaine injection is an effective method of anesthesia for prostate biopsy.
Purpose: We define energy requirements for stone micro indentation as a quantifiable event equiva... more Purpose: We define energy requirements for stone micro indentation as a quantifiable event equivalent to in vivo energy delivery and investigate the change in indentation characteristics with time. Materials and Methods: The 7 stones extracted from 7 patients were cut, embedded in resin a n d polished. Multiple micro indentations were performed on each stone section using a diamond Vickers micro indentor with a 500X light microscope and video system. The resulting indentations were observed by optical and scanning electron microscopy as a function of time. Organic matrix content w a s determined by dissolving stones in ethylenediaminetetraacetic acid solution. Results: The energy requirement for stone indentation varies among stones (median range 43.6 to 109.9 kg./mm.') and at different locations in the same stone. Indentations relaxed by 10 to 70% during the first 2 weeks aRer indentation. Stones w i t h a high organic matrix content were ductile and the phenomenon of indentation relaxation was pronounced. Brittle, low matrix stones relaxed t o a lesser extent. Conclusions: The relaxation phenomena m a y have a practical implementation when consideri n g repeat shock wave lithotripsy. A significant fraction of the energy invested in a stone which did not cause fracture or critical cracks is lost within 1 t o 2 weeks after the procedure, particularly i n elastic stones w i t h a high organic matrix content. We suggest that the preferred interval for repeat shock wave lithotripsy be less than 2 weeks.
Radical prostatectomy is associated with diffirulty in determining the division site of the ureth... more Radical prostatectomy is associated with diffirulty in determining the division site of the urethra adjacent to the apical region of the prostate. We present the results of a feasibility clinical trial in three patients to determine whether intraoperative transrectal ultrasonography may assist during radical retropubic prostatectomy. Using this technique the apex is readily identified and a detailed view of the urethral stump could be T he number of radical prostatectomies performed has greatly increased in the United States in the last decade. 1 Although the surgical technique was refined by Walsh and cowork-ers1•l and popularized ever since, intraoperative management of the apical region is occasionally a ABBREVIATIONS
Aims: To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). ... more Aims: To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). Methods: One hundred and four patients (age 60 AE 15 years) who were referred for multichannel UDS were prospectively recruited and randomized into 2 groups: (1) received a leaflet containing detailed information regarding the examination; (2) did not receive a leaflet. Patients who were unable to complete the questionnaire due to mental disorders and patients who had previously undergone UDS were excluded. The leaflets were mailed to the patients in group 1 one month before the examination. This leaflet included information on how the examination would be performed, its purpose, recommended preparation, potential complications, and common events that might occur in association with the examination, such as incontinence. Emotional distress was measured by the State Anxiety Inventory (SAI)-a validated questionnaire composed of 20 items measuring anxiety. These measures are divided into two psychological domains: (1) positive well being; (2) psychological distress. Patients filled out the SAI immediately before entering the examination room. Results: Demographics and clinical and psychological co-morbidities were similar between the groups. The ''psychological distress'' score was significantly lower in group 1 (13.1 AE 2.9 vs. 24.8 AE 5.8, P < 0.001), whereas there was no difference in the ''positive well being'' score. Conclusions: We recommend providing patients with an information leaflet on UDS since it significantly reduces anxiety levels. Neurourol. Urodynam.
We examined the feasibility of performing ureteroscopy under sedation only. Twenty-eight ureteros... more We examined the feasibility of performing ureteroscopy under sedation only. Twenty-eight ureteroscopies performed with sedation only were compared to 18 performed in an operating room setting. Durability towards the procedure was good in 86% of the cases. Stone-free rates were 42 and 72%, respectively. Fifty-seven percent of the patients required hospitalization with the most common complication being low-grade fever. Although our success rate is less favorable for sedation only, this setting is feasible, and in nearly half of the patients hospitalization was avoided with no need for an expensive operating room facility. Careful patient selection, a sharp learning curve and small-french instruments combined with pneumatic lithotriptors may also improve the results.
We explored the biocompatibility of fluidized canine small-intestinal submucosa (SIS) for periure... more We explored the biocompatibility of fluidized canine small-intestinal submucosa (SIS) for periureteral injection and as a patch graft for bladder augmentation in pigs. Gross evaluation 8 weeks after submucosal injection showed persistence of the nodule. Histologic examination showed thickened submucosa with spindle cells embedded in poorly organized fibrous material. There was no evidence of inflammatory reaction or granuloma formation. Subserosal nodules likewise persisted and demonstrated capillary ingrowth. Grafts of SIS became epithelialized within 3 weeks with maintenance of bladder capacity. Ingrowth of capillaries and smooth muscle could be seen in later specimens. Although further studies with longer follow-up are needed, SIS appears to be a promising graft material in the urinary tract.
Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the fem... more Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the femoral arteries of 54 patients. The main factors that might affect the results were reviewed: associated diseases, severity of ischemic symptoms, location and type of lesions (stenosis or occlusion and their length), and presence of disease distal to the site dilated. The vascular status of the patients in our series was more severe than in most others. Improvement at follow-up (average 15 months) was maintained in 74% of 66 radiographically successful PTAs. Poor nmoff was the only factor found to affect the outcome deleteriously. Intra-arterial pressure measurements performed during the procedure and vascular laboratory studies were most valuable in assessing immediate and long-term results. Wide variations in results of PTA published in the literature are due to differences in methods of selection, evaluation, and reporting. A plea is made for future presentations of PTA series in an analyzable and comparable way, including and correlating all relevant variables as in the model suggested by the present study. (J VAse SFRG 1986; 3:583-90.) Transluminal treatment of arteriosclerotic occlusive disease with use of a percutaneously introduced catheter was first reported by Dotter and Judldns 1 in 1964. Gruntzig and Hopff 2 introduced the balloon catheter in 1974 for percutaneous transluminal angioplasty (PTA). Since then it has been widely used for dilatation of vascular stenosis or recanalization of o-zcluded arteries. Tlv " purpose of this article is to present our experieffce with I~A with special emphasis on a comprehensive evaluation of all clinical, arteriographic, and hemodynamic data obtained before, during, and following the procedure. This form of reporting could serve as a model for analysis and comparison of results of PTA in different series.
Superficial transitional cell carcinoma (TCC) has significant rates of recurrence and progression... more Superficial transitional cell carcinoma (TCC) has significant rates of recurrence and progression, therefore accurate urinary makers for early diagnosis and follow-up are essential. Urine cytology is the oldest marker, constantly used clinically and considered the "gold standard". In this review we will summarize the properties of different molecular markers for TCC and their yield compared to cytology. Briefly, the older markers--BTA stat, BTA TRAK and NMP22 are more sensitive than cytology, but their specificity is lower, especially in patients with underlying urologic pathologies. FDP (fibrinogen degradation products) analysis is rapid and the test is available clinically. It's sensitivity is higher than cytology for low grade tumors, but specificity is low. Of the newer markers, telomerase has a high sensitivity, and a specificity similar to urine cytology, but also has an increased rate of false positive results. HA-HAase (Hyaluronidase) and CK20 have promising sensitivity and specificity, but are still unavailable for clinical use. CK20 has the additional advantage of being able to detect premalignant conditions as well as predicting recurrence. The role of urinary markers in replacing cystoscopy and urine sediment cytology in the follow-up of TCC and in hematuria work up is still uncertain. It is possible that urinary markers in different panel arrays will have a role in the future for those indications and perhaps in the screening of populations at risk, such as smokers and workers exposed to occupational hazards.
Objective: This study was carried out to determine whether ejaculation may modify the serum prost... more Objective: This study was carried out to determine whether ejaculation may modify the serum prostate-specific antigen (PSA) level and to investigate whether postejaculation serum PSA may play a role in male hypofertility work-up. Methods: Serum PSA concentration was determined before and 1 h after ejaculation in 18 healthy men (group A) and in 16 men with male-factor infertility (group B). PSA change (delta) was recorded and analyzed. Results: Postejaculation serum PSA differed significantly from basal levels (p = 0.0037 by the Wilcoxon signed rank test). Following ejaculation, a rise was noticed in 74% of subjects. The median relative change in PSA concentration was 54%. No difference in respect to mean, median and relative change was observed between study groups. In two cases (6%), PSA rose from normal level to more than 4 ng/ml. Conclusion: A significant postejaculation serum PSA elevation does occur, it is thus recommended that men abstain from ejaculation for 24 h prior to PSA sampling. Postejaculation PSA was not found to significantly correlate with hypofertility.
Recent advances in laparoscopic surgery have allowed urologists to perform laparoscopic bladder s... more Recent advances in laparoscopic surgery have allowed urologists to perform laparoscopic bladder suspension; however, laparoscopic suturing techniques have a steep learning curve and make the procedure more difficult and time consuming. We describe a new technique that combines extraperitoneal laparoscopic bladder neck mobilization through a single port with the ease of a needle suspension urethropexy in order to avoid the need for vaginal incisions and the use of laparoscopic suturing techniques. The procedure has been performed in four patients, all of whom are continent and voiding with complete bladder emptying. Postoperative pain was minimal, allowing most patients to be discharged the day after surgery. In the future, the procedure may be performed on an outpatient basis.
Complete metabolic evaluation was performed in 21 patients with infected renal lithiasis. Patient... more Complete metabolic evaluation was performed in 21 patients with infected renal lithiasis. Patients with pure struvite stones (struvite +/- carbonate apatite) were significantly less likely to have metabolic abnormalities than patients who had struvite +/- carbonate apatite+calcium oxalate (2 of 14 v 7 of 7, P = 0.0003). Urine calcium excretion was markedly higher in the mixed stone group than the pure struvite group (342 +/- 98 mg/24 h v 136 +/- 82 mg/24 h; P &lt; 0.0001). The differing opinions among researchers regarding the likelihood of finding metabolic abnormalities in patients with urolithiasis and infection probably reflect differences in the definitions of the populations studied. If patients with calculi containing only struvite +/- carbonate apatite are evaluated, we believe that few significant metabolic abnormalities will be identified.
Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the fem... more Sixty-nine percutaneous transluminal angioplasties (PTAs) were performed in the iliac and the femoral arteries of 54 patients. The main factors that might affect the results were reviewed: associated diseases, severity of ischemic symptoms, location and type of lesions (stenosis or occlusion and their length), and presence of disease distal to the site dilated. The vascular status of the patients in our series was more severe than in most others. Improvement at follow-up (average 15 months) was maintained in 74% of 66 radiographically successful PTAs. Poor runoff was the only factor found to affect the outcome deleteriously. Intra-arterial pressure measurements performed during the procedure and vascular laboratory studies were most valuable in assessing immediate and long-term results. Wide variations in results of PTA published in the literature are due to differences in methods of selection, evaluation, and reporting. A plea is made for future presentations of PTA series in an analyzable and comparable way, including and correlating all relevant variables as in the model suggested by the present study.
Local hyperthermia to the prostate has initially been found to be of considerable beneficial valu... more Local hyperthermia to the prostate has initially been found to be of considerable beneficial value in cancer of the gland and later also in benign prostatic hypertrophy (BPH) and in chronic prostatitis. The Prostathermer has been especially developed and used for this purpose. 124 patients with BPH, who have been treated by this method, were reevaluated after 1 year. This thermotherapy was well tolerated, and no noticeable complications were encountered. A sustained definite improvement in objective and subjective obstructive symptoms and signs was seen in 51% of the cases. Such definite and persistent improvement was best obtained when treatments were performed twice weekly for 60 min over a period of 3 weeks. Those patients with the more severe obstructive symptoms fared best. A full explanation for the effectiveness of this treatment of BPH has yet to be found. Although local hyperthermia cannot, at this stage, be considered as a radical form of treatment of BPH, it may offer definite relief to about 50% of the cases, particularly to those unwilling or unsuitable for surgery.
Purpose: We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on ... more Purpose: We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on patient well-being. Materials and Methods: We enrolled 211 consecutive men who underwent a total of 218 biopsy events in a questionnaire based survey focusing on pain, anxiety and erectile dysfunction risk factors. Surveys were administered before, and immediately, 1 week and 1 month after biopsy. Quantitative information on the intensity of symptoms and signs was obtained using a uniform grading system. Results: Intraoperative pain considered severe in 20% of the biopsy events was associated with pain in the first 24 hours postoperatively, leading to analgesic use in 10%. Inflammatory infiltrate in the biopsy core and younger patient age correlated with persistent pain on days 2 and 7 after biopsy, respectively. Preoperative anxiety was reported in 64% of biopsy events and predictive of intraoperative pain. Anxiety peaked before result disclosure. Erectile dysfunction attributed to anxiety in anticipation of biopsy was reported in 7% of cases. At days 7 and 30, 15% of previously potent patients reported erectile dysfunction. Conclusions: The impact of prostate biopsy on patient well-being begins while waiting for the scheduled procedure. Shortening the anticipation period before results are disclosed and administering pre-biopsy anxiety decreasing measures may benefit patients. Analgesic therapy is recommended in younger patients, those reporting moderate to severe intraoperative pain and those with known prostatic inflammatory infiltrate. The risk of acute erectile dysfunction should be discussed cautiously with patients who are potent before biopsy.
Purpose: We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones ... more Purpose: We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones not alleviated by shock wave lithotripsy (SWL). Materials and Methods: A total of 28 females and 53 males with a mean age of 53 years (range 18 to 86) were studied. They had been treated with a mean of 3.2 previous SWLs. Mean stone size was 9.2 mm (range 4 to 22) and the mean number of stones per patient was 1.27 (range 1 to 5) for a total of 103 stones overall. In 70 patients there was 1 stone. Rigid and flexible ureteroscopes were used in 8 and 67 cases, respectively, while a combined approach was used in 6. A holmium:YAG laser was used for fragmentation in 52 patients. Success was defined as stone-free status or residual fragments less than 3 mm. Results: The overall success rate was 67%. RIRL yielded a 46% stone-free rate. Of the 44 patients 17 (39%) had residual stones less than 3 mm, while 13 required ancillary procedures. There were no residual ureteral stones. Original stone size correlated inversely with the success rate. Most failures involved lower pole stones, in that laser fiber deflection prevented reaching them in 9 cases. The procedure was interrupted due to extravasation or bleeding in 5 patients and 6 had postoperative urinary tract infections (16% overall complication rate). Conclusions: RIRL effectively and safely alleviated upper tract stones unresponsive to earlier SWL. It can be considered salvage therapy in such cases. RIRL is well suited for treating stones less than 2 cm with better stone-free rates than SWL in the same circumstances. Residual stones were more likely in lower pole cases.
Bleeding during retropubic radical prostatectomy arises from venous structures in the majority of... more Bleeding during retropubic radical prostatectomy arises from venous structures in the majority of cases. Since its introduction two decades ago, the nerve-sparing procedure with surgical control of the dorsal venous complex has led to a reduction in blood loss and blood transfusion rate. The reducton in blood loss is a result of better understanding of the prostatic blood vessel anatomy, extensive surgical experience over time, and reduction in transfusion triggers with an acceptance of lower postoperative hemoglobin values. Increased blood loss during RRP is associated with poorer outcomes most probably due to surgical difficulties. But as for now, there are no decisive risk factors for clinically significant bleeding during RRP although newer technologies for hemostasis of the dorsal vein complex are being utilized.
A case of crossed fused renal ectopia with urosepsis due to multiple struvite calculi in the left... more A case of crossed fused renal ectopia with urosepsis due to multiple struvite calculi in the left lower pole of the orthotopic renal unit is presented. The patient had a neurogenic bladder secondary to myelodysplasia, bilateral ureteral reflux, and had undergone multiple orthopedic operations previously, including posterior iliopsoas transplantation through the iliac bone (Sharrard procedure). After controlling the infection, nephrostolithotomy was performed. Three percutaneous accesses including one through the opening in the left iliac bone were required to gain access to all the stones. The patient was rendered stone free and subsequently underwent bladder augmentation and ureteral reimplantation. The management of complicated renal units is reviewed with respect to crossed renal fusion.
We determined the efficacy of anesthesia for prostate biopsy by periprostatic lidocaine injection... more We determined the efficacy of anesthesia for prostate biopsy by periprostatic lidocaine injection. A total of 90 consecutive patients undergoing prostate biopsies were randomized into lidocaine and placebo groups of 45 each in double-blind fashion. A 5 ml. dose of 1% lidocaine or 0.9% sodium chloride was injected via 23 gauge needles inserted through the transrectal ultrasound probe working channel and aimed at the prostatic neurovascular bundles bilaterally. Patients completed a symptom questionnaire applying a visual analog scale of 0-none to 10-maximal addressing pre-procedure anxiety, overall pain and discomfort throughout the procedure, pain during biopsy punctures and patient tolerance, as judged by the operator. Student&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s t test was used to analyze continuous variables and the chi-square test was applied for categorical data. Linear regression was done to determine intervariable influences. The average pain level throughout the procedure was 3.06 in the lidocaine group versus 4.15 in the control group (p = 0.04), while the pain level during biopsy punctures was 1.51 versus 3.98 (p = 0.0001) and patient tolerance was 1.06 versus 1.93 (p = 0.018). The level of discomfort throughout the procedure was lower in the lidocaine group with borderline significance (4.31 versus 5.24, p = 0.077). The lidocaine and control groups were comparable regarding average patient age (65 and 66 years, respectively). Prostate volume was similar in the 2 groups (68.5 versus 63 ml.). The median number of biopsy punctures was 7 and 8, respectively. Cancer was identified in 10 patients (22.2%) per group. Periprostatic lidocaine injection is an effective method of anesthesia for prostate biopsy.
Purpose: We define energy requirements for stone micro indentation as a quantifiable event equiva... more Purpose: We define energy requirements for stone micro indentation as a quantifiable event equivalent to in vivo energy delivery and investigate the change in indentation characteristics with time. Materials and Methods: The 7 stones extracted from 7 patients were cut, embedded in resin a n d polished. Multiple micro indentations were performed on each stone section using a diamond Vickers micro indentor with a 500X light microscope and video system. The resulting indentations were observed by optical and scanning electron microscopy as a function of time. Organic matrix content w a s determined by dissolving stones in ethylenediaminetetraacetic acid solution. Results: The energy requirement for stone indentation varies among stones (median range 43.6 to 109.9 kg./mm.') and at different locations in the same stone. Indentations relaxed by 10 to 70% during the first 2 weeks aRer indentation. Stones w i t h a high organic matrix content were ductile and the phenomenon of indentation relaxation was pronounced. Brittle, low matrix stones relaxed t o a lesser extent. Conclusions: The relaxation phenomena m a y have a practical implementation when consideri n g repeat shock wave lithotripsy. A significant fraction of the energy invested in a stone which did not cause fracture or critical cracks is lost within 1 t o 2 weeks after the procedure, particularly i n elastic stones w i t h a high organic matrix content. We suggest that the preferred interval for repeat shock wave lithotripsy be less than 2 weeks.
Radical prostatectomy is associated with diffirulty in determining the division site of the ureth... more Radical prostatectomy is associated with diffirulty in determining the division site of the urethra adjacent to the apical region of the prostate. We present the results of a feasibility clinical trial in three patients to determine whether intraoperative transrectal ultrasonography may assist during radical retropubic prostatectomy. Using this technique the apex is readily identified and a detailed view of the urethral stump could be T he number of radical prostatectomies performed has greatly increased in the United States in the last decade. 1 Although the surgical technique was refined by Walsh and cowork-ers1•l and popularized ever since, intraoperative management of the apical region is occasionally a ABBREVIATIONS
Aims: To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). ... more Aims: To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). Methods: One hundred and four patients (age 60 AE 15 years) who were referred for multichannel UDS were prospectively recruited and randomized into 2 groups: (1) received a leaflet containing detailed information regarding the examination; (2) did not receive a leaflet. Patients who were unable to complete the questionnaire due to mental disorders and patients who had previously undergone UDS were excluded. The leaflets were mailed to the patients in group 1 one month before the examination. This leaflet included information on how the examination would be performed, its purpose, recommended preparation, potential complications, and common events that might occur in association with the examination, such as incontinence. Emotional distress was measured by the State Anxiety Inventory (SAI)-a validated questionnaire composed of 20 items measuring anxiety. These measures are divided into two psychological domains: (1) positive well being; (2) psychological distress. Patients filled out the SAI immediately before entering the examination room. Results: Demographics and clinical and psychological co-morbidities were similar between the groups. The ''psychological distress'' score was significantly lower in group 1 (13.1 AE 2.9 vs. 24.8 AE 5.8, P < 0.001), whereas there was no difference in the ''positive well being'' score. Conclusions: We recommend providing patients with an information leaflet on UDS since it significantly reduces anxiety levels. Neurourol. Urodynam.
We examined the feasibility of performing ureteroscopy under sedation only. Twenty-eight ureteros... more We examined the feasibility of performing ureteroscopy under sedation only. Twenty-eight ureteroscopies performed with sedation only were compared to 18 performed in an operating room setting. Durability towards the procedure was good in 86% of the cases. Stone-free rates were 42 and 72%, respectively. Fifty-seven percent of the patients required hospitalization with the most common complication being low-grade fever. Although our success rate is less favorable for sedation only, this setting is feasible, and in nearly half of the patients hospitalization was avoided with no need for an expensive operating room facility. Careful patient selection, a sharp learning curve and small-french instruments combined with pneumatic lithotriptors may also improve the results.
We explored the biocompatibility of fluidized canine small-intestinal submucosa (SIS) for periure... more We explored the biocompatibility of fluidized canine small-intestinal submucosa (SIS) for periureteral injection and as a patch graft for bladder augmentation in pigs. Gross evaluation 8 weeks after submucosal injection showed persistence of the nodule. Histologic examination showed thickened submucosa with spindle cells embedded in poorly organized fibrous material. There was no evidence of inflammatory reaction or granuloma formation. Subserosal nodules likewise persisted and demonstrated capillary ingrowth. Grafts of SIS became epithelialized within 3 weeks with maintenance of bladder capacity. Ingrowth of capillaries and smooth muscle could be seen in later specimens. Although further studies with longer follow-up are needed, SIS appears to be a promising graft material in the urinary tract.
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Papers by Yoram Siegel