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Cheng JW, Wagner H, Hernandez BC, Hu BR, Ko EY, Ruckle HC. Stressors and Coping Mechanisms Related to Burnout Within Urology. Urology 2020; 139:27-36. [DOI: 10.1016/j.urology.2019.11.072] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/04/2019] [Accepted: 11/19/2019] [Indexed: 11/17/2022]
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Woods-Burnham L, Stiel L, Martinez SR, Sanchez-Hernandez ES, Ruckle HC, Almaguel FG, Stern MC, Roberts LR, Williams DR, Montgomery S, Casiano CA. Psychosocial Stress, Glucocorticoid Signaling, and Prostate Cancer Health Disparities in African American Men. Cancer Health Disparities 2020; 4:https://companyofscientists.com/index.php/chd/article/view/169/188. [PMID: 35252767 PMCID: PMC8896511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Recent advances in our understanding of racial disparities in prostate cancer (PCa) incidence and mortality that disproportionately affect African American (AA) men have provided important insights into the psychosocial, socioeconomic, environmental, and molecular contributors. There is, however, limited mechanistic knowledge of how the interplay between these determinants influences prostate tumor aggressiveness in AA men and other men of African ancestry. Growing evidence indicates that chronic psychosocial stress in AA populations leads to sustained glucocorticoid signaling through the glucocorticoid receptor (GR), with negative physiological and pathological consequences. Compelling evidence indicates that treatment of castration-resistant prostate cancer (CRPC) with anti-androgen therapy activates GR signaling. This enhanced GR signaling bypasses androgen receptor (AR) signaling and transcriptionally activates both AR-target genes and GR-target genes, resulting in increased prostate tumor resistance to anti-androgen therapy, chemotherapy, and radiotherapy. Given its enhanced signaling in AA men, GR-together with specific genetic drivers-may promote CRPC progression and exacerbate tumor aggressiveness in this population, potentially contributing to PCa mortality disparities. Ongoing and future CRPC clinical trials that combine standard of care therapies with GR modulators should assess racial differences in therapy response and clinical outcomes in order to improve PCa health disparities that continue to exist for AA men.
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Affiliation(s)
- Leanne Woods-Burnham
- Center for Health Disparities and Molecular Medicine and Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Laura Stiel
- Loma Linda University School of Behavioral Health, Loma Linda, CA, USA
| | - Shannalee R. Martinez
- Center for Health Disparities and Molecular Medicine and Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Evelyn S. Sanchez-Hernandez
- Center for Health Disparities and Molecular Medicine and Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Herbert C. Ruckle
- Department of Surgical Urology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Frankis G. Almaguel
- Center for Health Disparities and Molecular Medicine and Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA
- Loma Linda University Cancer Center, Loma Linda, CA, USA
| | - Mariana C. Stern
- Departments of Preventive Medicine and Urology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Lisa R. Roberts
- Loma Linda University School of Nursing, Loma Linda, CA, USA
| | - David R. Williams
- Department of Social and Behavioral Sciences, Harvard University School of Public Health
| | - Susanne Montgomery
- Center for Health Disparities and Molecular Medicine and Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA
- Loma Linda University School of Behavioral Health, Loma Linda, CA, USA
| | - Carlos A. Casiano
- Center for Health Disparities and Molecular Medicine and Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Abstract
Urethral characterization can be difficult for patients and providers alike. This article describes an evidence-based protocol for difficult urethral catheter insertions in male patients.
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Affiliation(s)
- Janelle Warren
- In Loma Linda, Calif., Janelle Warren is an FNP in the inpatient adult urology unit at Loma Linda University Medical Center, and Herbert C. Ruckle is a Roger Barnes chair and professor in the department of urology at Loma Linda University School of Medicine
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Cheng JW, Wagner H, Hernandez BC, Ruckle HC. Consistencies and Discrepancies Between the Expectations of Urology Trainees and the Experience of Practicing Urologists. Urology 2019; 127:42-48. [DOI: 10.1016/j.urology.2018.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/11/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
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Shen J, Ruckle D, Li R, Keheila M, Alsyouf M, Schober J, Tryon D, Stokes P, Ruckle HC, Baron P, De Vera M, Baldwin DD. How a Donor Nephrectomy Population Can Help Give Perspective to the Effects of Renal Parenchymal Preservation During Partial Nephrectomy. J Endourol 2019; 33:417-422. [PMID: 30838888 DOI: 10.1089/end.2018.0654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction: Volume of renal parenchymal loss is known to affect postoperative renal function after partial nephrectomy (PN). We utilize a novel comparison using donor nephrectomy (DN) patients to demonstrate the primary effect parenchymal volume loss plays on postoperative renal function following PN. Materials and Methods: Records of 250 living donor (DN) and 118 PN patients were retrospectively reviewed. Baseline characteristics and preoperative estimated glomerular filtration rate (eGFR)s were recorded. Percent changes in eGFR and incidences of surgically induced chronic kidney disease (CKD-S) in short, intermediate, and long-term postoperative periods were compared. Univariate and multivariate analyses of prognostic factors for development of CKD-S were performed. The PN group was further divided into subgroups with different lengths of warm ischemia time (WIT) and compared with DN patients. Results: At baseline, DN patients were younger, less likely to be male, had lower body mass index, lower American Society of Anesthesiologists, and higher preoperative eGFR (all p < 0.001). At hospital discharge, intermediate follow-up, and latest follow-up, renal function changes in DN and PN groups were -40.5% vs. -3.6%, -34.1% vs. -5.5%, and -33.2% vs. -4.4%, respectively (all p < 0.001). More DN than PN patients developed CKD-S (p < 0.001). DN was a significant risk factor for the development of chronic kidney disease on univariate and multivariate analyses (p < 0.001). On subgroup analysis, both subgroups with WIT 1 to 30 minutes and 31 to 60 minutes had less renal function decline at all time points compared with DN (p < 0.001). Conclusions: Volume of renal parenchyma retained is the dominant driver of postoperative renal function after nephrectomy, compared with all other factors. Surgeons should minimize parenchymal loss during PN to optimize postoperative renal function.
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Affiliation(s)
- Jim Shen
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - David Ruckle
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Roger Li
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Mohamed Keheila
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Muhannad Alsyouf
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Jared Schober
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - David Tryon
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Phillip Stokes
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Herbert C Ruckle
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
| | - Pedro Baron
- 2 Department of Transplantation, Loma Linda University Health, Loma Linda, California
| | - Michael De Vera
- 2 Department of Transplantation, Loma Linda University Health, Loma Linda, California
| | - D Duane Baldwin
- 1 Department of Urology and Loma Linda University Health, Loma Linda, California
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Cheriyan S, Mowery H, Ruckle D, Keheila M, Myklak K, Alysouf M, Atiga C, Khuri J, Khater N, Faaborg D, Ruckle HC, Baldwin DD, Baldwin DD. The Impact of Operating Room Noise Upon Communication During Percutaneous Nephrostolithotomy. J Endourol 2016; 30:1062-1066. [DOI: 10.1089/end.2016.0498] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Salim Cheriyan
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Hayley Mowery
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - David Ruckle
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Mohamed Keheila
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Kristene Myklak
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Muhannad Alysouf
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Chase Atiga
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Jacob Khuri
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Nazih Khater
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Daniel Faaborg
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - Herbert C. Ruckle
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - D. Daniel Baldwin
- Department of Urology, Loma Linda University Health, Loma Linda, California
| | - D. Duane Baldwin
- Department of Urology, Loma Linda University Health, Loma Linda, California
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Tryon D, Myklak K, Alsyouf M, Conceicao C, Peplinski B, Arenas JL, Faaborg D, Ruckle HC, Baldwin DD. Renal Vascular Clamp Placement: A Potential Cause of Incomplete Hilar Control during Partial Nephrectomy. J Urol 2015; 195:756-62. [PMID: 26417645 DOI: 10.1016/j.juro.2015.09.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Previous benchtop studies have shown that robotic bulldog clamps provide incomplete vascular control of a Penrose drain. We determined the efficacy of robotic and laparoscopic bulldog clamps to ensure hemostasis on the human renal artery. The effect of clamp position on vascular control was also examined. MATERIALS AND METHODS Fresh human cadaveric renal arteries were used to determine the leak point pressure of 7 bulldog clamps from a total of 3 manufacturers. Five trials were performed per clamp at 4 locations, including the fulcrum, proximal, middle and distal positions. Comparison was done using the Kruskal-Wallis test with p <0.05 considered significant. RESULTS None of the bulldog clamps leaked at a pressure less than 215 mm Hg when applied at the proximal, middle or distal position. In general leak point pressure decreased as the artery was positioned more distal along the clamp. The exception was when the vessel was placed at the fulcrum position. At that position 80% to 100% of trials with the Klein laparoscopic, 100% with the Klein robotic (Klein Robotic, San Antonio, Texas) and 60% to 80% with the Scanlan robotic (Scanlan International, Saint Paul, Minnesota) clamp leaked at pressure below 215 mm Hg. CONCLUSIONS Each vascular clamp adequately occluded flow at physiological pressure when placed at the proximal, middle or distal position. Furthermore, these results demonstrate that there is leakage at physiological pressure when the artery is placed at the fulcrum of certain clamp types. These results suggest that applying a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and intraoperative bleeding.
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Affiliation(s)
- David Tryon
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Kristene Myklak
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Muhannad Alsyouf
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Carol Conceicao
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Brandon Peplinski
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Javier L Arenas
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Daniel Faaborg
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Herbert C Ruckle
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - D Duane Baldwin
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
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Myklak K, Mowery H, Alsyouf M, Li R, Lightfoot M, Atiga C, Tryon D, Hodgson H, Conceicao C, Faaborg D, Arenas JL, Khater N, Ruckle HC, Baldwin DD, Baldwin DD. MP30-10 INTRAOPERATIVE NOISE POLLUTION AND ITS EFFECT UPON COMMUNICATION DURING PERCUTANEOUS NEPHROSTOLITHOTOMY. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Li R, Ruckle HC, Schlaifer AE, El-Shafei A, Yu C, Jones JS. The Effect of Androgen Deprivation Therapy Before Salvage Whole-gland Cryoablation After Primary Radiation Failure in Prostate Cancer Treatment. Urology 2015; 85:1137-1142. [PMID: 25799176 DOI: 10.1016/j.urology.2014.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/01/2014] [Accepted: 12/19/2014] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To define the effects of androgen deprivation therapy (ADT) used prior to salvage cryoablation (SC) for the treatment of recurrent localized prostate cancer after radiation. METHODS Patients from the Cryo On-Line Database registry undergoing SC after radiation failure were divided according to whether they had previously received or not received ADT. Baseline characteristics including demographics and presalvage cancer risk were compared. Biochemical progression-free survival (bPFS) as defined by the Phoenix criteria was compared between the 2 groups as a whole and also in D'Amico risk-stratified subgroups. In addition, postsurgical complications such as urinary fistula, retention, incontinence, and erectile dysfunction were compared. RESULTS Two groups consisting of 254 and 486 patients with and without pre-SC ADT were analyzed. The patients who received ADT were younger (P = .003) and had higher presalvage D'Amico risks (P <.001). The 5-year bPFS was 63.8% and 39.3% for the hormone-naïve and the pre-SC ADT patients, respectively (P <.001). On subgroup analysis, the difference in 5-year bPFS was significant only for patients with a high D'Amico cancer risk (54.3% vs 30.5%; P = .013). On multivariate analysis, presalvage prostate-specific antigen (hazard ratio [HR], 1.7), Gleason score ≥ 8 (HR, 2.5), and use of pre-SC ADT (HR, 1.7) correlated with biochemical recurrence. Additionally, patients receiving pre-SC ADT experienced less urinary retention (P = .001) and incontinence (P = .008) but were more likely to be impotent (P = .010). CONCLUSION Patients receiving ADT before SC, especially those with high-risk prostate cancer, had worse 5-year bPFS. Added caution is needed when selecting patients having previously received ADT for salvage cryotherapy.
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Affiliation(s)
- Roger Li
- Department of Urology, Loma Linda University Medical Center, Loma Linda, CA
| | - Herbert C Ruckle
- Department of Urology, Loma Linda University Medical Center, Loma Linda, CA.
| | - Amy E Schlaifer
- Department of Urology, Loma Linda University Medical Center, Loma Linda, CA
| | - Ahmed El-Shafei
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Urology Department, Medical School, Cairo University, Giza, Egypt
| | - Changhong Yu
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Urology Department, Medical School, Cairo University, Giza, Egypt
| | - J Stephen Jones
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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Olgin G, Alsyouf M, Han D, Li R, Lightfoot M, Smith DL, Nicolay L, Ruckle HC, Baldwin DD. POSTOPERATIVE CYSTOGRAM FINDINGS PREDICT INCONTINENCE FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY. J Endourol 2014. [DOI: 10.1089/end.2014.0236.ecc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Li R, Ruckle HC, Creech JD, Culpepper DJ, Lightfoot MA, Alsyouf M, Nicolay L, Jellison F, Baldwin DD. A Prospective, Randomized, Controlled Trial Assessing Diazepam to Reduce Perception and Recall of Pain During Transrectal Ultrasonography-Guided Biopsy of the Prostate. J Endourol 2014; 28:881-6. [DOI: 10.1089/end.2014.0043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Roger Li
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Herbert C. Ruckle
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Jon D. Creech
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - David J. Culpepper
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | | | - Muhannad Alsyouf
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Lesli Nicolay
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Forrest Jellison
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - D. Duane Baldwin
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
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12
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Anderson KM, Ruckle HC, Baldwin DD. Robotic-assisted surgery and the evolution of the radical prostatectomy. MINERVA UROL NEFROL 2012; 64:97-122. [PMID: 22617305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The surgical treatment of prostate cancer has evolved considerably since it was first described in 1905. With the introduction of a robotic, surgical-assist device, minimally invasive techniques for prostate removal have been increasingly utilized throughout the world. Currently, there is a large body of literature suggesting that robotic-assisted laparoscopic prostatectomy is associated with certain improved perioperative and postoperative outcomes and similar cancer control rates compared to open radical prostatectomy. The goal of this review is to objectively evaluate and describe the current state-of-the-art in surgical technique, perioperative and long-term outcomes, complications and the future of robotic-assisted laparoscopic radical prostatectomy.
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Affiliation(s)
- K M Anderson
- Department of Urology, Loma Linda University Medical Center, Loma Linda, CA, USA
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Heldt JP, Jellison FC, Yuen WD, Tenggardjaja CF, Lui PD, Ruckle HC, Barker GR, Baldwin DD. Patients with End-Stage Renal Disease Are Candidates for Robot-Assisted Laparoscopic Radical Prostatectomy. J Endourol 2011; 25:1175-80. [DOI: 10.1089/end.2010.0680] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jonathan P. Heldt
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Forrest C. Jellison
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Walter D. Yuen
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | | | - Paul D. Lui
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Herbert C. Ruckle
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Gary R. Barker
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - D. Duane Baldwin
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California
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Jellison FC, Smith JC, Heldt JP, Spengler NM, Nicolay LI, Ruckle HC, Koning JL, Millard WW, Jin DH, Baldwin DD. Effect of low dose radiation computerized tomography protocols on distal ureteral calculus detection. J Urol 2009; 182:2762-7. [PMID: 19837431 DOI: 10.1016/j.juro.2009.08.042] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE Unenhanced multidetector computerized tomography is the imaging modality of choice for urinary calculi but exposes patients to substantial radiation doses with a subsequent risk of radiation induced secondary malignancy. We compared ultra low dose and conventional computerized tomography protocols for detecting distal ureteral calculi in a cadaveric model. MATERIALS AND METHODS A total of 85 calcium oxalate stones 3 to 7 mm long were prospectively placed in 14 human cadaveric distal ureters in 56 random configurations. The intact kidneys, ureters and bladders were placed in a human cadaveric vehicle and computerized tomography was performed at 140, 100, 60, 30, 15 and 7.5 mA seconds while keeping other imaging parameters constant. Images were independently reviewed in random order by 2 blinded radiologists to determine the sensitivity and specificity of each mA second setting. RESULTS Overall sensitivity and specificity were 98% and 83%, respectively. Imaging using 140, 100, 60, 30, 15 and 7.5 mA second settings resulted in 98%, 97%, 97%, 96%, 98% and 97% sensitivity, and 83%, 83%, 83%, 86%, 80% and 84% specificity, respectively. Interobserver agreement was excellent (kappa >0.87). There was no significant difference in sensitivity or specificity at any mA second settings. All false-negative results were noted for 3 mm calculi at a similar frequency at each mA second setting. CONCLUSIONS Ultra low dose computerized tomography protocols detected distal ureteral calculi in a fashion similar to that of conventional computerized tomography protocols in a cadaveric model. These protocols may decrease the radiation dose up to 95%, reducing the risk of secondary malignancies.
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Affiliation(s)
- Forrest C Jellison
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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Jellison FC, Nicolay LI, Heldt JP, Smith JC, Spengler N, Ruckle HC, Baldwin DD. THE EFFECT OF ULTRA LOW-DOSE RADIATION CT PROTOCOLS UPON DETECTION OF DISTAL URETERAL CALCULI. J Urol 2009. [DOI: 10.1016/s0022-5347(09)62312-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Harper JD, Kaiser S, Ebrahimi K, Lamberton GR, Hadley HR, Ruckle HC, Baldwin DD. Prior video game exposure does not enhance robotic surgical performance. J Endourol 2008; 21:1207-10. [PMID: 17949327 DOI: 10.1089/end.2007.9905] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Prior research has demonstrated that counterintuitive laparoscopic surgical skills are enhanced by experience with video games. A similar relation with robotic surgical skills has not been tested. The purpose of this study was to determine whether prior video-game experience enhances the acquisition of robotic surgical skills. SUBJECTS AND METHODS A series of 242 preclinical medical students completed a self-reported video-game questionnaire detailing the frequency, duration, and peak playing time. The 10 students with the highest and lowest video-game exposure completed a follow-up questionnaire further quantifying video game, sports, musical instrument, and craft and hobby exposure. Each subject viewed a training video demonstrating the use of the da Vinci surgical robot in tying knots, followed by 3 minutes of proctored practice time. Subjects then tied knots for 5 minutes while an independent blinded observer recorded the number of knots tied, missed knots, frayed sutures, broken sutures, and mechanical errors. RESULTS The mean playing time for the 10 game players was 15,136 total hours (range 5,840-30,000 hours). Video-game players tied fewer knots than nonplayers (5.8 v 9.0; P = 0.04). Subjects who had played sports for at least 4 years had fewer mechanical errors (P = 0.04), broke fewer sutures (P = 0.01), and committed fewer total errors (P = 0.01). Similarly, those playing musical instruments longer than 5 years missed fewer knots (P = 0.05). CONCLUSIONS In the extremes of video-game experience tested in this study, game playing was inversely correlated with the ability to learn robotic suturing. This study suggests that advanced surgical skills such as robotic suturing may be learned more quickly by athletes and musicians. Prior extensive video-game exposure had a negative impact on robotic performance.
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Affiliation(s)
- Jonathan D Harper
- Division of Urology, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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Abstract
PURPOSE We reviewed the clinical course of patients in whom urothelial carcinoma developed following radiation therapy for prostate cancer. MATERIALS AND METHODS A retrospective review of all patients between 1990 and 2005 with the diagnosis of bladder and prostate cancer was performed. Of 125 total patients new onset urothelial carcinoma developed in 11 after undergoing external beam radiation therapy for prostate cancer. RESULTS Whole pelvis external beam radiation therapy with a proton boost to the prostate was the radiation modality in 7 of the 11 patients (64%), while the remaining 4 patients received standard external beam radiation only. Urothelial carcinoma was detected a mean of 3.07 years after completion of radiation therapy in the proton group, compared to a mean latency period of 5.75 years in the standard radiation group (p = 0.09). Average patient age at diagnosis was 72 years (range 64 to 84). All patients presented with gross hematuria and had cystoscopic findings of coexisting radiation cystitis. Of the 11 patients 5 (45%) presented with grade 3 carcinoma and eventually 7 (64%) required radical cystectomy. Urothelial tumors with sarcomatoid features (carcinosarcoma and spindle cell sarcomatoid) developed in 2 patients (18%). Of the 11 patients 10 (91%) were nonsmokers at the time of urothelial carcinoma diagnosis. CONCLUSIONS Urothelial carcinoma in patients with previous radiation therapy for prostate cancer is often high grade, and the majority of patients have cancer progression requiring cystectomy. A high incidence of urothelial carcinoma with sarcomatoid features was seen in these patients.
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Affiliation(s)
- Satyan K Shah
- Division of Urology, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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Leocádio DE, Ruckle HC, Curhan DJ. Ureteral obstruction by uterine artery aneurysm in third trimester of pregnancy. Urology 2006; 67:1290.e7-9. [PMID: 16697445 DOI: 10.1016/j.urology.2005.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 11/01/2005] [Accepted: 12/02/2005] [Indexed: 11/20/2022]
Abstract
Uterine artery aneurysm (UAA) is an uncommon complication of pregnancy. Its diagnosis before postpartum hemorrhage is rare. We report on a patient who presented with symptomatic ureteral obstruction secondary to UAA. The hydronephrosis was managed by ureteral stenting. The UAA was successfully embolized after a planned cesarean section delivery. UAA is a rare and clinically significant cause of hydronephrosis during pregnancy.
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Affiliation(s)
- Dean E Leocádio
- Department of Urology, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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19
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Abstract
AIMS Renal angiomyolipoma (AML) associated with tuberous sclerosis (TS) presents a treatment dilemma due to multifocal tumors with a potential for significant growth and subsequent hemorrhage. We reviewed the literature and our experience with AML and TS patients to determine the long-term behavior of these lesions. MATERIALS AND METHODS We reviewed 8 patients (16 renal units) with bilateral renal AMLs and comorbid TS. We evaluated their renal function, renal imaging, and clinical course. Patients were followed for a mean of 11.5 years (range 3.5 - 21 years). RESULTS The records of 8 patients (7 females, 1 male) with a mean age of 33.1 years (range 21 - 54) were evaluated. The mean serum creatinine of these patients at the time of diagnosis was 0.75 mg/dl (range 0.4 - 1.1). Mean serum creatinine at last follow-up was 0.83 mg/dl (range 0.6 - 1.3). The average size of the largest lesion was 13.9 cm (range: 0.5 - 28). Of the 8 patients, 6 received treatment during the course of their disease, including arterial embolization of 7 renal units in 5 symptomatic patients (2 patients needed 2 embolizations). Partial nephrectomy was performed on 2 renal units in 2 patients, and a total nephrectomy was performed in 1971 on another patient. Currently, all 8 patients have stable renal function; 4 patients are asymptomatic with regards to their lesions, while the other 4 patients report transient flank pain adequately controlled with oral analgesics (2 patients with propoxyphene plus acetaminophen 100/650 mg PO t.i.d. p.r.n., the other 2 patients with ibuprofen 600 mg PO p.r.n.). None of the patients experienced life-threatening hemorrhage or required dialysis. CONCLUSIONS Our study and a review of the literature have not revealed an obvious or quantitative risk of morbidity or mortality from renal hemorrhage directly related to AMLs of any specific size in TS patients. Due to multiple lesions and distortion of anatomy it can be difficult to distinguish individual lesions for preemptive treatment in asymptomatic patients. If size criteria alone are used, multiple treatments will be required over the course of the patient's life. Also, preemptive treatment exposes patients to iatrogenic morbidity. Consideration should be given to medical management of AMLs in TS patients with asymptomatic, slowly enlarging tumors that maintain features of an AML. Embolization, partial nephrectomy, or other ablative treatments (i.e. cryotherapy and RFA) can be reserved for symptomatic patients.
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Affiliation(s)
- D A Hadley
- Division of Urology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA
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Roehrborn CG, Rhee EY, Miller SD, Brawer MK, Heron SP, Ruckle HC, Loisides P, Freedman SJ. 1565: Initial Results of a Randomized Multi-Center Trial Comparing the Efficacy and Safety of Indigo Optima Laser Treatment with Tamsulosin in Men with LUTS and BPH. J Urol 2005. [DOI: 10.1016/s0022-5347(18)35699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Baron PW, Baldwin DD, Hadley HR, Ojogho ON, Ruckle HC, Concepcion W. Hand-assisted laparoscopic donor nephrectomy is safe and results in increased kidney donation. Am Surg 2004; 70:901-5. [PMID: 15529847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The impact of hand-assisted laparoscopic donor nephrectomy on kidney allograft function, perioperative complications, and organ supply was evaluated by retrospective analysis of 41 hand-assisted laparoscopic donor nephrectomy patients and their recipients between January and October 2003. Serum creatinine at discharge, length of stay, estimated blood loss, operative time, and perioperative complications were analyzed. The mean values for laparoscopic donors and their recipients were 1.2 +/- 0.3 and 1.3 +/- 0.8 mg/dL for creatinine, 3.3 +/- 0.8 and 6.7 +/- 3 days for length of stay, and 110.4 +/- 76.9 and 111.6 +/- 56 mL for estimated blood loss, respectively. No major complications occurred in the laparoscopic donors. The number of living kidney donors increased by 94% compared to the mean of the previous 4 years following implementation of the laparoscopic program. Hand-assisted laparoscopic donor nephrectomy is safe, results in excellent allograft function, and significantly increases donation.
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Affiliation(s)
- Pedro W Baron
- Transplantation Institute, Loma Linda University Medical Center, Loma Linda, California, USA
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22
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Baron PW, Baldwin DD, Hadley HR, Ojogho O, Ruckle HC, Concepcion W. Hand-Assisted Laparoscopic Donor Nephrectomy is Safe and Results in Increased Kidney Donation. Am Surg 2004. [DOI: 10.1177/000313480407001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The impact of hand-assisted laparoscopic donor nephrectomy on kidney allograft function, perioperative complications, and organ supply was evaluated by retrospective analysis of 41 hand-assisted laparoscopic donor nephrectomy patients and their recipients between January and October 2003. Serum creatinine at discharge, length of stay, estimated blood loss, operative time, and perioperative complications were analyzed. The mean values for laparoscopic donors and their recipients were 1.2 ± 0.3 and 1.3 ± 0.8 mg/dL for creatinine, 3.3 ± 0.8 and 6.7 ± 3 days for length of stay, and 110.4 ± 76.9 and 111.6 ± 56 mL for estimated blood loss, respectively. No major complications occurred in the laparoscopic donors. The number of living kidney donors increased by 94% compared to the mean of the previous 4 years following implementation of the laparoscopic program. Hand-assisted laparoscopic donor nephrectomy is safe, results in excellent allograft function, and significantly increases donation.
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Affiliation(s)
- Pedro W. Baron
- Transplantation Institute, Loma Linda University Medical Center, Loma Linda, California
| | - D. Duane Baldwin
- Division of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - H. Roger Hadley
- Division of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - O.N. Ojogho
- Transplantation Institute, Loma Linda University Medical Center, Loma Linda, California
| | - Herbert C. Ruckle
- Division of Urology, Loma Linda University Medical Center, Loma Linda, California
| | - Waldo Concepcion
- Transplantation Institute, Loma Linda University Medical Center, Loma Linda, California
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23
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Baldwin DD, Maynes LJ, Berger KA, Desai PJ, Zuppan CW, Zimmerman GJ, Winkielman AM, Sterling TH, Tsai CK, Ruckle HC. Laparoscopic warm renal ischemia in the solitary porcine kidney model. Urology 2004; 64:592-7. [PMID: 15351615 DOI: 10.1016/j.urology.2004.04.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2004] [Accepted: 04/19/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine the effect of a laparoscopic approach on warm renal ischemia in the pig with a solitary kidney. Although the maximal safe duration for warm ischemia during open partial nephrectomy is commonly accepted to be 30 minutes, the maximal safe ischemic time during laparoscopic partial nephrectomy has not been previously determined. METHODS Sixteen farm pigs underwent unilateral laparoscopic right nephrectomy. Two weeks later, the pigs underwent complete laparoscopic mobilization of the remaining left kidney and were randomized to complete hilar clamp times of 0, 30, 60, or 90 minutes. Serum creatinine was evaluated before right nephrectomy and at days 0, 2, 4, 7, 14, and 30 after renal ischemia during laparoscopy. All renal specimens were evaluated by an experienced nephropathologist in a blinded fashion. RESULTS The serum creatinine remained stable at all points in the control and 30-minute ischemia groups. The serum creatinine level rose initially on days 2 and 4 in the 60-minute and 90-minute ischemia groups but returned to baseline by day 7. At harvest, no statistically significant difference was found among the groups in serum creatinine or histologic features. CONCLUSIONS Renal ischemic times up to 90 minutes during laparoscopy were well tolerated by the solitary porcine kidney. Possible explanations for this finding include the protective effect of a solitary kidney and the potential protective effect of relative ischemic preconditioning provided by the pneumoperitoneum.
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Affiliation(s)
- D Duane Baldwin
- Division of Urology, Loma Linda University School of Medicine, Loma Linda, California 92354, USA
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Wang Z, Ramin SA, Tsai C, Lui P, Ruckle HC, Beltz RE, Sands JF, Slattery CW. Evaluation of PCR-ELISA for determination of telomerase activity in prostate needle biopsy and prostatic fluid specimens. Urol Oncol 2002; 7:199-205. [PMID: 12644217 DOI: 10.1016/s1078-1439(02)00191-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The conventional TRAP assay will determine telomerase activity in tissue or other specimens. However, methodological disadvantages limit its clinical use. We evaluated a modified TRAP assay, the telomerase PCR-ELISA, as a practical clinical system for measuring its activity in conjunction with prostate cancer (PCa). We examined telomerase activity by both TRAP and PCR-ELISA assays in 48 sextant needle biopsy (SNB) specimens from dye-marked areas of the prostate glands of 7 PCa patients. Each specimen was histologically confirmed as cancerous or cancer-free by examining a paired specimen taken from the same marked area. In addition, prostatic fluid (PF) specimens were analyzed from 18 patients, 9 of whom were diagnosed with PCa while 9 were diagnosed as cancer-free but mostly with BPH. The results on individual SNB specimens matched well for the two methods. The sensitivity (91%) and specificity (69%) for the PCR-ELISA measurements were consistent with those for the conventional TRAP assay, 88% and 81%, respectively. Quantitatively, with the PCR-ELISA assay, the mean telomerase activity (24.5+/-28.4 units) per needle core with PCa cells was significantly higher than that in needle cores without PCa cells (7.2+/-2.2 unit), as it was with the conventional TRAP assay, namely 25.6+/-27.8 units and 7.3+/-1.8 units, respectively. In PF specimens from PCa patients, which had a lower mean telomerase than was found in needle cores containing PCa cells (7.1+/-1.5 units in the PCR-ELISA, 7.2+/-1.8 units in the conventional TRAP assay), statistical analysis showed good matching between the results from the two assays, overall. In conclusion, the PCR-ELISA can be considered a reliable method to determine telomerase activity as an adjunct in the diagnosis and treatment of prostate cancer.
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Affiliation(s)
- Zhilian Wang
- Department of Biochemistry, School of Medicine, Loma Linda University, Loma Linda, CA 92350, USA
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25
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Kim JY, Ruckle HC, Ramin SA. Partial nephrectomy for renal cell carcinoma in an allograft kidney 15 years after transplantation. J Urol 2001; 165:1205. [PMID: 11257674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Affiliation(s)
- J Y Kim
- Division of Urology, Loma Linda University School of Medicine, Loma Linda, California, USA
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Wang Z, Ramin SA, Tsai C, Lui P, Herbert PJ, Kyeyune-Nyombi E, Ruckle HC, Beltz RE, Sands JF. Detection of telomerase activity in prostatic fluid specimens. Urol Oncol 2000; 6:4-9. [PMID: 11113366 DOI: 10.1016/s1078-1439(00)00094-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report here the extended use of the telomeric repeat amplification protocol (TRAP) assay for the detection of telomerase activity in fresh prostatic fluid obtained from anesthetized patients. Telomerase activity was detected in pellet extract and/or supernatant fluid of specimens obtained from 25 of 30 prostate cancer (PCa) patients (83%), whereas no activity was similarly detectable in specimens taken from 8 of 9 patients (89%) without clinical evidence of PCa. The positive predictive value (PPV) of the TRAP assay for PCa in this pilot study was 96%. We found a strong correlation between telomerase activity in prostatic fluid specimens and serum prostate specific antigen (PSA) values. Telomerase activity was found in 84% of specimens from patients with PSA values >4 ng/ml, whereas in specimens from patients with PSA values </=4 ng/ml, only 29% tested positive for telomerase activity. In patients with PSA values above the standard 0 to 4 ng/ml reference range, the PPV of the TRAP assay was 84%. Furthermore, telomerase activity could be detected in 85% of the specimens from PCa patients with Gleason scores >4. In prostatic fluid from PCa patients with Gleason scores of </=4, telomerase activity was detected 50% of the time. The PPV was 92% when a Gleason score of 4 was used as the lower limit. This pilot study raises the possibility of utilizing telomerase activity as an aid in PCa detection.
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Affiliation(s)
- Z Wang
- Department of Biochemistry, School of Medicine, Loma Linda University, 92354, Loma Linda, CA, USA
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27
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Weil DA, Ruckle HC, Lui PD, Saukel W. Kaposi's sarcoma of the testicle. AIDS Read 1999; 9:455-6, 461. [PMID: 12737136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
The penis and scrotum are the genitourinary tract organs most frequently involved in Kaposi's sarcoma (KS). However, solid organ involvement is rare. A 32-year-old man with AIDS presented with cutaneous KS, which subsequently metastasized to the right testicle.
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Affiliation(s)
- D A Weil
- Department of Urology, Loma Linda University School of Medicine, Loma Linda, California, USA
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28
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Abstract
OBJECTIVES Male urinary incontinence secondary to intrinsic sphincter deficiency (ISD) is a possible complication of transurethral resection of the prostate (TURP) or radical prostatectomy (RP). For objective assessment of urinary sphincteric competence, we used perfusion sphincterometry (PS) to measure the retrograde urethral perfusion pressure (RUPP). METHODS A retrospective and prospective analysis of 60 neurologically normal patients of varying continence status was performed. The subjects were divided into three groups: continent patients with no previous prostate surgery (group 1), continent patients after prostatectomy (group 2), and incontinent patients after prostatectomy (group 3). All patients underwent PS with the technique described. All incontinent patients (group 3) had a filling cystometrogram (CMG) to rule out detrusor instability. RESULTS Continent patients with no prior prostate surgery (group 1) had a mean RUPP of 101 +/- 16 cm H2O; continent postprostatectomy patients (group 2) had a mean RUPP of 77 +/- 14 cm H2O; and incontinent postprostatectomy patients (group 3) had a mean RUPP of 36 +/- 11 cm H2O. The differences were statistically significant (P <0.001). There was no statistically significant difference in RUPP when the patients in groups 2 and 3 were stratified into TURP and RP groups. CONCLUSIONS PS is a simple and accurate technique for objective evaluation of lower sphincter competence. Patients with stress incontinence after prostatectomy have a statistically significant decrease in RUPP compared with continent controls. In combination with cystourethroscopy and filling CMG, PS can be useful in the evaluation of postprostatectomy incontinence.
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Affiliation(s)
- B R Bamshad
- Division of Urology, Loma Linda University Medical Center, California 92354, USA
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29
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Baldwin DD, Beaghler MA, Ruckle HC, Poon MW, Juriansz GJ. Ureteroscopic treatment of symptomatic caliceal diverticular calculi. Tech Urol 1998; 4:92-8. [PMID: 9623623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Renal calculi that reside in caliceal diverticula are difficult to treat. Numerous treatment modalities have been used, including extracorporeal shock wave lithotripsy, laparoscopy, and percutaneous treatment. All therapies directed at fragmenting the stones are limited by the ability of these fragments to pass through the narrow diverticular neck. More recently, the retrograde approach using small-caliber flexible ureteroscopes has been applied successfully in the treatment of diverticular calculi. A description of our retrograde technique is presented. The ultimate success of this technique is dependent upon familiarity with the basic principles of ureteroscopy and successful clearance of stone fragments from the diverticulum.
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Affiliation(s)
- D D Baldwin
- Division of Urology, Loma Linda University School of Medicine, California, USA
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30
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Ramin SA, Beaghler MA, Ruckle HC, McLaughlin KP. Endoscopic treatment of continent urinary reservoir calculi. Tech Urol 1997; 3:114-8. [PMID: 9297774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Formation of calculi is a late complication of continent urinary diversions. The techniques of percutaneous and transstomal treatment of these stones are described. Three patients underwent percutaneous placement of a rigid nephroscope into three different types of continent reservoirs and fragmentation of stones (2-5 cm in size) using ultrasonic lithotripsy. Preoperative CT scan of the abdomen and pelvis with oral and intrareservoir contrast was essential in finding the safest location for percutaneous access. One patient, with small stones, underwent placement of a flexible cystoscope through the continent efferent limb and Holmium laser lithotripsy. There were no instances of reservoir perforation. There was minimal blood loss, with an average operative time of 165 min. Ultrasonic lithotripsy of large stones through a percutaneous approach and Holmium laser lithotripsy for smaller stones via a flexible cystoscope placed through the efferent limb are safe and effective ways to treat calculi within continent urinary diversions.
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Affiliation(s)
- S A Ramin
- Department of Urology, Loma Linda University School of Medicine, CA 92350, USA
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Hamlin JA, Smith DC, Taylor FC, McKinney JM, Ruckle HC, Hadley HR. Renal angiomyolipomas: long-term follow-up of embolization for acute hemorrhage. Can Assoc Radiol J 1997; 48:191-8. [PMID: 9193419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To determine if elective, angiographically directed embolization of enlarged renal angiomyolipomas can be used to prevent future hemorrhagic episodes in patients with tuberous sclerosis and thus avoid nephrectomy. PATIENTS AND METHODS Records were reviewed for all 5 patients who underwent elective, subtotal embolization of large, symptomatic angiomyolipomas at the authors' institution between 1975 and 1996. RESULTS All 5 patients had tuberous sclerosis and bilateral renal angiomyolipomas. Initial embolization in these patients was performed in 1975, 1981, 1993 (2 patients) and 1994. In 1 patient only a single embolization session was required. In another, initial embolization on the left side was followed by embolization on the right 13 months later. Two patients underwent 2 sessions, and 1 patient had 4 sessions over a 13-year period. Subtotal embolization with particulate material led to a decrease in size of the most severely affected portion of the kidney. One large angiomyolipoma underwent sterile liquefaction after embolization; percutaneous catheter drainage was required. The embolization allowed subsequent partial nephrectomy in this patient. CONCLUSION Embolization is effective for the long-term management of renal angiomyolipomas in patients with tuberous sclerosis; in this way nephrectomy and loss of renal function can usually be avoided.
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Affiliation(s)
- J A Hamlin
- Department of Radiology, Loma Linda University Medical Center, Calif 92354, USA
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Benjamin DS, Oberg KC, Saukel GW, Ruckle HC, Stewart SC. Histopathologic evaluation of the canine prostate following electrovaporization. J Urol 1997; 157:1144-8. [PMID: 9072559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Transurethral electrovaporization of the prostate (TVP) for symptomatic benign prostatic hypertrophy (BPH) has proven to be efficacious with minimal patient morbidity. When compared to transurethral resection of the prostate (TURP), TVP demonstrates comparable postoperative flow rates, American Urologic Association (AUA) symptom score indices, and a potential cost savings. However, in the human studies it has not been possible to correlate these clinical parameters with procedure-related histopathologic changes in the prostate immediately postoperative or during wound healing. The following study was done using a canine model in an effort to evaluate these histopathologic changes. METHODS AND MATERIALS Fifteen hounds (25-35 kg.) underwent antegrade electrovaporization of the prostate, via an open cystotomy, using a Circon ACMI USA series resectoscope and video equipment. The dogs were sacrificed and the prostates harvested at various intervals postoperatively (0-11 weeks). The prostates were evaluated grossly as well as histologically for cavitary defects, depth of necrosis, and cellular response. RESULTS Prostates examined immediately following the procedure demonstrated superficial necrosis (less than 2 mm.) in the region of vaporized tissue. One week postoperatively, the vaporized regions demonstrated an intense acute inflammation amidst superficial necrosis with focal hemorrhage and dystrophic calcification. Transient glandular cystic changes developed, but were resolving by seven weeks postoperatively. Re-epithelialization was underway by the third postoperative week and epithelial stratification underway by the fifth week. There was no extension of the initial two millimeter zone of necrosis at any time point examined. CONCLUSION TVP in the canine model vaporizes prostatic tissue at the site of contact. Only a shallow remnant of necrosis remains at the site of vaporization, indicating the highly localized effect of this technique. Healing at the site of vaporization occurs in a rapid and expected manner. These data provide a histopathologic rationale for the minimal morbidity and the efficacious nature of this technique demonstrated in clinical studies.
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Affiliation(s)
- D S Benjamin
- Loma Linda University School of Medicine, Department of Urology, California, USA
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Benjamin DS, Ruckle HC, Hadley HR. Local recurrence of renal cell carcinoma causing duodenal-inferior vena caval fistula: case report and review of the literature. Urology 1996; 48:636-8. [PMID: 8886075 DOI: 10.1016/s0090-4295(96)00220-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We report the first case of a duodenal-inferior vena caval (IVC) fistula resulting from locally recurrent renal cell carcinoma (RCC). A 45-year-old man presented with gross hematuria and underwent a right radical nephrectomy to treat a solid renal mass. Histologic evaluation showed RCC, Stage pT3aN0M0. The patient presented 21 months later in hemorrhagic shock, with upper gastrointestinal bleeding. He underwent an exploratory laparotomy and Whipple procedure for a mass in the second portion of the duodenum extending to the inferior vena cava with a secondary duodenal-IVC fistula. We describe this case and review the previously published reports of duodenal-IVC fistulae.
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Affiliation(s)
- D S Benjamin
- Division of Urology, Loma Linda University School of Medicine, CA 92354, USA
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Harris D, Ruckle HC. Serologic markers in prostate cancer. West J Med 1996; 164:344-5. [PMID: 8732740 PMCID: PMC1303516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
Iatrogenic immunosuppression following renal transplantation has been associated with the development and progression of multiple neoplasms, including transitional cell carcinoma (TCC). We present the first report of invasive TCC of the bladder managed with radical cystectomy in a cardiac transplant recipient. The short survival of this patient, despite organ-confined disease at the time of cystectomy, illustrates the necessity of early diagnosis and aggressive treatment of malignancy following organ transplantation.
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Affiliation(s)
- D D Baldwin
- Division of Urology, Loma Linda University, California 92350, USA
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Abstract
Closure of renal parenchymal defects created by partial nephrectomy can be difficult. We describe a method of using exogenous material to bolster the strength of the parenchymal closure. The horizontal mattress sutures closing the renal parenchyma are less likely to tear through the parenchyma as the result of the application of a more uniform tension across a broad front. This technique is particularly helpful for large and irregular defects. Tying the closure sutures over an exogenous bolster material aids in a rapid, hemostatic, and watertight closure.
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Affiliation(s)
- H Zincke
- Department of Urology, Mayo Clinic, Rochester, Minnesota, USA
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37
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Ruckle HC, Zincke H. Potency-sparing radical retropubic prostatectomy: a simplified anatomical approach. J Urol 1995; 153:1875-7. [PMID: 7752337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A simplified method of nerve sparing radical retropubic prostatectomy for clinical stage T2a prostate cancer is described based on primary isolation of both neurovascular bundles and secondary division of the urethra, with the puboprostatic ligaments undivided to provide suspension of the deep venous complex above the urethra. The principles for this approach after division of the deep vein complex are based on early unilateral incision of the prostatic fascia laterally, parallel to the ipsilateral neurovascular bundle and extending from the proximal prostate to the urethra; separation of anterior (prostatic) and posterior (rectal) Denonilliers' fascia, which leaves the neurovascular bundle invested in the latter tissue; perforation and incision of contralateral prostatic fascia at its urethroprostatic angle, with cranial extension of the fascial opening dropping the ipsilateral neurovascular bundle invested in its fascia (Denonvilliers' posterior), and anastomotic division of the urethra at its entrance into the prostate.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Mayo Clinic, Rochester, Minnesota, USA
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Lang GS, Ruckle HC, Hadley HR, Lui PD, Stewart SC. One hundred consecutive laparoscopic pelvic lymph node dissections: comparing complications of the first 50 cases to the second 50 cases. Urology 1994; 44:221-5. [PMID: 8048197 DOI: 10.1016/s0090-4295(94)80135-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To report the outcome of our first 100 consecutive laparoscopic pelvic lymph node dissections (LPLND) and compare the early complication rate of the first 50 cases (14%) to the second 50 cases (4%). METHODS We reviewed 100 patients who underwent LPLND: Ninety-six patients had carcinoma of the prostate and underwent LPLND prior to radical prostatectomy or definitive radiation therapy. Four patients had histologically proved penile (2) or bladder carcinoma (2) and underwent LPLND to assess their pelvic lymph nodes. RESULTS We encountered 7 major and minor complications in our first 50 cases, and 2 minor complications in our second 50 cases. The overall complication rate was 9% (9 of 100). CONCLUSIONS We believe that modification of our operative technique and changes in patient management resulted in a lower complication rate in the second 50 patients. We conclude that although LPLND has a significant learning curve, it is a viable surgical staging option for patients with urologic pelvic malignancies.
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Affiliation(s)
- G S Lang
- Division of Urology, Loma Linda University School of Medicine, California
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Abstract
OBJECTIVES To report and discuss five cases of renal cell carcinoma (RCC) in which preoperative imaging studies were equivocal with regard to the presence and extent of vena caval tumor thrombus or in which dynamic intraoperative imaging of the vena cava was advantageous. METHODS We reviewed the cases of five patients who had conflicting preoperative imaging studies and reviewed the literature applying to this clinical situation. RESULTS Two patients whose preoperative magnetic resonance imaging studies suggested inferior vena caval tumor thrombus were shown, on intraoperative color Doppler ultrasound, not to have tumor thrombus but rather turbulent flow within the vena cava mimicking thrombus. In two patients intraoperative ultrasound (IOUS) was used to image the position of the tumor thrombus as it was manipulated to allow for safe vena caval clamp placement. In one patient we used real-time imaging to visualize thrombus extraction from the heart. CONCLUSIONS Intraoperative ultrasound real-time imaging is beneficial in two specific situations: in those cases in which the presence of renal vein or inferior vena cava involvement is equivocal based on preoperative imaging techniques and when there is a need to identify intraoperatively the limits of a known tumor thrombus to allow subsequent safe placement of a caval clamp.
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Affiliation(s)
- D D Harris
- Division of Urology, Loma Linda University, School of Medicine, California
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40
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Velagapudi SR, Frydenberg M, Oesterling JE, Bergstralh EJ, Moore SB, Ruckle HC, Zincke H. Homologous blood transfusion in patients with prostate cancer: no effect on tumor progression or survival. Urology 1994; 43:821-7. [PMID: 8197646 DOI: 10.1016/0090-4295(94)90143-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine the effect of perioperative blood transfusions in patients with prostate cancer who underwent radical prostatectomy, we analyzed 1,785 patients with a follow-up of five years or more who were treated during a twenty-one-year period (1966 to 1987). METHODS Patients were divided into three groups according to the number of units transfused during the perioperative period: group 1, 0 units (n = 440), group 2, 1 to 2 units (n = 746), and group 3, 3 or more units (n = 599). RESULTS With univariate analysis, no statistically significant differences were found among the three groups in overall survival rate (71%, 75%, and 71% at ten years; p = 0.48), cause-specific survival rate (89%, 88%, and 86% at ten years; p = 0.36), or progression-free survival rate (61%, 68%, and 68% at ten years; p = 0.83). Adjusting for tumor grade, pathologic stage, and hormonal therapy using the Cox statistical model, we found no significant association between the blood-use group and overall survival rate (p = 0.45), cause-specific survival rate (p = 0.17), or progression-free survival rate (p = 0.34). The estimated relative risk and 95 percent confidence interval associated with blood transfusion (three or more units versus none) were as follows: 1.03 and 0.76 to 1.38 for total mortality, 1.56 and 0.95 to 2.56 for cause-specific death, and 1.20 and 0.91 to 1.57 for disease progression, respectively. CONCLUSIONS According to these findings, withholding homologous blood transfusion, except for infectious precautions, should not be based on the suspicion that it can accelerate death from cancer in patients who undergo radical prostatectomy for prostate cancer.
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Affiliation(s)
- S R Velagapudi
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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41
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Abstract
BACKGROUND Serum prostate-specific antigen (PSA), when used in combination with existing detection methods, improves the clinician's ability to detect early and potentially curable prostate cancer. FINDINGS This report describes clinically important issues about use of the serum PSA concentration for detecting early prostate cancer. Other PSA-related factors--PSA density, PSA velocity, and age-specific reference ranges--seem to enhance the ability of clinicians to distinguish benign prostatic conditions from early prostate cancer. Because digital rectal examination only minimally affects the serum PSA concentration, delaying a determination after this examination is unnecessary. Finasteride therapy for benign prostatic hyperplasia should be initiated only after the prostate has been evaluated for cancer because this 5 alpha-reductase inhibitor lowers the serum PSA value by approximately 50%; however, reassessment of the prostate for cancer is necessary if the PSA level fails to decrease as expected or increases to more than 2 ng/mL during finasteride treatment. CONCLUSION Currently, PSA is the most important, accurate, and clinically useful tumor marker for prostate cancer.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Mayo Clinic, Rochester, MN 55905
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42
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Abstract
FINDINGS The prostate-specific antigen (PSA) level alone does not facilitate precise pathologic staging on an individual basis, although advanced stage tends to correlate with an increased PSA level. The staging accuracy of PSA, however, can be enhanced by considering the variables of tumor grade and clinical stage. Staging radionuclide bone scans in asymptomatic, untreated patients with clinically localized prostate cancer and a PSA value of less than 10.0 ng/mL are unnecessary. After radical prostatectomy, the serum PSA level is exquisitely sensitive to recurrent or residual disease. Ultrasensitive PSA assays can increase the sensitivity of PSA as a tumor marker after surgical removal of the prostate. Currently, however, the clinical usefulness of PSA concentrations detected in the ultrasensitive range after radical prostatectomy is unknown. Serum PSA values aid in monitoring patients who have received definitive radiation therapy for prostate cancer. Patients in whom the serum PSA level decreases to the reference range have a favorable prognosis. An increasing serum PSA concentration after radiation therapy heralds progressive prostate cancer. The serum PSA level after androgen deprivation therapy (ADT) also has prognostic importance in that a decrease to the normal range predicts a prolonged remission in most patients. Because expression of PSA is under direct hormonal influence, however, ADT can decrease the serum PSA value independent of antitumorigenic activity. Patients who have received ADT must be closely monitored for signs of clinical progression because, in some patients, a serum PSA concentration within the reference range may underestimate actual tumor burden and activity. CONCLUSION PSA is the most useful and accurate tumor marker for staging and monitoring prostate cancer after therapy.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Mayo Clinic Rochester, MN 55905
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43
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Abstract
We describe the laparoscopic treatment of a symptomatic, stone-filled caliceal diverticulum in a patient who would have otherwise required open surgical excision of the diverticulum. Laparoscopic management was chosen as an alternative to an open operation in this patient because the anterior location of the diverticulum precluded treatment with percutaneous nephrolithotomy, while the stone burden and stenotic orifice precluded management with extracorporeal shock wave lithotripsy. The patient had no morbidity, returned to the preoperative activity level by 2 weeks and remains asymptomatic. The options for managing caliceal diverticula are discussed.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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44
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Abstract
Tumors are known to produce factors suppressing immune functions. We previously showed that a murine renal cell carcinoma (Renca) suppressed macrophage function in vitro and that this suppression was abolished by co-incubation with extracts of two Chinese medicinal herbs. We now report that these phytochemicals are capable of inhibiting growth of Renca in vivo. BALB/c mice were transplanted intraperitoneally (IP) with 1-2 x 10(5) Renca cells. One day after tumor transplant, mice were randomized into two groups. One group was treated IP, daily for 10 days, with 100 microliters of phytochemicals containing 500 micrograms each of Astragalus membranaceus and Ligustrum lucidum, while the other group received saline as controls. A cure rate of 57% was obtained with these phytochemicals when the initial tumor load was 2 x 10(5), and 100% when the initial tumor load was 1 x 10(5). Additional experiments were performed to investigate the mechanisms involved in this protection. Splenic macrophages from tumor-bearing mice were shown to have depressed chemiluminescent oxidative burst activity, and this depression was restored with phytochemical treatment. Splenocytes from mice transplanted with Renca responded less favorably to interleukin-2 (IL-2) in generating lymphokine-activated killer (LAK) cells; again this depression was restored with phytochemical treatment. Our data suggest that these phytochemicals may have exerted their antitumor effects via augmentation of phagocyte and LAK cell activities.
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Affiliation(s)
- B H Lau
- Department of Microbiology, School of Medicine, Loma Linda University, California 92350
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45
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Abstract
Prostate-specific antigen (PSA) is a kallikrein-like serine protease that, for all practical purposes, is specific for prostatic tissue. PSA is usually detected at low concentrations (0.0-4.0 ng/ml) in the serum and is the most important tumor marker for detecting otherwise unsuspected prostate cancer; it also useful for monitoring the response of prostate cancer to various types of therapy. Androgen deprivation therapy (ADT) includes bilateral orchiectomy, luteinizing hormone-releasing hormone (LHRH) agonists, antiandrogens, and 5-alpha-reductase inhibitors. Treatment of benign prostatic hypertrophy (BPH) or prostate cancer with ADT usually decreases the serum PSA concentration. Recent basic science research has demonstrated that the expression of the PSA gene is controlled by androgens acting via the androgen receptor. Therefore, in some patients a low serum PSA concentration will be the result of hormonal down-regulation of the genetic expression of PSA and not the result of the antitumorigenic activity of the therapy. Nevertheless, in spite of the direct effect of ADT on PSA expression, PSA remains a valuable prostate cancer tumor marker for prognosticating the response to ADT and portending clinical progression after this type of treatment for most patients.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Mayo Clinic, Rochester, MN 55905
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46
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Abstract
Renal tumors including renal cortical adenoma, renal cell carcinoma (hypernephroma), oncocytoma, angiomyolipoma (hamartoma), medullary fibroma, juxtaglomerular cell tumor, nephroblastoma (Wilms' tumor), mesoblastic nephroma, renal blastema, sarcoma, and secondary metastatic lesions are discussed. The syndromes of tuberous sclerosis, von Hippel-Lindau disease, and acquired renal cystic disease are reviewed. Renal cell carcinoma accounts for 85% of clinically relevant renal tumors. Development of renal cell carcinoma appears to be associated with loss of tumor suppressor genes on the short arm of chromosome 3. Over the past year, there were no major advances in the imaging of renal tumors. Ultrasound and computed tomography remain the standards, whereas magnetic resonance imaging, although having a high sensitivity for detection of renal masses, is used primarily for staging the inferior vena cava. The only effective therapy for localized renal cell carcinoma remains surgical resection. There are objective responses seen with immune modulation therapy (interferon-alpha, interleukin-2), but cures are infrequent.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Mayo Clinic, Rochester, MN 55905
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47
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Kavoussi LR, Sosa E, Chandhoke P, Chodak G, Clayman RV, Hadley HR, Loughlin KR, Ruckle HC, Rukstalis D, Schuessler W. Complications of laparoscopic pelvic lymph node dissection. J Urol 1993; 149:322-5. [PMID: 8426411 DOI: 10.1016/s0022-5347(17)36069-x] [Citation(s) in RCA: 194] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Intraoperative and postoperative complications were assessed in the first 372 patients undergoing laparoscopic pelvic lymph node dissection at 8 medical centers. In 16 patients laparoscopic node dissection could not be completed due to patient body habitus or technical difficulties. Of these aborted procedures 14 occurred during the initial 8 dissections at each institution. A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). Based on our experience, there is a significant learning curve associated with performing laparoscopic pelvic node dissection. However, with experience and adherence to laparoscopic surgical principles, the risk of complications may be minimized.
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Affiliation(s)
- L R Kavoussi
- Department of Urology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115
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48
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Abstract
Fracture of the penis is a rupture of the rigid corporeal body. Nine consecutive patients with this malady were managed by an operative repair, which included degloving of the penis, evacuation of the hematoma, and closure of the corporeal tear. Postoperatively all patients reported excellent rigidity of a straight penis. We conclude that operative management of a fractured corporeal body is safe and effective.
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Affiliation(s)
- H C Ruckle
- Department of Urology, Loma Linda University, School of Medicine, California
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49
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Woolley JL, Lau BH, Ruckle HC, Torrey RR. Phagocytic and natural killer cytotoxic responses of murine transitional cell carcinoma to postsurgical immunochemotherapy. J Urol 1988; 140:660-3. [PMID: 3411696 DOI: 10.1016/s0022-5347(17)41750-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Postsurgical immunochemotherapy with Corynebacterium parvum (CP) and cis-diamminedichloroplatinum (II) (CDDP) was evaluated in mice with transitional cell carcinoma (MBT-2). C3H/He mice were transplanted subcutaneously in the hind limb with 5 x 10(5) tumor cells. Ten to 14 days later when the tumor reached a diameter of five to seven mm., it was surgically removed. Mice were then randomized into four groups to receive a total of three treatments on days 1, 3 and 5 after surgery: 1) saline (control group); 2) CP, 250 micrograms. into the surgical site; 3) CDDP, 5 micrograms./gm. body weight intraperitoneally; and 4) combined CP and CDDP. Recurrence of tumor occurred in 70%, 52%, 55% and 28% of mice receiving surgery only, CP, CDDP, and combined CP and CDDP respectively. In the second part of the experiment, phagocytic activity using chemiluminescence assay and natural killer (NK) activity using chromium-51 release assay were determined with cells from the peritoneum, spleen and inguinal lymph nodes. CP or CDDP alone enhanced the phagocytic and NK activity. The most significant enhancement was obtained with cells from the inguinal lymph nodes of mice receiving combined CP and CDDP, the group with the lowest tumor recurrence. These results suggest that combination of CP and CDDP may be useful in control of postsurgical recurrence of bladder cancer.
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Affiliation(s)
- J L Woolley
- Department of Urology, School of Medicine, Loma Linda University, CA 92350
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