Phillip C. Ginsberg

Single port access adrenalectomy.

OBJECTIVE To report the first single port access (SPA) adrenalectomy to minimize patient discomfort through a less invasive procedure. METHODS/RESULTS We performed the first SPA in a 63-year-old, otherwise healthy Caucasian female who had a 4.5-cm left adrenal mass that was incidentally discovered on computed tomography scan of the abdomen and pelvis. Through a 2-cm single longitudinal supraumbilical incision extended down to the abdominal fascia, three 5-mm ports were placed through separate facial entry points, to make a triangular port arrangement. The adrenal vein was identified and ligated using hemoclips. The remainder of the dissection was done using hemocoagulation. The adrenal gland was extracted via an EndoCatch bag device by removing one 5-mm port and upsizing to a 12-mm port. CONCLUSION We report on the first SPA adrenalectomy. Although this technology is still in its infancy, the use of a single port for surgery provides a means to provide a potentially better patient outcome with a less invasive procedure.

A new diagnostic algorithm for the evaluation of microscopic hematuria

OBJECTIVES To evaluate a new diagnostic algorithm for microscopic hematuria in which intravenous urography (IVU) is performed as a secondary radiographic study when microhematuria has persisted for 3 months after the initial workup with renal ultrasound (US) and cystoscopy was negative. METHODS We evaluated 372 consecutive patients who presented with microhematuria and negative urine cultures and cytologic findings at our institution. All patients underwent renal US scanning and cystoscopy as their initial evaluation. All patients underwent re-evaluation 3 months after the initial workup. Patients with persistent microhematuria with no apparent etiology were then evaluated with IVU. RESULTS The initial evaluation was negative in 212 of 372 patients. Eighty-one of these patients had persistence of their microhematuria at the 3-month follow-up without a definitive diagnosis. Seventy-five of these patients underwent IVU. Abnormalities were found in 11 of the 75 patients. Six patients had renal stones, two had ureteral stones, two had ureteral tumors, and one had a tumor of the renal pelvis. Forty of the 131 patients with resolution of their microhematuria underwent IVU at their request. All those studies were normal. CONCLUSIONS The combination of cystoscopy and renal US along with urinalysis, urine culture, and cytology is a good initial evaluation in patients with microhematuria. Those patients with persistent microhematuria after 3 months without definite etiology of the bleeding may still benefit from IVU.

Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia

OBJECTIVES To determine the effect of discontinuation of alpha-blockade and continuation of finasteride in men with lower urinary tract symptoms and enlarged prostates receiving combination treatment and to determine whether the alpha-blocker dose influences the ability to discontinue it. METHODS We treated 272 consecutive men with a prostate size greater than 40 g and American Urological Association symptom score greater than 20 with 5 mg finasteride and 2 mg doxazosin daily. Two hundred forty men reported a favorable response to therapy, defined as any reduction in symptom score and toleration of the medications. The dose was maintained at 2 mg doxazosin in 100 men and was titrated to 4 mg doxazosin in 80 patients and to 8 mg doxazosin in an additional 60 patients. We discontinued doxazosin at 3, 6, 9, or 12 months, while continuing finasteride, and then re-evaluated the patients 1 month later to determine whether any worsening of symptoms had resulted. RESULTS In patients discontinuing doxazosin at 3 months, success (defined as no increase in symptom score and no desire to resume doxazosin) was reported by 20%, 15%, and 13% of those taking 2, 4, and 8 mg, respectively. In patients discontinuing doxazosin at 6 months, success was reported by 48%, 45%, and 40% of those taking 2, 4, and 8 mg, respectively. In patients discontinuing doxazosin at 9 months, success was reported by 84%, 80%, and 73% of those taking 2, 4, and 8 mg, respectively. In patients discontinuing doxazosin at 12 months, success was reported by 84%, 85%, and 87% of those taking 2, 4, and 8 mg, respectively. CONCLUSIONS Patients with lower urinary tract symptoms and moderately enlarged prostates initially receiving combination therapy using finasteride and an alpha-blocker are likely to experience no significant symptom deterioration after discontinuing the alpha-blocker after 9 to 12 months of combination therapy regardless of the dose of alpha-blocker chosen.

Estimated Blood Loss Underestimates Calculated Blood Loss during Radical Retropubic Prostatectomy

Objective: To compare the calculated blood loss for radical retropubic prostatectomy (RRP) with the anesthesiologist’s and operating surgeon’s estimates of operative blood loss. Methods: A retrospective review of 52 consecutive patients undergoing RRP between January 1999 and February 2000 was performed. Patient charts were reviewed for preoperative hemoglobin (Hgb_i), preoperative hematocrit (Hct_i), body weight (Wt), anesthesiologist’s and surgeon’s estimated blood loss (EBL_A and EBL_S), and postoperative day one morning hemoglobin (Hgb_f) and hematocrit (Hct_f). For each patient, the actual blood loss (ABL), i.e., the amount of blood that left the patient’s body, was calculated as the average ABL_n resulting from two computations of the following formula: ABL_n = (EBV × (H_i – H_f)) / ((H_i + H_f)/2) + (500 × T_u) where: (1) estimated blood volume (EBV) is assumed to be 70 cm³/kg; (2) H_i and H_f represent Hgb_iand Hgb_f for one computation and Hct_i and Hct_f for the second computation, and (3) T_u is the sum of autologous whole blood (AWB), packed red blood cells (PRBC), and cell saver (CS) units transfused. For each patient, ABL was compared with EBL_A and EBL_S. Descriptive statistics of the pooled data were calculated. Results: The mean (± SD) age was 60 ± 7.1 years. The mean ABL was 2,774 ± 1,014 cm³. Patients received an average of 1.96 U CS, 0.14 U PRBC, and 0.42 U AWB. Five patients (9.6%) were exposed to homologous blood. The average ABL_net (i.e. ABL reduced by the amount of CS returned) was 1,794 ± 806 cm³. EBL_A and EBL_S were 1,337 ± 676 and 1,300 ± 658 cm³, respectively. Conclusion: During radical retropubic prostatectomy, anesthesiologists and urologists both appear to underestimate blood loss as determined by standard calculation.

Minimal incision living donor nephrectomy: improvement in patient outcome

OBJECTIVES To analyze the minimal incision living donor (MILD) nephrectomy and compare it with the standard open donor (SOD) nephrectomy with respect to incision size, operative time, complication rate, length of hospital stay, and recipient creatinine. METHODS Forty-five consecutive patients who underwent MILD nephrectomy were compared with 13 patients who had previously undergone SOD nephrectomy. The MILD nephrectomy was performed through a minimally invasive incision using a modified, anterolateral, retroperitoneal approach without a rib resection. The incision length, operative time, complication rates, length of hospital stay, and recipient creatinine were analyzed. RESULTS The average incision length in the MILD group was 8.6 cm compared with 21.8 cm in the SOD group (P >0.005.) The operative times (209 minutes in the MILD group versus 191 minutes in the SOD group) were not significantly different. Four postoperative complications were encountered in the SOD group and seven in the MILD group. The average hospital stay for the MILD patients was 2.5 days compared with 4.6 days in the SOD group, and as the procedure was refined, the length of stay was reduced to 1 day in 3 patients. The recipient creatinine at 1 and 6 months was 1.39 and 1.4 mg/dL in the MILD group, respectively. CONCLUSIONS The MILD nephrectomy allows the patient to undergo a less morbid procedure with a more aesthetic incision. Patients have fewer complications, minimal anesthesia exposure, and short hospital stays.

Improved Continence after Radical Retropubic Prostatectomy Using Two Pubo-Urethral Suspension Stitches

Objectives: To determine if placement of urethral suspension stitches during radical retropubic prostatectomy improves postoperative urinary continence. Methods: Between January 1997 and January 1998 we performed radical retropubic prostatectomy on 50 men. The first 25 consecutive men had their surgery without urethral suspension stitches while the next 25 received placement of two anastomotic urethral suspension stitches anchored to the lower portion of the pubic bone. Patients were interviewed six months postoperatively and each underwent valsalva leak-point pressure measurement. Patients were categorized as either completely continent (requiring no pads and having no measurable valsalva leak point), socially continent (zero or one pad per day), or incontinent (two or more pads per day). Results: In the urethral suspension group, 8/25 (32%) patients were completely continent and did not have a measurable valsalva leak-point pressure while 3/25 (12%) without urethral suspension were completely continent. Of the remaining patients in the urethral suspension group, 13/17 (76%) patients were socially continent while 4/17 (24%) were incontinent. The mean valsalva leak-point pressure in the 17 patients with suspension stitches was 89.6 ± 21.6 cm H2O. In the patients without urethral suspension, there were 22 patients who had some degree of incontinence. Among non-stitch patients, 13/22 (59%) were socially continent while 9/22 (41%) were incontinent. The average valsalva leak-point pressure in these patients was 74.0 ± 16.7 cm H2O, which was significantly lower than those with the suspension (p = 0.015). Conclusion: Placement of anastomotic urethral suspension stitches during radical retropubic prostatectomy may increase the likelihood of complete postoperative urinary continence. The urethral suspension stitches also increase valsalva leak-point pressure, which may improve the percentage of patients with socially acceptable incontinence.

Role of Urologic Evaluation in the Adult Spina bifida Patient

Objective: To evaluate a population of adult spina bifida patients performing clean intermittent catheterization (CIC) and determine the indications for urologic consultation and intervention. Methods: We evaluated 52 adults (ages 18–37 years) with a history of lumbar myelomeningocele, all of whom performed CIC and were dry between catheterizations. We excluded 12 patients with conditions potentially predisposing to renal insufficiency (staghorn calculus, n = 3; multiple admissions for pyelonephritis, n = 5; history of vesicoureteral reflux, n = 2, and renal scarring on ultrasound, n = 2), leaving 40 patients evaluable. Each patient kept a catheterization diary for 2 weeks from which an average catheterized volume was recorded. Results: In patients with normal ultrasound and normal serum creatinine (<1.5 mg/dl), there were no individuals (0/20) whose average catheterized volume corresponded to a bladder pressure of >40 cm H2O on cystometry. However, in the patients with hydronephrosis and/or elevated creatinine, 30% (6/20) had average catheterized volumes corresponding to a bladder pressure of >40 cm H2O, and are therefore theoretically at risk for upper tract deterioration. Conclusion: Many spina bifida patients receive urologic care only as children, and those without urinary calculi or urinary incontinence are assumed to be urologically stable. However, certain patients have urodynamic parameters which put them at risk for renal deterioration even if they appear to be problem-free. We recommend a yearly renal ultrasound and serum creatinine determination in all adult spina bifida patients with immediate urologic consultation and urodynamics if either is abnormal.

Discontinuation of Alpha-Blockade after Initial Treatment with Finasteride and Doxazosin for Bladder Outlet Obstruction

Objectives: Patients with symptomatic bladder outlet obstruction and moderately enlarged prostates can receive durable relief from finasteride. However, the delayed onset of action has led many clinicians to prescribe an α-blocker in addition to finasteride early in therapy for more rapid symptom relief. Our goal was to determine when to discontinue the α-blocker in this group of patients. Methods: We enrolled 100 consecutive men with an estimated prostate size of >40 g and an AUA symptom score of ≧20, who reported an initially favorable response to combination therapy with 5 mg finasteride and 2 mg doxazosin daily. The average symptom score reduction at 1 month was 3.3. We discontinued the doxazosin at 3, 6, 9, or 12 months, while continuing finasteride, then reevaluated patients 1 month later to determine if the patients reported any worsening of symptoms. Results: Twenty-five patients discontinued doxazosin at 3 months. Five (20%) were successfully discontinued, reporting no change in symptom score. Twenty reported worsening symptoms. Twenty-five patients discontinued doxazosin at 6 months. Twelve (48%) were successfully discontinued, reporting no change in symptom scores. Thirteen (52%) reported worsening symptoms. Twenty-five patients discontinued doxazosin at 9 months. Twenty-one (84%) were successfully discontinued, reporting no change in symptom scores. Four (16%) reported worsening symptoms. Twenty-five patients discontinued doxazosin at 12 months. Twenty-one (84%) were successfully discontinued, reporting no change in symptom scores. Four (16%) reported worsening symptoms. Conclusion: Patients with symptomatic bladder outlet obstruction and moderately enlarged prostates who are placed initially on combination therapy using finasteride and an α-blocker are likely to tolerate discontinuation of the α-blocker after 9 months of combination therapy.

Use of a prostate model to assist in training for digital rectal examination

OBJECTIVES To assess the accuracy of prostate size estimation on digital rectal examination (DRE) before and after training with a three-dimensional prostate model relative to prostate volume by transrectal ultrasound (TRUS). METHODS A total of 100 subjects underwent DRE by one of four family physicians (FP1, n = 34; FP2, n = 26; FP3, n = 22; and FP4, n = 18). One half were examined before any training on DRE prostate size examination and one half after the physicians were trained. Training involved teaching with a three-dimensional prostate model having posterior surface areas corresponding to the average dimensions of six different prostate volumes. The FPs were instructed to estimate the prostate size on the DRE to the nearest 5 g. A single urologist unaware of the DRE results performed TRUS on all patients to measure the prostate volume. RESULTS Before training, the DRE size estimates ranged from 10 to 100 g (mean +/- SD 32.8 +/- 21.6), with a TRUS volume of 11 to 122 g (mean +/- SD 38.9 +/- 23.1). The correlation between the DRE and TRUS estimates was 0.25, suggesting low agreement (intraclass correlation coefficient [ICC] 0.35, 95% confidence interval 0.31, 0. 38). After training, 50 different patients had DRE size estimates of 10 to 100 g (mean +/- SD 39.4 +/- 19.7) and TRUS volume of 10 to 119 g (mean +/- SD 41.5 +/- 24.1). The correlation between the techniques was higher in patients examined after training (r = 0. 765), suggesting much better agreement between the techniques (ICC 0. 87; 95% confidence interval 0.86, 0.88). Among the physicians, agreement between DRE and TRUS was higher after training (ICC 0.64 to 0.96) than before training (ICC 0.02 to 0.49). CONCLUSIONS Although the subjects examined before and after training differed, the agreement between TRUS and DRE prostate size estimates by the FPs appeared to be stronger after training with a three-dimensional prostate model. This model may be a useful tool to assist in training FPs and medical students to measure prostate size on DRE.

Effects of irrigation fluid temperature on core body temperature during transurethral resection of the prostate

OBJECTIVES To determine the effect irrigation fluid temperature has on core body temperature changes in patients undergoing transurethral resection of the prostate (TURP). METHODS Fifty-six male patients (mean age 71.2 +/- 8.2 years) scheduled for TURP were enrolled in the study. Patients were randomized to one of two groups. Group 1 consisted of 27 patients who received room temperature irrigation fluid (70 degrees F) throughout TURP; group 2 consisted of 29 patients whose procedure was performed with warmed irrigation fluid (91.5 degrees F). The irrigation fluid used for both groups was glycine. The baseline temperature, final temperature, total time in the operating room, and amount of irrigation fluid used during the procedure were recorded for each patient. RESULTS No significant difference in the average time spent in the operating room or in the total irrigation fluid used between the two groups was observed. Of the 27 patients who received room temperature irrigation fluid, 15 (55.6%) had a decrease in body temperature. A decrease in temperature was observed in 21 (72.4%) of the 29 patients who received warm irrigation fluid. Groups 1 and 2 had 12 (44.4%) of 27 and 8 (27.6%) of 29 patients, respectively, who demonstrated an elevation in their core body temperature. CONCLUSIONS The results of our study suggest that irrigation fluid temperature is not a factor responsible for altering the core body temperature in patients undergoing TURP.