Li-Ming Su

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (94)193.34 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess the effect of nerve sparing (NS) quality on self-reported patient urinary outcomes after radical prostatectomy. A total of 102 preoperatively potent men underwent laparoscopic or robotic radical prostatectomy; NS was prospectively graded at surgery using a 0-4 scale/neurovascular bundle. Urinary functional outcomes were measured by validated Expanded Prostate Cancer Index Composite questionnaire at baseline and follow-up time points (1, 3, 6, 9, and 12 months) in 99 men who underwent various degrees of NS. Mixed linear regression was used to analyze the effect of NS quality and other clinical factors on urinary outcomes. Patients with at least 1 neurovascular bundle spared completely, along with its supportive tissues (NS grade 4/4), noted significantly improved Expanded Prostate Cancer Index Composite urinary functional and continence outcomes as early as 1 month postoperatively and up to 12 months. Significantly less urinary bother was also noted in these men by 9-12 months postoperatively. Multivariate analysis revealed that bilateral or unilateral excellent NS (at least 1 bundle graded 4/4), increasing time from surgery, young patient age, and lower body mass index positively and significantly affected urinary functional outcomes, including pad use. Men who received excellent unilateral NS recovered urinary function about as well as men who had both neurovascular bundles spared in similar fashion. The quality of NS significantly influences patient-defined urinary functional convalescence. Completely sparing at least 1 neurovascular bundle along with its supportive tissues has a dramatic effect on the recovery of urinary continence and quality of life in preoperatively potent men.
    Urology 10/2013; · 2.42 Impact Factor
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    ABSTRACT: To review a multi-institutional series of robot-assisted nephroureterectomy (RANU) for management of upper urinary tract urothelial carcinoma (UUTUC) with respect to technique and perioperative outcomes. Between May 2007 and July 2011, 43 RANU were performed at three institutions for UUTUC with review of perioperative outcomes. A three- or four-armed robotic technique was used in all cases based on surgeon preference and the entirety of all procedures was performed using the robot-assisted technique. Single and two robot-docking techniques are described. The mean (range) operating time was 247 (128-390) min, blood loss was 131 (10-500) mL and the median (range) length of stay was 3 (2-87) days. Pathology was pTa in nine patients, pT1 in 14 patients, pT2 in three patients, pT3 in 15 patients and pT4 in two patients. Lymph node dissection was performed in 22 patients (51%) with a mean (range) lymph node count of 11 (4-23). There were six postoperative complications: bleeding requiring a blood transfusion (grade II), splenic bleeding (grade IV), two cases of pneumonia (grade II) and two cases of rhabdomyolysis (grades II and IV). Nine recurrences (six bladder, two within the retroperitoneum and one in the contralateral collecting system) have been found to date on routine surveillance with a mean follow-up of 9 months. RANU is a feasible alternative to laparoscopic and open techniques. Particular steps of the operation including sutured closure of the cystotomy and regional lymphadenectomy are facilitated with the use of robot-assisted surgery. Long-term outcomes are necessary to assess the relative efficacy of these approaches to more established techniques; however, early perioperative outcomes appear promising.
    BJU International 08/2013; 112(4):E295-300. · 3.05 Impact Factor
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    ABSTRACT: To clarify the role of phosphodiesterase type 5 (PDE5) inhibitors in post-prostatectomy penile rehabilitation (PPPR). To compare nightly and on-demand use of PDE5 inhibitors after nerve-sparing minimally invasive radical prostatectomy (RP). We conducted a single-institution, double-blind, randomized controlled trial of nightly vs on-demand 50-mg sildenafil citrate after nerve-sparing minimally invasive RP. A total of 100 preoperatively potent men, aged <65 years, with scores on the Erectile Function domain of the International Index of Erectile Function (IIEF-EF) ≥26, underwent nerve-sparing surgery. The patients were randomized to either nightly sildenafil and on-demand placebo (nightly sildenafil group), or on-demand sildenafil and nightly placebo (on-demand sildenafil group; maximum on-demand dose six tablets/month) for 12 months. Patients then underwent a 1-month washout period. Validated measures of erectile function (IIEF-EF score and the Expanded Prostate Cancer Index Composite [EPIC]) were compared between treatment groups over the entire 13-month time course, using multivariable mixed linear regression models. The treatment groups were well matched preoperatively (mean age 54.3 vs 54.6 years, baseline IIEF-EF score 29.4 vs 29.3, for the nightly vs the on-demand sildenafil groups, respectively). No significant differences were found in erectile function between treatments (nightly vs on-demand sildenafil) at any single timepoint after RP, after adjusting for potential confounding factors. When evaluated over all timepoints simultaneously, no significant effects of treatment group (nightly vs on-demand sildenafil) were found on recovery of potency, as assessed by absolute IIEF-EF scores (P = 0.765), on percentage of men returning to an IIEF-EF score >21 (P = 0.830), or on IIEF-EF score recovery to a percentage of baseline value (P = 0.778). When evaluated over all timepoints simultaneously, no significant effects of treatment group were found on secondary endpoints such as assessment of potency (including EPIC item 59 response 'erections firm enough for intercourse'), attempted intercourse frequency or confidence. Erectile recovery up to 1 year after RP does not differ between previously potent men who use sildenafil nightly compared to on-demand. This trial does not support chronic nightly sildenafil as being any better than on-demand sildenafil for use in penile rehabilitation after nerve-sparing minimally invasive RP.
    BJU International 05/2013; · 3.05 Impact Factor
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    ABSTRACT: Background: During laparoscopic or robotic assisted laparoscopic prostatectomy, the surgeon lacks tactile feedback which can help him tailor the size of the excision. Ultrasound elastography (USE) is an emerging imaging technology which maps the stiffness of tissue. In the paper we are evaluating USE as a palpation equivalent tool for intraoperative image guided robotic assisted laparoscopic prostatectomy. Material/Methods: Two studies were performed: 1) A laparoscopic ultrasound probe was used in a comparative study of manual palpation versus USE in detecting tumor surrogates in synthetic and ex-vivo tissue phantoms; N=25 participants (students) were asked to provide the presence, size and depth of these simulated lesions, and 2) A standard ultrasound probe was used for the evaluation of USE on ex-vivo human prostate specimens (N=10 lesions in N=6 specimens) to differentiate hard versus soft lesions with pathology correlation. Results were validated by pathology findings, and also by in-vivo and ex-vivo MR imaging correlation. Results: In the comparative study, USE displayed higher accuracy and specificity in tumor detection (sensitivity=84%, specificity=74%). Tumor diameters and depths were better estimated using USE versus with manual palpation. USE also proved consistent in identification of lesions in ex-vivo prostate specimens; hard and soft, malignant and benign, central and peripheral. Conclusions: USE is a strong candidate for assisting surgeons by providing palpation equivalent evaluation of the tumor location, boundaries and extra-capsular extension. The results encourage us to pursue further testing in the robotic laparoscopic environment.
    Medical science monitor: international medical journal of experimental and clinical research 10/2012; 18(11):CR635-642. · 1.22 Impact Factor
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    ABSTRACT: To compare perioperative, oncological and functional outcomes of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP) with emphasis on health-related quality of life (HRQOL) data as few studies exist. Patients underwent RALP or LRP by a single, fellowship trained surgeon with a standard clinical care pathway. HRQOL data using the Expanded Prostate Cancer Index Composite (EPIC) were collected at 0, 3, 6 and 12 months after 175 consecutive LRP and 174 RALP procedures. Urinary and sexual function outcomes were compared using two methods: (1) EPIC summary/subscale analyses described as percent return to baseline function and (2) traditional single-question analysis. The two groups were statistically similar with respect to demographics, clinical stage, perioperative outcomes, stage-specific surgical margin rates, and baseline urinary and sexual function scores. There was no statistical difference in postoperative urinary function between RALP and LRP using EPIC or single-question analyses at 3, 6 and 12 months. EPIC questionnaire data showed a greater return to baseline sexual function over time (mixed model analysis) in RALP than in LRP patients who had a bilateral nerve sparing procedure (Sexual Summary Score, P= 0.005; Sexual Function and Bother Subscales, P= 0.007). Using EPIC, RALP patients receiving a bilateral nerve sparing procedure showed improved percent return to baseline potency at 3 and 6 months (P < 0.025) compared with LRP patients, but had similar outcomes at 12 months (73.7% vs 66.2%, P= 0.3). Single-question analysis suggested improved potency after RALP compared with LRP, with a greater percentage of RALP patients reporting successful sexual intercourse in the past 4 weeks (87.5% vs 66.7% at 12 months, P= 0.06). When comparing surgical techniques, RALP and LRP groups showed statistically similar postoperative urinary function outcomes. RALP patients had an earlier return of sexual function when compared with LRP patients after a bilateral nerve sparing procedure.
    BJU International 09/2011; 109(6):898-905. · 3.05 Impact Factor
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    ABSTRACT: Laparoscopic nephroureterectomy is a well-established surgical treatment option for patients with transitional cell carcinoma of the upper urinary tract and has well-published data supporting an advantage in decreased patient morbidity compared to open techniques with similar oncologic outcomes. With the recent addition of the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA), robot-assisted laparoscopic nephroureterectomy (RLNUx) may provide additional technical advantages to the surgeon to further improve upon the outcomes noted with the conventional laparoscopic technique. This chapter provides a detailed description of the RLNUx technique, its indications, contraindications, preoperative preparation, operative steps, and complications. KeywordsLaparoscopy-Nephroureterectomy-Robotic surgery-Transitional cell carcinoma
    02/2011: pages 89-96;
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    ABSTRACT: Outcome measures following radical prostatectomy are not standardized. Though excellent potency rates are widely reported, few studies address a return to baseline function. We analyze validated sexual health-related quality-of-life outcomes by a strict definition, a return to baseline function, and compare them to less stringent, yet more frequently referenced, categorical definitions of potency. Patients undergoing laparoscopic radical prostatectomy from April 2001 to September 2007 completed the Expanded Prostate Cancer Index Composite (EPIC) questionnaire at baseline and 3, 6, 12, and 24 months postoperatively. We defined a return to baseline as a recovery to greater than one-half standard deviation of the studied population below the patient's own baseline (clinically detectable threshold). We compared these outcomes to a categorical definition of potency involving intercourse frequency. To limit confounders, we performed subset analyses of preoperatively potent men who received bilateral nerve preservation. Factors predictive of return to baseline function were assessed in multivariable analysis. A total of 568 patients met inclusion criteria. Mean age and follow-up were 57.2 years and 16.9 months, respectively. Using the categorical definition, 85% of preoperatively potent men with bilateral nerve preservation were "potent" at 24 months; however, only 27% returned to their baseline sexual function. In multivariable analyses baseline function, number of nerves spared, and age were independent predictors of a return to baseline function. While most preoperatively potent men who receive bilateral nerve preservation engage in intercourse postoperatively, few return to their baseline sexual function. We believe that these data provide context for the expectations of patients who elect extirpative therapy.
    World Journal of Urology 02/2011; 29(1):29-34. · 2.89 Impact Factor
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    ABSTRACT: Inadvertent bladder injury is a potential complication of various urological and pelvic surgeries. Bladder injury can also be a complication of natural orifice transluminal endoscopic surgery (NOTES). The aim of this study was to test the feasibility of a NOTES approach to repair bladder lacerations in a blinded porcine study. Intentional bladder lacerations were made to mimic accidental injury during NOTES in 7 pigs. In 3 animals, the site of bladder injury was identified and repaired by a blinded endoscopist. Bladder laceration and transluminal access sites were closed with Endoclips. Leak test was performed to confirm adequate closure. Survival animals were monitored postoperatively and surgical sites were inspected for abscess, bleeding, or damage to surrounding structures at necropsy. Complete endoscopic closure of bladder injuries was achieved in all 7 animals with a negative leak test. The site of laceration was successfully identified by the blinded endoscopist and repaired in all 3 animals in which it was attempted. Survival animals had an uneventful postoperative course without any complications. This blinded feasibility study shows that urinary bladder injury occurring during NOTES can be successfully managed via a NOTES approach using currently available endoscopic accessories.
    JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 01/2011; 15(3):285-90. · 0.81 Impact Factor
  • Journal of Urology - J UROL. 01/2011; 185(4).
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    ABSTRACT: Radical nephroureterectomy with formal bladder cuff excision was first proposed in 1933 by Kimball and Ferris (J Urol 31: 257, 1933) for the treatment of papillomatous tumors of the renal pelvis and ureter. This approach has become standard of care for upper urinary tract neoplasms as many of these tumors are characterized by multifocality, high ipsilateral recurrence rates after partial resection, and low (<5%) incidence of contralateral disease. In 1991, Clayman et al. first described a laparoscopic approach to nephroureterectomy (Clayman RV, Kavoussi LR, Figenshau RS, Chandhoke PS, Albala DM, J Laparoendosc Surg 1(6):343–349, 1991). A laparoscopic approach to upper tract neoplasm has become more prevalent with increasing evidence supporting equivalent oncologic outcomes (Bariol SV, Stewart GD, McNeill SA, Tolley DA, J Urol 172(5):1805–1808, 2004; Muntener M, Nielsen ME, Romero FR, Schaeffer EM, Allaf ME, Brito FA, Pavlovich CP, Kavoussi LR, Jarrett TW, Eur Urol 51:1639–1644, 2007; Capitanio U, Shariat SF, Isbarn H, Weizer A, Remzi M, Roscigno M, Kikuchi E, Raman JD, Bolenz C, Bensalah K, Koppie TM, Kassouf W, Fernandez MI, Strobel P, Wheat J, Zigeuner R, Langner C, Waldert M, Oya M, Guo CC, Ng C, Montorsi F, Wood CG, Margulis V, Karakieweicz PI, Eur Urol 56(1):1–9, 2009; Waldert M, Remzi M, Klinger HC, Mueller L, Marberger M, BJU Int 103(1):66–70, 2009; Berger A, Haber GP, Kamoi K, Aron M, Desai MM, Kauok JH, Gill IS, J Urol 180(3):849–854, 2008; Kawauchi A, Fujito A, Ukimura O, Yoneda K, Mizutani Y, Miki T, J Urol 169(3):890–894, 2003; Stifelman MD, Hyman MJ, Shichman S, Sosa RE, J Endourol 15(4):391–395, 2001; McNeill SA, Chrisofos M, Tolley DA, BJU Int 86(6):619–623, 2000) and a faster convalescence (Stifelman MD, Hyman MJ, Shichman S, Sosa RE, J Endourol 15(4):391–395, 2001; Gill IS, Sung GT, Hobart MG, Savage SJ, Meraney AM, Schweizer DK, Klein EA, Novick AC, J Urol 164(5):1513–1522, 2000; Shalhav AL, Dunn MD, Portis AJ, Elbahnasy AM, McDougall EM, Clayman RV, J Urol 163(4):1100–1104, 2000) as compared to open surgery. More recently, robot-assisted radical nephroureterectomy (RARNU) has been described as an alternative to laparoscopic nephroureterectomy. RARNU offers the potential advantages of improved surgeon efficiency in suturing, ergonomics, and ease of bladder reconstruction after bladder cuff excision without compromise to oncologic efficacy (Park SY, Jeong W, Ham WS, Kim WT, Tha KH, BJU Int 104:June 10(11):1718–1721, 2009; Park SY, Jeong W, Choi YD, Chung BH, Hong SJ, Rha KH, Yonsei Med J 49(6):897–900, 2008; Eun D, Bhandari A, Boris R, Rogers C, Bhandari M, Menon M, BJU Int 100(5):1121–1125, 2007). In this chapter we describe the technique of robot-assisted laparoscopic nephroureterectomy.
    12/2010: pages 143-158;
  • Ryan Turpen, Hany Atalah, Li-Ming Su
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    ABSTRACT: Since its initial description in 2000, robot-assisted laparoscopic radical prostatectomy (RALP) has rapidly grown in popularity with the majority of men with prostate cancer seeking this approach over other surgical techniques. As compared to conventional laparoscopic radical prostatectomy, RALP has experienced more rapid adoption by a broader range of urologists including those with limited laparoscopic training and in a brief few years has virtually supplanted the laparoscopic approach in the US. While debate still remains as to its relative superiority over open surgery, its minimally invasive approach, superior optics, three dimensional visualization, and intuitive ergonomic movements of the wristed robotic instrumentation have made RALP more attractive to patients and surgeons alike. The technique of RALP has undergone considerable modifications since its early description that was based upon the original standardized approach of laparoscopic radical prostatectomy. Herein, we describe the transperitoneal posterior approach to RALP.
    12/2010: pages 47-67;
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    ABSTRACT: To investigate the association of prostate weight with recovery of sexual function after minimally invasive radical prostatectomy. Between April 2001 and September 2007, two surgeons performed 856 consecutive laparoscopic radical prostatectomies for clinically localized prostate cancer. Patients were stratified into three groups by prostate weight: <35 g, 35-70 g, and >70 g. Sexual and urinary outcomes were assessed prospectively using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Patients who underwent nerve sparing (unilateral or bilateral) with complete preoperative EPIC data, a minimum preoperative Sexual Health Inventory for Men score ≥21, and a minimum of 3 months of complete postoperative EPIC data were included in the analysis. Of the cohort of 856 men, 324 (38%) had complete, evaluable data and met the inclusion criteria for this study. Preoperatively, there were no significant differences by prostate weight in the EPIC sexual function or bother subscale scores or the proportion of patients participating in sexual intercourse. Postoperatively, we observed statistically similar returns to baseline EPIC sexual function and bother subscale scores and participation in sexual intercourse across all gland weight groups at all time points. EPIC sexual domain scores and the proportions of patients participating in sexual intercourse continued to increase up to 24 months postoperatively, but no group returned to preoperative function at any sampling point. Prostate size is not associated with postoperative recovery of sexual function in men undergoing minimally invasive radical prostatectomy.
    Urology 12/2010; 77(4):952-6. · 2.42 Impact Factor
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    ABSTRACT: • To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes. • A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate-specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. • Pathological and biochemical outcomes of the three cohorts were examined. • Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). • In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. • Kaplan-Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups. • RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence-free survival between groups. • Further prospective studies are warranted to determine whether any particular technique is superior with regard to long-term clinical outcomes.
    BJU International 11/2010; 107(12):1956-62. · 3.05 Impact Factor
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    ABSTRACT: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.
    The Journal of urology 10/2010; 184(6):2291-6. · 3.75 Impact Factor
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    ABSTRACT: There is no universally accepted instrument to measure sexual function (SF) in men. We compare validated SF measures in a single cohort. We compare the Sexual Health Inventory for Men (SHIM), Expanded Prostate Cancer Index Composite SF domain (EPIC-SF), and a reconstructed University of California Los Angeles Prostate Cancer Index SF domain (PCI-SF) in 856 men scheduled for radical prostatectomy. We define potency thresholds for the PCI-SF and EPIC-SF. Mean age, body mass index, Gleason sum, and PSA were 57 years, 26.7 kg/m(2), 6.3, and 5.9 ng/mL, respectively. Mean instrument scores were as follows: SHIM 20.1; EPIC-SF 65; PCI-SF 71. All instruments were significantly intercorrelated (r = 0.99 for EPIC-SF vs PCI-SF, r = 0.75 for SHIM vs EPIC-SF, r = 0.77 for SHIM vs PCI-SF, all P < .001). The SHIM had the greatest negative skew and ceiling effect (P < .001). Although high scores on either the EPIC-SF or PCI-SF translated reliably to high SHIM scores, the reverse was not true. Subjects who reported no erectile dysfunction (ED) on the SHIM (>or=22) had diverse overall SF, whereas those who scored highly on the EPIC-SF or PCI-SF had both excellent erectile function (potency) and overall SF (including orgasmic function, erectile function, and sexual desire). EPIC-SF scores >or=65 and PCI-SF scores >or=75 define men that are both potent and have good SF. The SHIM is intended as an instrument to assess ED. It is, however, inadequate as a measure of overall SF. The EPIC-SF and PCI-SF capture gradations of both sexual and erectile function and may also be used to define potency more comprehensively.
    Urology 08/2010; 76(2):380-6. · 2.42 Impact Factor
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    Ryan Turpen, Hany Atalah, Li-Ming Su
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    ABSTRACT: Since it was introduced in 1999, the da Vinci Surgical System has become an integral tool in urologic surgery, specifically in the management of localized prostate cancer. The original technique of robot-assisted laparoscopic prostatectomy (RALP) was developed and standardized in 2000 at the Institut Mutualiste Monsouris. Since that time, the technique of RALP has undergone various modifications. The driving force behind the evolution of the RALP technique in the past decade has been based on efforts to improve upon the three main objectives of surgery, namely the 'trifecta' of cancer cure and the preservation of potency and of urinary continence. In this review, we aim to provide an update on the midterm oncologic outcomes of RALP and focus specifically on two technical modifications that have been introduced in an effort to optimize the outcomes of potency and earlier return of urinary continence.
    Therapeutic Advances in Urology 12/2009; 1(5):251-8.
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    ABSTRACT: Renal transplantation is acknowledged as the preferred method of renal replacement therapy, offering significant advantages for individuals with end-stage renal disease (ESRD) as compared to dialysis. In addition to improved overall survival and quality of life, renal transplantation remains the most cost-effective treatment; in fact, it remains one of the most cost-effective therapies in health care (1). Due to the aging population, increasing frequency of predisposing conditions such as diabetes and hypertension as well as improved life-expectancy resulting from enhanced medical management of patients with ESRD, the incidence and prevalence of ESRD have increased dramatically. As a result, the growing number of patients with ESRD who would benefit from transplantation has overwhelmed the supply of cadaveric donor kidneys. The United Network for Organ Sharing (UNOS) and the Organ Procurement and Transplantation Network (OPTN) estimate that the number of patients awaiting transplantation in the United States will increase by approximately 3,000 per year (2,3). Thus, the gap between supply and demand for renal allografts continues to grow such that 72,942 candidates are currently on the waiting list for a kidney and 48,176 (66%) have been on the list for over a year (3). Though expanded criteria for cadaveric organs including using extremes of age and double kidney donation has increased supply, it still falls short of the continually increasing demand. Key Wordslaparoscopy-living donor-nephrectomy-transplantation
    11/2009: pages 209-230;
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    ABSTRACT: As surgical operative technology improves, surgeons today have the ability to visualize fine structures and detailed anatomy. There are a number of advances that have been made to optimize patient outcomes with better tissue characterization in urologic procedures. This article focuses on advances in intraoperative imaging and tissue characterization for various urologic procedures. Each modality is presented with its corresponding applications in urology. The following techniques are covered: optical coherence tomography, confocal fluorescent microscopy, near infrared fluorescence imaging, elastography, intraoperative ultrasonography, and a neurovascular bundle surgical mapping aid.
    Urologic Clinics of North America 06/2009; 36(2):213-21, ix. · 1.39 Impact Factor
  • Paul Swain, Herman S Bagga, Li-Ming Su
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    ABSTRACT: Natural orifice translumenal endoscopic surgery (NOTES) requires an intentional perforation of a hollow lumen to pass an endoscope into an otherwise inaccessible body cavity with diagnostic or therapeutic intent. The limitations of current flexible instruments for this purpose are outlined, including the unsuitability for NOTES of current flexible needle knives, guidewires, balloons, overtubes, grasping forceps, and scissors. The development of novel suturing instruments, trocars, articulating instruments, flexible bipolar forceps, flexible clips, magnetic devices, and staplers as well as the advent of manual mechanical manipulators for flexible accessories is outlined. New instrument solutions for endosurgery are described, such as articulating flexible accessories for gastroscopes, novel "platforms" that can be rigidized, and unconventional scope arrangements. Debatably, the greatest current benefit of NOTES is that it may lead to further development of better instrumentation for endosurgery.
    Journal of endourology / Endourological Society 06/2009; 23(5):773-80. · 1.75 Impact Factor
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    ABSTRACT: One of the next frontiers of minimally invasive surgery is natural orifice translumenal endoscopic surgery (NOTES). This article focuses on the perspectives and limitations of imaging and navigation in NOTES soft-tissue surgery. Based on our in-vitro and in-vivo studies, with the applicability of different systems for image-guided soft-tissue endoscopic surgery, early experience with NOTES, and long-term experience with advanced endoluminal, laparoscopic robot-assisted endoscopic surgery, we performed a review of the literature. The aim was a critical analysis of the current role of imaging during NOTES. There are several steps/problems with NOTES that might be significantly alleviated by use of imaging and soft-tissue navigation. One has to distinguish between preoperative planning and intraoperative imaging or navigation. NOTES represents a hybrid technique of laparoscopy and endoscopy with similar limitations in perception and two-dimensional imaging; however, the use of flexible instruments increases the complexity with respect to the spatial orientation. This applies not only for the surgeon, but also for tracking devices for surgical navigation systems. Unlike optical navigation systems, electromagnetic and endoscopic (inside-out) tracking devices might be best suited to NOTES. The safe realization and standardization of NOTES represents a real challenge that necessitates close and effective interdisciplinary collaboration of surgeon, technicians, informatics, and endoscopic and applied industries. Image-guided soft-tissue navigation may be very helpful to minimize the hazards of the technically challenging procedure.
    Journal of endourology / Endourological Society 05/2009; 23(5):793-802. · 1.75 Impact Factor

Publication Stats

2k Citations
193.34 Total Impact Points

Institutions

  • 2013
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2009–2013
    • University of Florida
      • Department of Urology
      Gainesville, FL, United States
    • Imperial College London
      • Section of Biosurgery and Surgical Technology
      London, ENG, United Kingdom
  • 2011
    • Mount Sinai School of Medicine
      • Department of Urology
      Manhattan, NY, United States
  • 2002–2011
    • Johns Hopkins Medicine
      • • Department of Urology
      • • Department of Surgery
      Baltimore, MD, United States
  • 2010
    • Charité Universitätsmedizin Berlin
      • Department of Urology
      Berlin, Land Berlin, Germany
  • 2008
    • North Shore-Long Island Jewish Health System
      New York City, New York, United States
    • Medical College of Wisconsin
      Milwaukee, Wisconsin, United States
  • 2002–2008
    • University of Maryland, Baltimore
      • Department of Surgery
      Baltimore, Maryland, United States
  • 2006
    • Universität Heidelberg
      • Department of Urology
      Heidelberg, Baden-Wuerttemberg, Germany
  • 2005
    • University of Washington Seattle
      • Department of Surgery
      Seattle, WA, United States