Li-Ming Su

University of Florida, Gainesville, Florida, United States

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Publications (116)322.83 Total impact

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    ABSTRACT: Results: Within 13 days we received ratings on all videos from all experts CE and within 11.5 hours we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal-consistency across videos of CE GEARS ratings remained low (ICC=0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video-level (R=0.82, p<0.001) and surgeon level (R=0.84, p<0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R=0.83, p<0.001) for the unique surgery-specific assessment question. Conclusions: We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid, scalable solution to triage technical skills.
    No preview · Article · Nov 2015 · Journal of Endourology
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    ABSTRACT: This study aimed at reviewing a contemporary series of patients who underwent robotic renal and adrenal surgery by a single surgeon at a tertiary referral academic medical center over a 6-year period, specifically focusing on the unique and serious complication of post-operative rhabdomyolysis of the dependent lower extremity. The cases of 315 consecutive patients who underwent robotic upper tract surgery over a 6-year period from August 2008 to June 2014 using a standardized patient positioning were reviewed and analyzed for patient characteristics and surgical variables that may be associated with the development of post-operative rhabdomyolysis. The incidence of post-operative rhabdomyolysis in our series was 3/315 (0.95 %). All three affected patients had undergone robotic nephroureterectomy. Those patients who developed rhabdomyolysis had significantly higher mean Body Mass Index, Charlson Comorbidity Index, and median length of stay than those who did not. The mean OR time in the rhabdomyolysis group was noted to be 52 min longer than the non-rhabdomyolysis group, though this value did not reach statistical significance. Given the trends of increasing obesity in the United States and abroad as well as the continued rise in robotic upper tract urologic surgeries, urologists need to be increasingly vigilant for recognizing the risk factors and early treatment of the unique complication of post-operative rhabdomyolysis.
    Full-text · Article · Sep 2015 · Journal of Robotic Surgery
  • Joseph Pugh · Amy Farkas · Li-Ming Su
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    ABSTRACT: Use of the da Vinci® surgical robotic system has expanded to numerous upper and lower urinary tract procedures. We describe our surgical technique and perioperative outcome of robotic distal ureterectomy with psoas hitch and ureteroneocystostomy for distal ureteral pathologies. Eight patients with a median age of 69.5 years old underwent robotic distal ureterectomy with psoas hitch and ureteroneocystostomy between April 2009 and August 2014. The entirety of all cases was performed robotically by a single surgeon at a tertiary academic medical center. Median operative time was 285 min (range: 210-360 min), estimated blood loss was 50 mL (range: 50-75 mL) and median length of hospital stay was 2.5 days (range: 1-6 days). There was one post-operative complication, a readmission for dehydration (Clavien I). It suggests that robotic distal ureterectomy with psoas hitch and ureteroneocystostomy is a safe and effective minimally invasive alternative for patients with distal ureteral pathology.
    No preview · Article · Apr 2015
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    Joseph Pugh · Amy Farkas · Li-Ming Su
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    ABSTRACT: Use of the da Vinci® surgical robotic systemhas expanded to numerous upper and lower urinary tract procedures. We describe our surgical technique and perioperative outcome of robotic distal ureterectomy with psoas hitch and ureteroneocystotomy for distal ureteral pathologies. Eight patients with a median age of 69.5 years old underwent robotic distal ureterectomy with psoas hitch and ureteroneocystotomy between April 2009 and August 2014. The entirety of all cases was performed robotically by a single surgeon at a tertiary academic medical center. Median operative time was 285 min (range: 210 - 360 min), estimated blood loss was 50 mL (range: 50 - 75 mL) and median length of hospital stay was 2.5 days (range: 1-6 days). There was one post-operative complication, a readmission for dehydration (Clavien I). It suggests that robotic distal ureterectomy with psoas hitch and ureteroneocystotomy is a safe and effective minimally invasive alternative for patients with distal ureteral pathology.
    Preview · Article · Mar 2015
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    ABSTRACT: Introduction and Objectives: Rectovesical fistulas are a rare but devastating complication of radical prostatectomy. Management can be challenging due to deep location in the pelvis and recent surgery. We present a case of a patient whose prostatectomy was complicated by unrecognized rectal injury and pelvic abscess. After diverting colostomy, he was referred for management of the resulting rectovesical fistula. The patient failed primary closure with a sliding rectal advancement flap. Methods: In this video, we demonstrate robotic repair of a rectovesical fistula. The fistula tract was first dissected posterior to the bladder. Due to the location of the fistula, a transvesical approach was also required to identify the distal end of the fistula. Once the fistula was completely separated from the bladder, it was primarily closed. An omental flap was then mobilized and secured over the fistula site. Results: The patient underwent successful repair using minimally invasive techniques, preventing the morbidity of a large open procedure. The repair was confirmed with retrograde urethrogram and CT with rectal contrast. Conclusions: Robotic rectovesical fistula repair using a combined anterior and posterior approach is a useful technique to allow complete visualization of the fistula tract and adequate separation of the rectum and bladder. The addition of an omental flap decreases recurrence and facilitates healing of damaged tissues. Using minimally invasive techniques the patient spared a large open reconstruction. No competing financial interests exist. Runtime of video: 6 mins 56 secs
    No preview · Article · Apr 2014 · The Journal of Urology
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    ABSTRACT: Introduction: This is a report on urinary function results from a randomized trial of nightly versus on-demand sildenafil after nerve-sparing radical prostatectomy (RP), a secondary objective. We analyzed the effects of these sildenafil administration schemes on urinary health-related quality of life after RP. Methods: In total, 100 potent men were equally randomized to nightly and on-demand sildenafil 50 mg after minimally-invasive RP for 1 year. Health-related quality of life questionnaires were administered at various postoperative intervals. Urinary function was assessed using appropriate expanded prostate cancer index composite (EPIC) subscales. Analyses of covariance and linear mixed-effects modeling were used to compare the effects of treatment over time on urinary recovery, controlling for age, nerve-sparing score, and time from surgery. Results: The nightly (n = 50) and on-demand (n = 50) sildenafil groups were well-matched at baseline. Nightly sildenafil patients had worse EPIC urinary bother and urinary irritative/obstructive subscale scores at 3 and 6 months after RP, even after controlling for multiple variables. On mixed-model analyses, the differences between groups for these EPIC subscales (4.9 and 2.5, respectively) were greater than documented thresholds for clinical significance. Increasing nerve-sparing score was associated with improvements in EPIC urinary summary, bother, incontinence, and function scores; time from surgery was associated with improvements in all EPIC urinary health-related quality of life subscales. Conclusions: In this specific population and drug dose, we found that on-demand short-acting phosphodiesterase-5 inhibitor (PDE5i) dosing may be more effective after RP to maximize early urinary health-related quality of life. In preoperatively potent men, nightly sildenafil 50 mg impaired urinary health-related quality of life more than on-demand use in the early months after nerve-sparing RP, independent of effects on urinary continence.
    Full-text · Article · Apr 2014 · The Journal of Urology
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    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.
    No preview · Article · Oct 2013 · Urology
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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.
    Full-text · Article · Aug 2013 · BJU International
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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.
    Preview · Article · May 2013 · BJU International

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  • No preview · Article · Apr 2013
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    ABSTRACT: Purpose: Chemokines are involved in cancer-related inflammation and malignant progression. In this study, we evaluated expression of CCR8 and its natural cognate ligand CCL1 in patients with urothelial carcinomas of bladder and renal cell carcinomas. Experimental design: We examined CCR8 expression in peripheral blood and tumor tissues from patients with bladder and renal carcinomas. CCR8-positive myeloid cells were isolated from cancer tissues with magnetic beads and tested in vitro for cytokine production and ability to modulate T-cell function. Results: We show that monocytic and granulocytic myeloid cell subsets in peripheral blood of patients with cancer with urothelial and renal carcinomas display increased expression of chemokine receptor CCR8. Upregulated expression of CCR8 is also detected within human cancer tissues and primarily limited to tumor-associated macrophages. When isolated, CD11b(+)CCR8(+) cell subset produces the highest levels of proinflammatory and proangiogenic factors among intratumoral CD11b myeloid cells. Tumor-infiltrating CD11b(+)CCR8(+) cells selectively display activated Stat3 and are capable of inducing FoxP3 expression in autologous T lymphocytes. Primary human tumors produce substantial amounts of the natural CCR8 ligand CCL1. Conclusions: This study provides the first evidence that CCR8(+) myeloid cell subset is expanded in patients with cancer. Elevated secretion of CCL1 by tumors and increased presence of CCR8(+) myeloid cells in peripheral blood and cancer tissues indicate that CCL1/CCR8 axis is a component of cancer-related inflammation and may contribute to immune evasion. Obtained results also implicate that blockade of CCR8 signals may provide an attractive strategy for therapeutic intervention in human urothelial and renal cancers.
    Full-text · Article · Jan 2013 · Clinical Cancer Research

  • No preview · Article · Jan 2013
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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.
    Full-text · Article · Oct 2012 · Medical science monitor: international medical journal of experimental and clinical research

  • No preview · Article · Apr 2012 · The Journal of Urology
  • Daniel Willis · Li-Ming Su
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    ABSTRACT: This chapter reviews the surgical techniques and published studies relevant to optimization of oncologic and functional outcomes during laparoscopic and robot-assisted radical prostatectomy. Since 2000, several studies have addressed methods for reducing positive surgical margins to optimize oncologic outcomes as well as reducing the morbidities associated with laparoscopic (LRP) and robot-assisted (RALP) radical prostatectomy, namely erectile dysfunction and urinary incontinence. Studies addressing functional outcomes have provided new and important technical insights into potential mechanisms for optimizing the preservation of potency and continence. The techniques of LRP and RALP have continued to evolve with significant efforts made to optimize functional outcomes following surgery. In the quest for achieving the “trifecta” of cancer cure, urinary continence, and potency, published outcomes to date suggest that the former two goals appear to be reasonably well achieved in properly selected patients, while avoiding postoperative erectile dysfunction remains the most challenging.
    No preview · Chapter · Jan 2012
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    ABSTRACT: PURPOSE OF REVIEW: New methods of imaging and image-guidance technology have the potential to provide surgeons with spatially accurate three-dimensional information about the location and anatomical relationships of critical subsurface structures and instrument position updated and displayed during the performance of surgery. Robotic platforms and technology in various forms continues to revolutionize surgery and will soon incorporate image guidance. RECENT RESEARCH: Image-guided surgery (IGS) for abdominal and urologic interventions presents complex engineering and surgical challenges along with potential benefits to surgeons and patients. Key concepts such as registration, localization, accuracy, and targeting error are necessary for surgeons to understand and utilize the potential of IGS. Standard robotic surgeries, such as partial nephrectomy and radical prostatectomy may soon incorporate IGS. SUMMARY: Research continues to explore the potential for combining image guidance and robotics to augment and improve a variety of surgical interventions.
    No preview · Article · Nov 2011 · Current opinion in urology
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    ABSTRACT: Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Few studies exist comparing functional outcomes between RALP and LRP using validated questionnaires. This single surgeon study utilizes data from the EPIC questionnaire that was collected prospectively to compare urinary and sexual function after prostatectomy. In this comparison, return of post-prostatectomy continence was similar between groups while RALP patients demonstrated earlier return of sexual function.
    No preview · Article · Sep 2011 · BJU International
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    ABSTRACT: Renal cell carcinoma (RCC), the most common human kidney cancer, is frequently infiltrated with tumor-associated macrophages (TAM) that can promote malignant progression. Here, we show that TAMs isolated from human RCC produce substantial amounts of the proinflammatory chemokine CCL2 and immunosuppressive cytokine IL-10, in addition to enhanced eicosanoid production via an activated 15-lipoxygenase-2 (15-LOX2) pathway. TAMs isolated from RCC tumors had a high 15-LOX2 expression and secreted substantial amounts of 15(S)-hydroxyeicosatetraenoic acid, its major bioactive lipid product. Inhibition of lipoxygenase activity significantly reduced production of CCL2 and IL-10 by RCC TAMs. In addition, TAMs isolated from RCC were capable of inducing in T lymphocytes, the pivotal T regulatory cell transcription factor forkhead box P3 (FOXP3), and the inhibitory cytotoxic T-lymphocyte antigen 4 (CTLA-4) coreceptor. However, this TAM-mediated induction of FOXP3 and CTLA-4 in T cells was independent of lipoxygenase and could not be reversed by inhibiting lipoxygenase activity. Collectively, our results show that TAMs, often present in RCCs, display enhanced 15-LOX2 activity that contributes to RCC-related inflammation, immunosuppression, and malignant progression. Furthermore, we show that TAMs mediate the development of immune tolerance through both 15-LOX2-dependent and 15-LOX2-independent pathways. We propose that manipulating LOX-dependent arachidonic acid metabolism in the tumor microenvironment could offer new strategies to block cancer-related inflammation and immune escape in patients with RCC.
    Full-text · Article · Sep 2011 · Cancer Research
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    ABSTRACT: We describe our multi-institutional experience using a laparoscopic clamp to induce selective regional ischemia during robot-assisted laparoscopic partial nephrectomy (RALPN) without hilar occlusion. A retrospective review of Institutional Revew Board-approved databases of patients who underwent selective regional clamping during RALPN at four institutions was performed. In 20 patients who were treated for elective indications, RALPN with parenchymal clamping was successful in 17 (85%). Mean age was 63 years (24-78 y). Median tumor diameter was 2.2 cm (1.1-7.2 cm). Mass location was polar in 13 (76%) and interpolar in 4 (24%). Median R.E.N.A.L. nephrometry score was 6 (4-10). Median overall operative time was 190 minutes (129-309 min), while selective clamp time was 26 minutes (19-52 min). Collecting system repair occurred in 8 (47%) patients. No patients needed a blood transfusion. There was no significant difference in preoperative (median 86 mL/min/1.73 m(2)) and immediate postoperative glomerular filtration rate (GFR) (median 78 mL/min/1.73 m(2), P=0.33) or with the most recent GFR (median 78 mL/min/1.73 m(2), P=0.54) at a mean follow-up of 6.1 months (1.2-11.9 mos). Final pathology determination revealed renal-cell carcinoma in 71% with no positive margins on frozen or final evaluation. In three additional patients who were undergoing RALPN, bleeding because of incomplete distal clamp compression necessitated subsequent central hilar clamping for the completion of the procedure. In our preliminary multi-institutional experience, regional ischemia using a laparoscopic parenchymal clamp is feasible during RALPN for hemostasis. Careful preoperative selection of patients is needed to determine ideal patient and tumor characteristics. Further comparison studies are necessary to determine the true utility of this technique.
    No preview · Article · Sep 2011 · Journal of endourology / Endourological Society

Publication Stats

3k Citations
322.83 Total Impact Points

Institutions

  • 2009-2015
    • University of Florida
      • Department of Urology
      Gainesville, Florida, United States
  • 2002-2010
    • Johns Hopkins University
      • • Department of Medicine
      • • Laboratory for Computational Sensing and Robotics
      • • Department of Surgery
      Baltimore, Maryland, United States
    • Johns Hopkins Medicine
      • • Department of Urology
      • • Department of Pathology
      • • Department of Surgery
      Baltimore, Maryland, United States
  • 2008
    • Medical College of Wisconsin
      Milwaukee, Wisconsin, United States
  • 2007-2008
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
  • 2006
    • Universität Heidelberg
      • Department of Urology
      Heidelberg, Baden-Wuerttemberg, Germany