William J. Harmon’s research while affiliated with Loyola University Medical Center and other places

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Publications (10)


Is a 1-CM margin necessary during nephron-sparing surgery for renal cell carcinoma?
  • Article

January 2002

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26 Reads

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96 Citations

Urology

Natania Y Piper

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Christopher Magee

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[...]

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William J Harmon

To determine whether a 1-cm margin is necessary for cancer control during nephron-sparing surgery (NSS) for renal cell carcinoma (RCC). A retrospective review of 67 patients who underwent NSS for RCC between 1990 and 2000 was conducted. The data collected included patient demographics, tumor size and location, histologic type and grade, margin status (positive or negative), and the shortest distance of normal parenchyma (in millimeters) around the tumor in the final pathologic specimen. Recurrence was determined from the clinical follow-up, which included physical examination, ultrasonography or computed tomography, and various laboratory tests. Fifty-five cases were performed open and 12 laparoscopically. The mean follow-up was 60 months (range 5 to 124). The mean tumor size was 3.0 cm (range 0.9 to 11.0). Seven patients were found to have a positive margin; 1 died of metastatic RCC, 1 was alive with systemic recurrence, and 5 had no evidence of disease. Of 11 patients with a negative margin distance of less than 1 mm, 9 were recurrence free, 1 had simultaneous local and pulmonary relapse, and the other had pulmonary recurrence only. The remainder of the study patients (n = 49) had negative margins greater than 1 mm, and all were alive without evidence of disease at the last follow-up. This review questions the necessity of a 1-cm margin to prevent recurrence after NSS for RCC. Additional studies to determine the optimal margin distance should be conducted.


Ureteral substitution with a stapled neoureter: A simplified Boari flap

December 2001

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45 Reads

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4 Citations

The Journal of Urology

We evaluate a new technique that will quickly and easily replace a long segment of ureter by creating a tapered neoureter (Boari flap) with bladder wall and absorbable staples. A neoureter was created in 14 pigs with native bladder and 75 mm. Polysorb gastrointestinal anastomosis staplers (U. S. Surgical, Norwalk, Connecticut). Urine culture and serum creatinine were obtained before neoureter creation. Neoureter length and time to construct were recorded. At 6 weeks serum creatinine was repeated, and ureteral stent removed with evaluation of the staple lines for stones and residual staples. At 4 months intravenous pyelogram, cystogram and serum creatinine were obtained before necropsy. The bladder, neoureter and kidneys were examined grossly and histologically for hydronephrosis, staples, stones and stenosis. Mean neoureter length was 13.4 cm. and mean time to construct was 15 minutes. Laboratory results were unremarkable. Of the 14 pigs 2 died of pneumonia before stent removal, and at autopsy neither had evidence of hydronephrosis nor anastomotic stricture. In the remaining 12 pigs there was no evidence of residual staples or stone formation with mucosa covering the staple line at cystoscopy and necropsy. Successful neoureter substitution was performed in 9 pigs with no gross or histological changes. There were 3 pigs that had evidence of hydronephrosis with histological findings of chronic pyelonephritis and 2 of them appeared atrophic compared to the contralateral kidney. Our study demonstrates a new technique for ureteral substitution with bladder and absorbable staples that may be performed quickly and easily. Furthermore, we show that absorbable staples can be safely incorporated into the urinary tract with minimal worry about encrustation or calculus formation.


The Broken Stone Basket: Configuration and Technique for Removal*

December 2001

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348 Reads

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19 Citations

Journal of endourology / Endourological Society

We investigated the ease of breakage of endoscopic stone baskets with the holmium:yttrium-aluminum-garnet (YAG) laser and their resultant configuration. More importantly, possible safe methods of retrieval were evaluated. Endoscopic stone baskets from Bard (Platinum Class 2.4F Flat and 3.0F Helical Wire), Cook (3.2F Captura, 3.2F Atlas, 3.0F N-Circle, 4.5F N-Force), and Microvasive (2.4F Zero Tip, 3.0F Gemini, 3.0F Segura) were broken once using the holmium:YAG laser. The energy (kJ) required to break one of the wires was recorded. Configuration was documented using photographs. Baskets were disassembled and assessed for extraction through a 7F open-ended catheter, an 8F/10F set, and a 20F peel-away sheath. Tipless baskets (N-Circle, Zero Tip) broke the easiest (range 0.02-0.03 kJ). Tipped baskets (Segura, Platinum Class Flat and Helical, Gemini, Captura, N-Force, Atlas) were more resistant, but all broke within the range (0.06-0.78 kJ) typically used for intracorporeal lithotripsy. Broken segments of wire tended to protrude outward, with tipless baskets having less change in configuration than tipped baskets. Tipless baskets could easily be pulled into any of the extracting devices, whereas tipped baskets could not. Baskets break at typical holmium:YAG intracorporeal lithotripsy energy settings. Tipless baskets break easiest and assume a safer configuration. Tipless baskets are extracted easily through a 7F open-ended catheter, 8F/10F set, or 20F sheath, while tipped baskets are unable to be extracted through any of these.



Bladder Rupture after Blunt Trauma: Guidelines for Diagnostic Imaging

November 2001

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369 Reads

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147 Citations

Journal of Trauma and Acute Care Surgery

The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.


Correlation of cytoscopic impression with histologic diagnosis of biopsy specimen of the bladder

July 2001

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77 Reads

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97 Citations

Human Pathology

There is a paucity of information in the contemporary literature that would permit assessment of the urologist's ability to endoscopically discriminate between benign and malignant lesions of the bladder or to predict the grade and stage of papillary neoplasms. This prospective study evaluates the correlation between cystoscopic impression of urothelial lesions and final histologic diagnoses. Sixty-four patients with 68 urothelial abnormalities requiring formal biopsy or endoscopic resection were evaluated prospectively. At the time of endoscopy, treating urologists completed questionnaires documenting the surgeon's endoscopic impression of disease type and extent and performed standard biopsy or resection of all suspicious lesions. Specimens were submitted for routine histopathologic analysis, and the results were correlated with the questionnaire data. Endoscopic evaluation correctly discriminated between dysplastic/malignant and benign/reactive lesions in this study with a sensitivity of 100%, specificity of 100%, and positive and negative predictive values of 100%. Urologists could not readily distinguish between low- and high-grade papillary urothelial lesions and were frequently unable to determine if a tumor was invasive, particularly if the degree of invasion was microscopic. Endoscopic impression at the time of bladder biopsy or resection is accurate and discriminates between the presence and absence of cancer. Endoscopic impression alone is a relatively poor staging tool with respect to extent of invasive disease and must be coupled with careful histopathologic analysis of biopsy material, bimanual examination when appropriate, and axial imaging for complete assessment of a given tumor.


Laparoscopic nephron-sparing surgery for solid renal masses using the ultrasonic shears

December 2000

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11 Reads

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93 Citations

Urology

To report our experience with laparoscopic nephron-sparing surgery (NSS) for solid renal masses. Between August 1998 and December 1999, 15 patients with solid renal masses underwent laparoscopic NSS at our institutions. Seven patients underwent a transperitoneal approach and eight a retroperitoneal approach. The kidneys were fully mobilized to allow inspection of all renal parenchyma. The ultrasonic shears were used to divide the renal parenchyma around the tumor in all cases. Renal surface hemostasis was then accomplished by welding a piece of oxidized regenerated cellulose gauze to the transected renal surface with the argon beam coagulator. Tumors were removed intact and sent for analysis of frozen section margin status. Laparoscopic NSS was successfully completed without complications in all patients. The mean tumor size was 2.3 cm (range 0.8 to 3.5), mean operative time was 170 minutes (range 105 to 240), and mean estimated blood loss was 368 mL (range 75 to 1000). The final pathologic finding was renal cell carcinoma in 12 patients and oncocytoma in 3 patients. All final surgical margins were negative. Patients were hospitalized for a mean of 2.6 days (range 2 to 4). Laparoscopic NSS for small, solid renal masses can be performed safely with a combination of the ultrasonic shears for renal parenchymal transection and argon beam coagulation and oxidized regenerated cellulose gauze for renal surface hemostasis.


The lion of the union: The pelvic wound of Joshua Lawrence Chamberlain

April 2000

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115 Reads

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4 Citations

The Journal of Urology

Major General Joshua Lawrence Chamberlain is a true American hero. His medical history and war wounds provide a rare snapshot of Civil War era medicine. In particular the most devastating injury was a rifle shot through the pelvis rupturing the bladder and urethra. We describe this injury and how it affected his life to provide insight into late 19th century urological care. All available references, including biographies, letters, surgical reports, military documents and prior medical summaries, were reviewed regarding Chamberlain's urological history. While leading the Union charge to Petersburg, Virginia on June 18, 1864, Chamberlain was struck with a minié ball anteriorly below the right greater trochanter. The ball coursed obliquely upward disrupting the bladder and urethra, and embedded behind the left acetabulum. An unprecedented wound exploration in the field hospital was performed to extract the bullet and "reconnect severed urinary organs." Hope for recovery was nonexistent as urine was seen exiting the lower wound postoperatively. This genitourinary injury required 4 subsequent repairs during Chamberlain's lifetime and ultimately left him with a draining urethrocutaneous fistula at the penoscrotal junction. Survival from catastrophic Civil War wounds was rare, especially from "gut wounds" which had a mortality rate of greater than 90%. Chamberlain not only survived but thrived with his sense of duty carrying him back to the battlefield and beyond. He was plagued during his life with recurrent cystitis and epididymo-orchitis, which in an era without antibiotics was especially miserable. Urosepsis is listed as the cause of death on his death certificate and whether this was true is debatable. However, even if this wound did not cause his death, it surely contributed to it.


Intraluminal, pneumatic lithotripsy for the removal of encrusted urinary catheters

January 2000

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79 Reads

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20 Citations

The Journal of Urology

Urologists frequently treat patients requiring long-term urinary drainage with a percutaneous nephrostomy tube or ureteral stent. When such tubes are neglected and become encrusted, removal challenges even experienced urologists. We describe a new, minimally invasive technique for safely and rapidly removing encrusted, occluded tubes using the Swiss Lithoclast pneumatic lithotriptor. Patients presenting with an encrusted urinary catheter were evaluated by excretory urography for renal function and obstruction. Gentle manual extraction of the tube was attempted, followed by traditional extracorporeal shock wave lithotripsy and/or ureteroscopy. When the tube was not extracted, patients were then treated with intraluminal insertion of a pneumatic lithotripsy probe. One patient presented with an encrusted, occluded nephrostomy tube and 2 had an encrusted, occluded, indwelling ureteral stent. None was removed by manual traction. Intraluminal encrustations prevented the pigtail portions of these tubes from uncoiling and removal. In each case a pneumatic lithotripsy probe was inserted into the lumen of the catheter and advanced in a jackhammer-like fashion. This technique resulted in disruption of the intraluminal encrustations and straightening of the tubes so that they were removed in an atraumatic manner. Intraluminal pneumatic lithotripsy is a safe, easy and rapid technique for removing encrusted urinary catheters. It is unique in that the pneumatic lithotripsy probe functions in an aqueous and nonaqueous environment, and dislodges intraluminal calcifications. We recommend its use as first line treatment for removing encrusted urinary catheters.


Citations (7)


... Urinary obstruction due to stent encrustations can typically lead to problems such as hydronephrosis, loss of renal function, and urosepsis (1,2). Numerous methods including some minimally invasive procedures such as ureterorenoscopic lithotripsy, percutaneous nephrolithotomy, and open surgical methods have been used in the literature for the treatment of stent encrustations due to forgotten DJ stents (3,4). This study presents five cases with stent encrustation due to forgotten DJ stents and the removal of these stents with holmium laser and percutaneous intervention. ...

Reference:

Stent Encrustation due to Forgotten Double-J Stents: A Series of Five Cases
Intraluminal, pneumatic lithotripsy for the removal of encrusted urinary catheters
  • Citing Article
  • January 2000

The Journal of Urology

... Various methods have been described in literature as an alternate to renal hilar control such as manual compression, 15 cable-tie devices, 16,17 use of soft bowel clamp or resection using 'hemostatic' energy sources. 18,19 These techniques eliminate or minimize warm ischemia thus potentially protecting the function of non-tumor bearing kidney. Manual compression of renal parenchyma can maintain a reno-protective effect and also reduce the risk of renal pedicle vascular injury. ...

Laparoscopic nephron-sparing surgery for solid renal masses using the ultrasonic shears
  • Citing Article
  • December 2000

Urology

... However, WLC has a limited ability to detect small or flat malignancies, particularly carcinoma in situ (CIS) [2]. Furthermore, several studies have shown that WLC is not suitable for accurate determining tumour stage and grade [3][4][5]. In 21-31% pathology showed benign or inflamed tissue while malignant bladder tumour was suspected [6,7]. ...

Correlation of cytoscopic impression with histologic diagnosis of biopsy specimen of the bladder
  • Citing Article
  • July 2001

Human Pathology

... Ureteral reconstruction represents a great challenge to the urologist, especially if a long segment of ureter is involved. Per decades, surgeons look for alternative ways to repair and to reconstruct the ureter, using different materials and techniques (1)(2)(3). ...

Ureteral substitution with a stapled neoureter: A simplified Boari flap
  • Citing Article
  • December 2001

The Journal of Urology

... Bladder injuries are associated with multisystem trauma. Since the amount of energy transferred needed for bladder perforation is significant, mortality from adjacent structure injuries is high [5]. ...

Bladder Rupture after Blunt Trauma: Guidelines for Diagnostic Imaging
  • Citing Article
  • November 2001

Journal of Trauma and Acute Care Surgery

... However, other scholars have suggested that the pseudocapsule and degenerated renal parenchyma around the tumor can prevent tumor cells from invading the surrounding normal renal parenchyma, so excision along the pseudocapsule around the tumor does not increase the positive rate of surgical margins [26,27]. In addition, studies have shown that although positive surgical margins may lead to local tumor recurrence, they do not affect the prognosis of patients [28]. In this study, although several patients had local recurrence of the tumor, there was no reduction in survival after undergoing a RN. ...

Is a 1-CM margin necessary during nephron-sparing surgery for renal cell carcinoma?
  • Citing Article
  • January 2002

Urology

... This maneuver was called a relocation or repositioning (6,7). However, it is clear that the use of a nitinol basket will bring an additional cost for the RIRS procedure (6,8,9). ...

The Broken Stone Basket: Configuration and Technique for Removal*
  • Citing Article
  • December 2001

Journal of endourology / Endourological Society