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Urologist
12 years of experience
Video profile
Accepting new patients

Education ?

Medical School Score
Loyola University Chicago (1998)
  • Currently 2 of 4 apples

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Ureteroscopy
Patients' Choice Award (2012, 2014)
Associations
American Board of Urology
American College of Surgeons
American Urological Association
American Society for Reproductive Medicine

Affiliations ?

Dr. Schuster is affiliated with 6 hospitals.

Hospital Affilations

Score

Rankings

  • St Anne Mercy Hospital
    3404 W Sylvania Ave, Toledo, OH 43623
    • Currently 4 of 4 crosses
    Top 25%
  • St. Vincent Mercy Children's Hospital
    Urology
    2213 Cherry St, Toledo, OH 43608
    • Currently 4 of 4 crosses
    Top 25%
  • Memorial Hospital
    715 S Taft Ave, Fremont, OH 43420
    • Currently 3 of 4 crosses
    Top 50%
  • Toledo Hospital
    2142 N Cove Blvd, Toledo, OH 43606
    • Currently 3 of 4 crosses
    Top 50%
  • St Luke's Hospital
    5901 Monclova Rd, Maumee, OH 43537
    • Currently 3 of 4 crosses
    Top 50%
  • Fulton County Health Center
    725 S Shoop Ave, Wauseon, OH 43567
    • Currently 3 of 4 crosses
    Top 50%
  • Publications & Research

    Dr. Schuster has contributed to 32 publications.
    Title Regional Collaboration to Improve Radiographic Staging Practices Among Men with Early Stage Prostate Cancer.
    Date October 2011
    Journal The Journal of Urology
    Excerpt

    We describe findings from a Urological Surgery Quality Collaborative project focused on improving the use of radiographic staging in men with newly diagnosed prostate cancer.

    Title Ideal Culture Time for Improvement in Sperm Motility from Testicular Sperm Aspirates of Men with Azoospermia.
    Date November 2007
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The motility of testicular derived spermatozoa reflects viability and predicts success during intracytoplasmic sperm injection. Although improvements in sperm motility are seen after incubation for extended periods, no guidelines suggest duration or media use for optimal improvement in motility. MATERIALS AND METHODS: Between July 1999 and February 2005 testicular aspirations were performed on 95 men with azoospermia, including 51 with obstructive azoospermia and 44 with nonobstructive azoospermia. Sperm motility was determined at initial collection and following incubation for 24 or 48 hours in processing media or Ham's F10 + protein. A mixed regression model controlling for testis side, media and baseline motility was created to analyze the change in motility between 24 and 48 hours. RESULTS: Mean motility improved from 3% to 20% at 24 hours and 25% at 48 hours for OA cases and from 0% to 5% at 24 hours and 11% at 48 hours for nonobstructive azoospermia cases. The improvement in motility from 24 to 48 hours was significant for obstructive azoospermia cases (p = 0.001). While media was a nonsignificant factor in regression models, when patients were grouped into categories of motility change there was a significantly better response to F10 compared to processing media (p = 0.03). CONCLUSIONS: Incubation in processing media or Ham's F10 + albumin media improves sperm motility with significant improvement noted between 24 and 48 hours for obstructive azoospermia cases. Ham's F10 + albumin media may provide extra benefit for cases of nonobstructive azoospermia or nerve injury. These results suggest the ideal timing of oocyte retrieval for intracytoplasmic sperm injection correlates with 48-hour sperm incubation for obstructive azoospermia cases, and 24 hours for nonobstructive azoospermia and nerve injury cases.

    Title Early Urinary Retention After Catheter Removal Following Radical Prostatectomy Predicts for Future Symptomatic Urethral Stricture Formation.
    Date October 2007
    Journal Urology
    Excerpt

    OBJECTIVES: Urinary retention after urethral catheter removal is a well-established complication of radical prostatectomy (RP). Its effect on subsequent urethral stricture formation has not been established. The objective of this study was to evaluate the association between post-RP early urinary retention (EUR) and subsequent symptomatic urethral stricture formation. METHODS: A total of 1289 patients who underwent RP from January 1998 to November 2004 at our tertiary medical center were included in a prospective database project. EUR was defined as that which occurred 7 days or earlier after urethral catheter removal and was identified by retrospective chart review. Multivariate logistic regression models were constructed to evaluate the association between EUR and symptomatic urethral stricture formation. RESULTS: Of the 1289 patients, 44 (3.4%) experienced EUR, and 16 of these patients (36.4%) developed symptomatic urethral strictures. The stricture rate for patients without EUR was 9.0% (112 of 1245). Compared with the patients without EUR, the patients with EUR had a greater rate of bladder neck contracture (94% versus 68%, P = 0.04) and exhibited a significantly decreased time to stricture formation (1.6 months versus 3.0 months, P = 0.002). After adjusting for patient age, clinical stage, surgeon, and Gleason score, the odds of developing a symptomatic urethral stricture were 4.7 times greater in the patients with EUR (95% confidence interval 2.3 to 9.6). CONCLUSIONS: The results of this study have shown that patients with EUR after RP are at a significantly greater risk of developing symptomatic urethral strictures, tend to form bladder neck contractures instead of more distal strictures, and to form strictures sooner after surgery. EUR might be a previously unrecognized risk factor for the development of post-RP urethral stricture.

    Title Long-term Follow-up After Epididymectomy for Chronic Epididymal Pain.
    Date October 2007
    Journal Urology
    Excerpt

    OBJECTIVES: Epididymectomy is an option for the relief of epididymal pain related to postoperative obstruction, epididymal cysts, or epididymitis. We performed 66 epididymectomies on 52 patients from 1996 to 2006 at our institution for localized epididymal pain. We evaluated the long-term symptomatic relief after epididymectomy. METHODS: All 52 epididymectomy patients were mailed questionnaires regarding their current pain level and satisfaction. Patients who did not return the questionnaires were interviewed by telephone for follow-up. RESULTS: Of the 52 patients, 34 returned 44 completed questionnaires (the patients with bilateral procedures were mailed a questionnaire for each side). The average age at epididymectomy was 44.2 years (range 25.0 to 67.9). The average follow-up was 45.8 months (range 4.2 to 119.3). Of the 34 procedures, 17 were left sided, 7 right sided, and 10 were bilateral; 25 had been performed for postvasectomy pain and 5 for obstruction related to hernia repair. Of the 44 cases, 31 (70%) reported no pain. Of the 13 still with pain, 8 (62%) reported less pain. Also, 90% were very satisfied or satisfied with their choice to undergo epididymectomy. CONCLUSIONS: We found excellent results after epididymectomy, especially for the indication of postvasectomy pain.

    Title Epididymal Obstruction Results in Isolated Sperm Heads in Post-vasectomy Rats.
    Date April 2007
    Journal International Journal of Andrology
    Excerpt

    The aim of this study was to determine if, following vasectomy, epididymal obstruction resulted in changes in vasal stump fluid using a rat vasectomy model. One hundred and twenty-two mature male rats underwent bilateral surgical vasectomy and subsequent unilateral epididymal obstruction. Animals were randomly assigned to one of the five cohorts, which determined the time to kill and vasal fluid assessment. Numbers of whole sperm and sperm heads were compared between the obstructed and non-obstructed sides. Parametric analysis of microscopic vasal fluid findings was performed using a paired t-test. Whole sperm and sperm heads were detected bilaterally among the initial five cohorts. On the obstructed epididymis side, percentage of whole sperm dropped from 36.9% to less than 1% and sperm heads increased from 63.2 to 99.7% at 12 weeks post-obstruction (p < 0.05 at each time interval). On the unobstructed side, percentage of whole sperm rose from 66.3 to 89.5% and sperm heads dropped from 33.7 to 10.5% (p < 0.05 at each time interval). At 12 weeks, the difference between the obstructed and non-obstructed sides for both percentage and quantity of whole sperm and heads was significant with a p value of <0.001. In this rat model, following vasectomy and subsequent epididymal obstruction, testicular vasal stump fluid will contain progressively diminishing numbers of whole sperm and increases in the percentage and absolute numbers of sperm heads.

    Title Fertility Issues for Men with Newly Diagnosed Prostate Cancer.
    Date February 2007
    Journal Urology
    Excerpt

    OBJECTIVES: With the increased use of prostate-specific antigen screening, younger men are being diagnosed with prostate cancer. A subset of these men is still interested in potentially having children after cancer treatment. To our knowledge, the topic of future fertility in patients with newly diagnosed prostate cancer has not previously been reported. METHODS: The charts of 8 patients with prostate cancer who were interested in future fertility before treatment were retrospectively reviewed. Preceding definitive treatment, the men underwent fertility counseling and were counseled to preserve semen before treatment. RESULTS: All 8 patients decided to have their semen stored using cryopreservation before their operation. After undergoing radical prostatectomy, one of the patients and his wife underwent successful intrauterine insemination and bore a child. CONCLUSIONS: A subset of men, regardless of age, diagnosed with prostate cancer will be interested in preserving their fertility for the future. Fertility options and potential counseling should be part of the routine pretreatment appointments in men undergoing treatment of prostate cancer.

    Title Premature Ejaculation.
    Date October 2006
    Journal Urologic Nursing : Official Journal of the American Urological Association Allied
    Excerpt

    Premature ejaculation is a common entity that can have a significant impact on an individual's sexual satisfaction and quality of life. Both behavioral and pharmacological options are available and effective for men presenting with this condition.

    Title Papillary Renal Cell Carcinoma Containing Fat Without Calcification Mimicking Angiomyolipoma on Ct.
    Date November 2004
    Journal Ajr. American Journal of Roentgenology
    Title Seminoma Nine Years After Cardiac Transplantation.
    Date June 2004
    Journal Transplantation
    Title Safety and Efficacy of Same-session Bilateral Ureteroscopy.
    Date April 2004
    Journal Journal of Endourology / Endourological Society
    Excerpt

    PURPOSE: Same-session ureteroscopy for bilateral urinary calculi would potentially reduce costs and the need for a second anesthetic compared with staged procedures. We sought to establish the safety and efficacy of same-session bilateral ureteroscopy relative to procedures for staged bilateral and multiple unilateral calculi in the context of contemporary instrumentation. PATIENTS AND METHODS: A series of 626 consecutive patients underwent ureteroscopy for calculi between January 1997 and August 2001. Among these, 34 patients with bilateral calculi (11 staged and 23 treated in one sitting) and 54 patients with multiple unilateral calculi in distinct locations were included in this study. Multivariable regression was used to determine the association of patient-specific and technical factors with postoperative morbidity. RESULTS: Stone-free rates were similar in the two groups and ranged from 50% to 100% depending on stone location. Postoperative complications occurred in 6 (11%) and 3 (14%) of the patients treated for multiple unilateral and for bilateral calculi in a staged procedure, respectively, compared with 7 (29%) of those undergoing same-session bilateral ureteroscopy (P = 0.12). Logistic regression revealed that same-session bilateral ureteroscopy (odds ratio [OR] 4.0; P = 0.02) and absence of a postoperative stent (OR 1.7; P = 0.03) were associated with added morbidity. However, the cumulative risk of performing staged bilateral procedures (14% per procedure) approximated that of bilateral ureteroscopy in one sitting (29%). CONCLUSION: Bilateral ureteroscopy carries an increased risk of postoperative morbidity. The risk is proportional to the number of renal units treated and may be assumed at once (e.g., same-session) or over time (e.g., staged) as it applies to patients requiring bilateral ureteroscopy.

    Title Isolation of Motile Spermatozoa from Semen Samples Using Microfluidics.
    Date March 2004
    Journal Reproductive Biomedicine Online
    Excerpt

    A microfluidic device was designed with two parallel laminar flow channels where non-motile spermatozoa and debris would flow along their initial streamlines and exit one outlet, whereas motile spermatozoa had an opportunity to swim into a parallel stream and exit a separate outlet. Motile sperm samples were prepared with density gradient separation (n = 5). Sperm motility was assessed the following day after exposing aliquots to polydimethylsiloxane (PDMS) used to construct the device. There was no difference in sperm motility when compared with unexposed aliquots (P > 0.05). Unprocessed semen samples (n = 10) were placed in wider channels and sperm motility and strict morphology were assessed from sorted outlets. Sperm motility increased from 44 +/- 4.5% to 98 +/- 0.4% (P < 0.05) and morphology increased from 10 +/- 1.05% to 22 +/- 3.3% (P < 0.05) following processing. Finally, density gradient prepared samples (n = 6) containing 5 x 10(6) motile spermatozoa/ml and 50 x 10(6) round immature germ cells/ml were sorted and assessed in a similar fashion. The ratio of motile spermatozoa to round immature germ cells in the wide inlet (1:10) was significantly improved in the thin outlet (33:1) (P < 0.05). This microfluidic device provides a novel method for isolating motile, morphologically normal spermatozoa from semen samples without centrifugation. This technology may prove useful in isolating motile spermatozoa from oligozoospermic samples, even with high amounts of non-motile gamete and/or non-gamete cell contamination. A movie sequence showing streaming and sorting of spermatozoa may be purchased for viewing on the internet at www.rbmonline.com/Article/847 (free to web subscribers).

    Title Ultra-rapid Freezing of Very Low Numbers of Sperm Using Cryoloops.
    Date December 2003
    Journal Human Reproduction (oxford, England)
    Excerpt

    BACKGROUND: With the availability of ICSI, men with severe oligozoospermia (<5x10(6)/ml) are able to reproduce. Current methods for cryopreservation of severe oligozoospermic samples are labour intensive and costly. The objective of this study was to evaluate whether freezing small numbers of motile sperm (approximately 100) was feasible using cryoloops. METHODS: Initial tests assessed the effect of various dilutions of cryoprotectants on pre-freezing sperm motility. Several solutions were further evaluated for their ability to cryoprotect sperm during ultra-rapid freezing. Sperm were placed on cryoloops and held in liquid nitrogen vapour for 5 min prior to freezing (ultra-rapid freezing) or directly submerged into liquid nitrogen. Using the optimal cryoprotectant and technique from these experiments, ultra-rapid and standard slow-rate freezing protocols were compared. RESULTS: Optimal sperm survival was seen when sperm in cryoloops were placed in liquid nitrogen vapour in test yolk buffer with 12% v/v glycerol versus other cryoprotectants. Using this cryoprotectant, post-thaw sperm motility is comparable between ultra-rapid and slow-rate freezing methods. CONCLUSION: Ultra-rapid freezing of very low numbers of sperm is feasible using cryoloops suspended in liquid nitrogen vapour for 5 min.

    Title Legal Considerations for Cryopreservation of Sperm and Embryos.
    Date August 2003
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To summarize the case law for cryopreservation of sperm and embryos and make recommendations for desirable characteristics that should be included in a cryopreservation clinic's disposition agreements. DESIGN: A literature review of case law and legal review articles was performed. SETTING: Academic research center. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULT(S): Two court cases involving cryopreserved semen and five cases involving cryopreserved embryos are reviewed. CONCLUSION(S): The state of the law surrounding cryopreservation is recent and unsettled. Disposition agreements can provide cryopreservation clinics some degree of certainty in this unsettled area of law. Those drafting cryopreservation disposition agreements are assisted by lessons learned from cryopreservation cases and insight gained from law review articles. It is evident that cryopreservation agreements will be most successful and most likely to be enforced if they are unambiguous, consistent with public policy, and include: a duration provision, each individual's contact information, the individual's provisions for use of their gametes in case of death, and responsibilities of cryopreservation clinic and individuals. Individuals must enter into agreements with a true understanding of the contained provisions.

    Title Passively Driven Integrated Microfluidic System for Separation of Motile Sperm.
    Date August 2003
    Journal Analytical Chemistry
    Excerpt

    This paper describes a self-contained integrated microfluidic system that can separate motile sperm from small samples that are difficult to handle using conventional sperm-sorting techniques. The device isolates motile sperm from nonmotile sperm and other cellular debris, based on the ability of motile sperm to cross streamlines in a laminar fluid stream. The device is small, simple, and disposable yet is an integrated system complete with sample inlets, outlets, sorting channel, and a novel passively driven pumping system that provides a steady flow of liquid; it requires no external power source or controls. The device fulfills a need in clinical settings where small amounts of sperm need to be sorted. It also opens the way for convenient bioassays based on sperm motility including at-home motile sperm tests.

    Title Identifying Patients Who Are Suitable for Stentless Ureteroscopy Following Treatment of Urolithiasis.
    Date July 2003
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Foregoing ureteral stents following ureteroscopy for urinary calculi is an evolving practice. Randomized trials support stent omission in select cases though generalizability is unclear and criteria for stentless ureteroscopy are unknown. Therefore, we sought to identify significant clinical characteristics affecting postoperative morbidity in unstented patients to provide a context for future randomized trials. MATERIALS AND METHODS: Of 837 ureteroscopic procedures for urolithiasis performed at our institution from January 1997 through January 2002 a ureteral stent was not placed in 226 (32%). Among these patients 47 had no stone at the time of the procedure leaving 219 (26%) who were treated for urinary calculus disease. Multivariate logistic regression was used to determine the association of 24 variables with postoperative morbidity. RESULTS: Of the 219 patients treated with ureteroscopy 39 (18%) had a postoperative complication, which was obstructive in 26 (12%), infectious in 10 (5%), and related to patient co-morbidity in 3 (1%). Factors associated with postoperative morbidity included renal pelvic location (p = 0.02), lithotripsy (p = 0.03), bilateral procedure (p = 0.07), history of urolithiasis (p <0.0001), diabetes mellitus (p = 0.06), recent/recurrent infection (p <0.0001), operative time 45 minutes or greater (p = 0.07), operative time 45 minutes or greater plus lithotripsy (p = 0.0004), operative time 45 minutes or greater plus ureteral dilation (p = 0.07) and bilateral stentless procedure (p = 0.005). CONCLUSIONS: Multiple patient and operative factors may predispose a patient to postoperative morbidity after a stentless procedure. Future trials should prospectively validate the role of these factors in either promoting (e.g., history of urolithiasis) or preventing (e.g., preoperative stent) a postoperative complication in the setting of stentless ureteroscopy.

    Title Radical Cystectomy for Bladder Cancer After Definitive Prostate Cancer Treatment.
    Date April 2003
    Journal Urology
    Excerpt

    OBJECTIVES: To review our perioperative experience with patients presenting with high-risk bladder cancer who had undergone prior therapy for prostate cancer. With the increase in diagnosis and subsequent treatment of prostate cancer, more patients presenting with high-risk bladder cancer have undergone prior therapy for prostate cancer. Radical cystectomy in these patients can be technically challenging and may be associated with added morbidity. METHODS: A retrospective review of 458 patients treated with radical cystectomy between January 1993 and January 2002 revealed 29 patients (mean age 72 years) who had received definitive treatment for prostate cancer prior to cystectomy for bladder carcinoma. The initial treatment in this cohort was radical prostatectomy or external beam radiotherapy in 12 (41%) and 17 (59%) men, respectively. Cystectomy was performed for transitional cell carcinoma in 25 (86%), small cell carcinoma in 2 (6%), and sarcoma in 2 (6%) patients. RESULTS: At the time of cystectomy, the mean blood loss was 1175 mL (range 275 to 3500), and the median length of hospitalization was 8 days (range 4 to 23). No intraoperative or perioperative deaths occurred in this cohort. Twenty-seven early complications were identified in 16 (55%) of 29 patients; no rectal injuries occurred. Patients with prior radiotherapy had a higher rate of extravesical bladder carcinoma (60%) than those patients treated with prior prostatectomy (33%). An orthotopic neobladder diversion was created in 5 patients (17%). CONCLUSIONS: Patients with bladder cancer previously treated for prostate cancer with external beam radiotherapy or radical prostatectomy have an increased risk of perioperative complications compared with patients undergoing cystectomy without prior therapy. This risk is not prohibitive, and radical cystectomy should remain the treatment of choice for high-risk bladder cancer in this population. Furthermore, orthotopic urinary diversion may be a reasonable option and should be considered in select patients.

    Title Diagnosis and Treatment of Ejaculatory Dysfunction.
    Date January 2003
    Journal The Urologic Clinics of North America
    Excerpt

    The normal ejaculatory process requires complex coordination and integration of neurologic, physiologic, anatomic, and psychologic events. An understanding of these processes is critical to evaluate properly and manage patients with ejaculatory dysfunction. With the advent of improved techniques to treat patients, some men with ejaculatory dysfunction are being offered the opportunity to reproduce. Further research on the ejaculatory process and associated dysfunctional states should continue to improve treatment for patients presenting with ejaculatory disorders.

    Title Ureteroscopic Treatment of Renal Calculi in Morbidly Obese Patients: a Stone-matched Comparison.
    Date November 2002
    Journal Urology
    Excerpt

    OBJECTIVES: To report a matched comparison of morbidly obese (MO) patients and normal weight (NW) patients who underwent ureteroscopic (URS) treatment of renal calculi. Shock wave lithotripsy and percutaneous nephrostolithotomy may be precluded in MO patients, and URS treatment offers a minimally invasive alternative. METHODS: We retrospectively reviewed the charts of patients who underwent URS at our institution between 1997 and 2000. Fifty-four patients underwent URS treatment solely for renal calculi. Sixteen MO patients underwent 18 procedures. Thirty-eight NW patients, who underwent 39 procedures, were matched to the MO patients by stone location and size. Stones were categorized by location and size, less than 10 mm or 10 mm or greater. The factors and outcomes assessed were stone length, operative time, presence of a ureteral stent, success, and complications. RESULTS: The overall success rate was 83% (15 of 18 procedures) for MO patients and 67% (26 of 39 procedures) for NW patients, but this difference was not significant (P = 0.23). The difference in the success rate for renal calculi 10 mm or greater (100% versus 38%) approached significance (P = 0.09). This may be related to other distinctions between the groups. URS treatment was often a salvage therapy in the NW group after other modalities failed. No significant differences were found between the other outcomes. CONCLUSIONS: URS treatment of renal calculi when matched for location and size is as successful and no more morbid in MO than in NW patients. URS treatment of renal calculi is a safe and effective first-line treatment for renal calculi in MO patients.

    Title Ureteroscopic Treatment of Lower Pole Calculi: Comparison of Lithotripsy in Situ and After Displacement.
    Date July 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Ureteroscopic management is a viable option for lower pole calculi less than 2 cm. Recently a technique was described to displace the calculus into a more accessible calix using a nitinol basket or grasper before lithotripsy. We compared the efficacy and safety of this technique with in situ treatment of small and intermediate lower pole calculi. MATERIALS AND METHODS: We retrospectively reviewed the records of 95 ureteroscopy cases performed at our institution from January 1997 through August 2001 for renal calculi located only in the lower pole. Preoperative patient characteristics, stone size, operative details, complications and outcomes were compared for calculi treated in situ and those displaced before treatment. RESULTS: Adequate followup was available on 78 patients. Patients in the displacement group were statistically older, more often had a preoperative indwelling ureteral stent and had a mean operative time that was 16 minutes longer (p = 0.04). Average stone diameter in the in situ and displacement groups was 8 and 10.3 mm., respectively (p = 0.04). In patients with radiographic followup greater than 1 month complete success was obtained for 77% of stones 1 cm. or less treated in situ versus 89% treated with displacement first (p = 0.43). For calculi greater than 1 cm. complete success was obtained for 2 of the 7 (29%) treated in situ versus all 7 (100%) treated with displacement (p = 0.005). CONCLUSIONS: When treating lower pole calculi 1 to 2 cm. via ureteroscopy, a higher success rate can be obtained with displacement into a more accessible calix before treatment.

    Title Ureteroscopy for the Treatment of Urolithiasis in Children.
    Date May 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Ureteroscopy for treating urolithiasis in prepubertal children has become more common with the advent of smaller instruments. We reviewed our experience with ureteroscopy for urolithiasis in this cohort of patients as well as the literature using this treatment modality in children. MATERIALS AND METHODS: Between 1994 and 2000 we performed 27 ureteroscopic stone extractions in 25 children. Ureteroscopy was done in a manner similar to that in adults. Ureteral dilation was performed when necessary to access the ureter. A stent was placed postoperatively if there was significant ureteral trauma. RESULTS: Of the 25 children 13 were male and 12 were female. Average age was 9.2 years (range 3 to 14). Stones were 2 to 12 mm. in greatest diameter (average 6). Of the 27 procedures the ureteral orifice was dilated before stone treatment in 15 (56%), while in 19 (70%) a stent was placed afterward. No intraoperative and 2 postoperative complications were identified. Overall 92% of the children were rendered stone-free after 1 procedure and 100% were stone-free after 2. CONCLUSIONS: Ureteroscopy for urolithiasis in prepubertal children is safe and effective. Routine ureteral dilation and ureteral stent placement are not always necessary in these patients.

    Title Postoperative Ileus After Abdominal Surgery.
    Date April 2002
    Journal Urology
    Title Flexible Ureteroscopy in Conjunction with in Situ Lithotripsy for Lower Pole Calculi.
    Date January 2002
    Journal Urology
    Excerpt

    OBJECTIVES: To demonstrate the efficacy and safety of ureteroscopy as a compromise in treating small and intermediate-size lower pole calculi. The optimal management of lower pole calculi remains controversial. Shock wave lithotripsy is associated with minimal morbidity but with suboptimal stone clearance rates. Conversely, percutaneous nephrostolithotomy has greater morbidity but stone-free rates greater than 90% regardless of size. METHODS: Seventy-two patients underwent ureteroscopy for lower pole calculi 2 cm or less (mean 8.7 mm) during a 3-year period. To minimize confounding, 11 patients with additional calculi at other ipsilateral renal sites and 1 patient with large (2.4 cm each) bilateral calculi were excluded. Two patients with bilateral lower pole calculi and four who required a second procedure were included in the analysis. Thus, the final cohort consisted of 60 patients who underwent 66 procedures. RESULTS: Of patients with follow-up longer than 1 month, 79% were stone free after a single procedure, and this improved to 88% after a second procedure in 4 patients. All 7 patients with follow-up less than 1 month had a reduction in stone burden after successful fragmentation. Overall, 8 patients required an auxiliary procedure. No intraoperative complications, and 7 (11%) postoperative complications occurred. CONCLUSIONS: Ureteroscopy for lower pole calculi is associated with minimal morbidity and stone-free rates comparable to shock wave lithotripsy for smaller stones. The greatest utility of ureteroscopy is in the management of intermediate-size calculi, for which it has substantially higher stone-free rates and lower repeated treatment rates than does shock wave lithotripsy.

    Title Revision Rate After Artificial Urinary Sphincter Implantation for Incontinence After Radical Prostatectomy: Actuarial Analysis.
    Date December 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We determined the actuarial revision rate for artificial urinary sphincters implanted in patients who were incontinent after radical prostatectomy. MATERIALS AND METHODS: We reviewed the records of 70 consecutive patients who were incontinent after radical prostatectomy and who underwent primary artificial urinary sphincter implantation at the University of Michigan between 1984 and 1999. Questionnaires were mailed to all patients with an indwelling device, and telephone calls were placed to those who did not respond to the mailing. Information about surgical revision and current continence status was obtained from chart review and questionnaire response. The Kaplan-Meier curves for actuarial freedom from operative revision were constructed. RESULTS: Of the 66 patients with available postoperative data 24 (36%) required reoperation at a mean followup of 41 months. The 5-year actuarial rate for freedom from any operative revision was 50%, and the corresponding rate for cuff revision was 60%. A single operative revision did not predispose the patient to further revision. Questionnaire data indicated a continence rate of 80% (range 0 to 2 pads). CONCLUSIONS: Approximately half of the patients who were incontinent after radical prostatectomy may expect to undergo operative revision within 5 years after artificial urinary sphincter implantation. Despite this high reoperation rate, an excellent level of continence is maintained.

    Title Comparison of Outcomes of Ureteroscopy for Ureteral Calculi Located Above and Below the Pelvic Brim.
    Date December 2001
    Journal Urology
    Excerpt

    OBJECTIVES: To compare the safety and efficacy of ureteroscopy performed for proximal and distal ureteral calculi in a contemporary cohort. Ureteroscopy has been used most often for distal ureteral calculi. However, advances in endoscopic equipment have facilitated access to the proximal urinary tract and have broadened the indications for ureteroscopy. METHODS: One hundred ninety-one patients underwent rigid and/or flexible ureteroscopy for ureteral calculi at the University of Michigan between January 1, 1997 and September 30, 1999. Only 7 patients with either bilateral calculi or steinstrasse were excluded. The final cohort consisted of 184 patients who underwent ureteroscopy for distal stones (n = 103) or middle/upper ureteral stones (n = 81). RESULTS: Bivariate analyses of pretreatment and perioperative characteristics were used to assess the sample population. The initial success rate for the distal and proximal ureteral calculi was 96% and 78%, respectively (P = 0.0008). After a "second-look" procedure in 4 and 7 patients with distal and proximal calculi, respectively, the success rate improved to 99% and 88%, respectively (P = 0.004). No differences were noted between groups regarding the intraoperative (P = 0.51) or postoperative (P = 0.85) complication rates. Multivariate logistic regression analysis confirmed that larger stone size (odds ratio 1.2, P = 0.0006) and proximal ureteral location (odds ratio 4.8, P = 0.01) are independent predictors of treatment failure. CONCLUSIONS: Ureteroscopic management of proximal and distal ureteral calculi is highly successful, and the difference in success rates has narrowed substantially. Currently, no greater risk is conferred to the patient for endoscopy of more proximal ureteral calculi.

    Title Complications of Ureteroscopy: Analysis of Predictive Factors.
    Date August 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Although overall and major complication rates of 10% to 20% and 0% to 6%, respectively, have been observed in large series of ureteroscopy, to our knowledge no systemic analysis to determine factors predictive of these complications has been reported. MATERIALS AND METHODS: We retrospectively reviewed all ureteroscopies performed at our institution for calculous disease from January 1997 through September 1999. A total of 322 procedures were performed by 5 attending surgeons. Intraoperative and immediate postoperative complications were identified. Bivariate and multivariate analysis was performed to identify associated factors with ureteral perforation and postoperative complications as the dependent variables. RESULTS: Bivariate analysis showed a significant association of ureteral perforation with increased operative time (p = 0.0001). In addition, we noted a significant association of postoperative complications with stones in the kidney (p = 0.0004), operative time (p = 0.05) and decreased surgeon experience (p = 0.0035) as well as a trend toward significance for the type of ureteroscope used (p = 0.0609). In multivariate logistic regression models ureteral perforation remained highly associated with operative time (p = 0.0005) when controlling for the other factors. Similarly decreased surgeon experience and a stone in the kidney were predictive of postoperative complications when controlling for the other factors (p = 0.004). CONCLUSIONS: Longer duration of the ureteroscopic procedure is strongly associated with ureteral perforation. The likelihood of immediate postoperative complications is greater when renal calculi are treated and less when the surgeon is more experienced.

    Title Pelvic Recurrences Post Cystectomy: Current Treatment Strategies.
    Date June 2001
    Journal Seminars in Urologic Oncology
    Excerpt

    Pelvic recurrence following cystectomy is a devastating problem for both physician and patient. Patients who recur locally usually do so within the first 2 years following surgery. Stage, grade, and possibly p53 status of the tumor are prognostic indicators for local failure. Patients with extensive disease at the time of diagnosis may benefit from adjuvant or neoadjuvant treatment to attempt to decrease the rate of recurrence. Treatment of patients with local failure should use a multimodality approach that includes systemic chemotherapy with or without local radiation therapy or surgery. Although rare, long-term survival can be achieved in selected patients.

    Title Use of Bipolar Electrocautery During Laparoscopic Donor Nephrectomy.
    Date June 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We describe a technique enabling easier placement of the endoscopic linear stapling device on the renal vein during laparoscopic nephrectomy. MATERIALS AND METHODS: Bipolar electrocautery rather than a clip applier was used in 20 laparoscopic donor nephrectomy cases to coagulate the renal vein branches before transection. Warm ischemia time of the specimens and the number of surgical clip applier devices used were compared with those in the 20 immediate preceding cases in which bipolar electrocautery was not used. RESULTS: Using bipolar electrocautery no clips were placed on the specimen side of the renal vein before stapling. Average warm ischemia time for the 20 kidneys in which bipolar electrocautery was performed was 2 minutes 13 seconds compared with 3 minutes 1 second for the previous 20 (p = 0.157). Significantly fewer clip applying devices were used in the 20 bipolar electrocautery cases (p = 0.005). CONCLUSIONS: Bipolar electrocautery of the renal vein branches enables easier placement of the endoscopic linear stapling device on the renal vein and the use of fewer surgical clip appliers during laparoscopic surgery. Because the bipolar electrocautery device is reusable, it decreases operative costs.

    Title Routine Placement of Ureteral Stents is Unnecessary After Ureteroscopy for Urinary Calculi.
    Date May 2001
    Journal Urology
    Excerpt

    OBJECTIVES: To report a matched comparison of patients with and without stenting after ureteroscopy for calculi, including middle or proximal ureteral and renal calculi. The elimination of routine stenting after ureteroscopy would prevent stent pain, minimize the need for re-instrumentation, and reduce costs-as long as efficacy and safety are not diminished. METHODS: Of 318 patients who underwent ureteroscopy, 81 (25%) did not have a ureteral stent placed. Of those, 51 were suitable for analysis and included patients with distal ureteral (n = 22), middle or proximal ureteral (n = 11), and renal calculi (n = 18). This cohort was matched to a stented group by stone size and location. RESULTS: The preoperative characteristics of the groups were similar. A stone-free rate of 86% and 94% was achieved in the stented and nonstented groups, respectively (P = 0.32). Complications in the nonstented group were less frequent (flank pain in 3 and postoperative nausea in 1) than in the stented group (hospital visits for flank pain in 12, persistent nausea and vomiting in 1, sepsis in 1, perinephric hematoma in 1, and urinary retention in 1) (total of 4 versus 16, P = 0.025). CONCLUSIONS: Ureteroscopy for distal ureteral stones without ureteral stent placement has been previously described. Our experience expands to include the elimination of stent placement after ureteroscopy for middle or proximal ureteral (22%) and renal (35%) calculi. Our data suggest that after ureteroscopies with short operative times and minimal ureteral trauma, ureteral stents may not be necessary, even if proximal ureteral or renal ureteroscopy has been performed.

    Title Testicular Histoplasmosis.
    Date November 2000
    Journal The Journal of Urology
    Title The Relative Amount of Epithelium, Muscle, Connective Tissue and Lumen in Prostatic Hyperplasia As a Function of the Mass of Tissue Resected.
    Date April 1999
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The relative amounts of epithelium, connective tissue, muscle and gland lumen in benign prostatic hyperplasia have been reported but they have not been correlated with prostate size. We determine if the relative amount of prostatic tissue varies with prostate size. MATERIALS AND METHODS: Paraffin blocks of transurethrally resected prostate tissue were randomly chosen from the archives of 58 patients with benign prostatic hyperplasia. Two new slides per patient were made and stained with prostate specific antigen or Masson trichrome, respectively. A total of 20 images from each slide were captured using a high resolution camera, digitized and analyzed with computer software for the relative percentage of the various tissue components. RESULTS: As the amount of prostate tissue resected increased from less than 10 to greater than 70 gm. the epithelium had a 4-fold increase from 5.37 to 21.92%, the muscle component had a 42% decrease from 28.46 to 16.62%, the lumen doubled from 7.05 to 14.01% and the connective tissue remained relatively unchanged from 35.58 to 31.53%. There was a statistically significant difference in all components of prostatic tissue except for connective tissue when comparing prostates less than 30 versus greater than 30 gm., including epithelium 6.52 versus 16.10% (p <0.01), muscle 28.45 versus 20.78% (p <0.01), lumen 7.42 versus 14.58% (p <0.01) and connective tissue 35.74 versus 32.45% (p <0.06). The stroma-to-epithelium and muscle-to-epithelium ratios each had a 9-fold decline (p = 0.01). CONCLUSIONS: As the prostate increases in size, there is statistically significant more epithelium and lumen, and less muscle tissue.

    Title Preliminary Noninvasive Back-pressure Recordings of Bladder Pressure.
    Date April 1997
    Journal Techniques in Urology
    Excerpt

    Obstructive voiding is best evaluated with urodynamics, including bladder pressure and urine flow rates. Until recently, the recording of bladder pressure required the use of a urethral catheter. In preliminary observations, a noninvasive back-pressure method using an external condom catheter has been introduced to determine bladder pressure. This device uses a side tube for pressure recording and an outlet tube that is clamped for short periods of time. We have investigated design criteria for back-pressure recording techniques. In the laboratory setting using a plastic model, we determined that a low compliance condom is needed. In addition, a back flow of fluid during the clamping procedure helps to obtain quick back pressures and facilitates evaluation of pressure when low flow rates are present. These modified condom devices were evaluated in four male subjects. Back pressures were not statistically different than bladder pressures recorded with a urethral catheter. The use of back pressures in the evaluation for obstructive uropathy can be enhanced by using a pressure and flow nomogram.

    Title Mnd2: a New Mouse Model of Inherited Motor Neuron Disease.
    Date August 1993
    Journal Genomics
    Excerpt

    The autosomal recessive mutation mnd2 results in early onset motor neuron disease with rapidly progressive paralysis, severe muscle wasting, regression of thymus and spleen, and death before 40 days of age. mnd2 has been mapped to mouse chromosome 6 with the gene order: centromere-Tcrb-Ly-2-Sftp-3-D6Mit4-mnd2-D6Mit 6, D6Mit9-D6Rck132-Raf-1, D6Mit11-D6Mit12-D6Mit14, mnd2 is located within a conserved linkage group with homologs on human chromosome 2p12-p13. Spinal motor neurons of homozygous affected animals are swollen and stain weakly, and electromyography revealed spontaneous activity characteristic of muscle denervation. Myelin staining was normal throughout the neuraxis. The clinical observations are consistent with a primary abnormality of lower motor neuron function. This new animal model will be of value for identification of a genetic defect responsible for motor neuron disease and for evaluation of new therapies.

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