Michael D Stifelman, M.D.

Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases
Dulabon, Lori M; Kaouk, Jihad H; Haber, Georges-Pascal; Berkman, Douglas S; Rogers, Craig G; Petros, Firas; Bhayani, Sam B; Stifelman, Michael D
2011 Mar;59(3):325-330, European urology
BACKGROUND: Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. OBJECTIVE: We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. MEASUREMENTS: Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. RESULTS AND LIMITATIONS: Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2cm vs 2.6cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3+/-7.4min vs 19.6+/-10.0min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons' prior robotic experience. CONCLUSIONS: The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons
— id: 128786, year: 2011, vol: 59, page: 325, stat: Journal Article,

Large left upper quadrant mass
Ernst, Amy A; Weiss, Steve J; Wachter, David A; Stifelman, Michael D
2011 Jul;29(6):693.e5-693.e7, American journal of emergency medicine
— id: 136666, year: 2011, vol: 29, page: 693.e5, stat: Journal Article,

A prospective evaluation of the utility of laparoscopic Doppler technology during minimally invasive partial nephrectomy
Hyams, Elias S; Perlmutter, Mark; Stifelman, Michael D
2011 Mar;77(3):617-620, Urology
OBJECTIVE: To evaluate the objective benefits of laparoscopic Doppler ultrasound (LDU) during robotic-assisted laparoscopic partial nephrectomy (RALPN). LDU has demonstrated subjective benefits for the evaluation of vascular structures during minimally invasive renal surgery. MATERIAL AND METHODS: An institutional review board-approved, prospective protocol was developed to compare hilar dissection time with and without LDU during RALPN. Primary endpoints included hilar dissection time and whether use of LDU changed operative management. The presence of accessory vessels (AV) on LDU and surgical dissection were recorded and compared with preoperative imaging. RESULTS: Fifty-three consecutive patients underwent RALPN (27 + LDU, 26 -LDU). There were no significant differences in demographic or disease factors. Total time for hilar dissection in the LDU arm (LDU + dissection) was significantly less than time for hilar dissection alone in the non-LDU arm (7.2 vs 11.0 minutes, P <.05). There were no intraoperative complications and there was no difference in estimated blood loss. Seven patients (26%) in the +LDU arm had accessory vessels discovered by LDU that were not seen on preoperative imaging. Five of these vessels were renal arteries that required clamping for either global or selective ischemia. LDU revealed persistent parenchymal flow after arterial clamping in 2 cases, allowing for successful double clamping or clamping of an accessory artery subsequently identified. LDU findings changed operative management in 7 of 27 patients (26%). CONCLUSIONS: LDU reduced time for hilar dissection, improved sensitivity for hilar vessel detection, and changed operative management based on findings. This evidence supports the use of LDU during minimally invasive partial nephrectomy
— id: 130898, year: 2011, vol: 77, page: 617, stat: Journal Article,

Robotic ureterolysis for relief of ureteral obstruction from retroperitoneal fibrosis
Keehn, Aryeh Y; Mufarrij, Patrick W; Stifelman, Michael D
2011 Jun;77(6):1370-1374, Urology
OBJECTIVE: To review our experience with robotic surgery for the management of retroperitoneal fibrosis (RPF) with ureteral obstruction. Ureteral obstruction is common in retroperitoneal fibrosis RPF. METHODS: Since April 2006, 21 patients have presented to our institution with ureteral obstruction, apparently from RPF. All underwent robotic biopsy. If frozen pathology reveals malignancy, is equivocal, and/or the fibrotic reaction is extensive, we stent the obstructed side(s) and await final pathology. If RPF is confirmed, medical therapy is initiated to relieve obstruction; failures receive salvage ureterolysis. Lymphomas are referred to medical oncology. If frozen pathology demonstrates RPF, immediate ureterolysis is performed, if technically feasible. Ureterolysis is not performed for uninvolved contralateral systems. We reviewed data with institutional review board approval. RESULTS: Of 21 patients, 3 were diagnosed with lymphoma and 18 with RPF. Seventeen patients (21 renal units) with RPF received robotic ureterolysis (11 primary, 6 salvage); the other patient died of trauma before intervention. The only perioperative complication, an enterocutaneous fistula, required bowel resection. Three patients required a secondary procedure to relieve obstruction. At a mean follow-up of 20.5 months, no renal unit has evidence of obstruction, and all patients have improved or resolved symptoms. Furthermore, none of the 13 patients who underwent a unilateral ureterolysis have had disease progression to the contralateral side. CONCLUSIONS: Robotic ureterolysis can be performed with minimal morbidity and provides durable success rates for relief of symptoms and obstruction in RPF. Biopsy remains integral to ruling out lymphoma. Empiric contralateral ureterolysis may not be necessary
— id: 134186, year: 2011, vol: 77, page: 1370, stat: Journal Article,

Multi-institutional analysis of robotic assisted partial nephrectomy for clinical stage T1b renal tumors: Perioperative outcomes in 445 patients
Petros F.G.; Haber G.P.; Dulabon L.M.; Sukumar S.; Trinh Q.D.; Bhayani S.B.; Stifelman M.D.; Kaouk J.H.; Rogers C.G.
2011 ;10(2):84-84, European Urology Supplements
Introduction & Objectives: Robotic Assisted Partial Nephrectomy (RAPN) has emerged as a viable approach to minimally invasive surgery for small renal tumors. There are few reports of RAPN for tumors > 4 cm. We evaluate perioperative outcomes of RAPN for clinical stage T1b tumors compared to RAPN for clinical stage T1a tumors in a large multi-institutional study. Materials & Methods: Data for 445 consecutive patients who underwent RAPN at four institutions between June 2006 and April 2010 were reviewed. Patients were stratified into two groups according to tumor size on preoperative radiographic imaging: 83 with clinical stage T1b tumors and 362 patients with clinical stage T1a tumors. Outcomes were compared between groups. Results: Median radiographic tumor size was 5.0 cm (4.1-11 cm) for cT1b tumors and 2.3 cm (0.7- 4 cm) for cT1a tumors. Patients with cT1b tumors had a greater warm ischemia time-(24 vs. 17 minutes, p<0.001), operative time-(194 vs. 180 minutes, p=0.017), blood loss-(200 vs. 150 ml, p=0.001) and rate of collecting system repair-(72.2% vs. 51.6%, p= 0.006). There was no statistically significant difference in percent decrease in mean estimated GFR between groups at one month-(9% vs. 4.5%, p=0.09). There was no difference in overall complications between groups. Conclusions: RAPN is safe and feasible for clinical stage T1b tumors, but has greater warm ischemia times, operative times, blood loss, and rate of collecting system repair compared to clinical stage T1a tumors
— id: 130958, year: 2011, vol: 10, page: 84, stat: Journal Article,

Osteoclast-like Giant Cell Tumor of the Renal Pelvis Associated With Urothelial Carcinoma: Computed Tomography, Gross, and Histologic Appearance
Rosenkrantz AB; Melamed J; Stifelman M
2011 Dec;78(6):1310-1312, Urology
Osteoclastoma-like giant cell tumor of the renal pelvis, similar to the entity more commonly occurring in bone, is very rare, having been reported in twelve previous cases to our knowledge. This is the first report of this entity, to our knowledge, to include its cross-sectional imaging appearance. A hyperdense area within the lesion on non-contrast CT may correspond with extensive hemorrhagic content of the lesion identified histologically. As in most prior cases, an adjacent smaller urothelial carcinoma of the renal pelvis was also identified. In the limited reported cases, this entity has exhibited highly aggressive behavior with poor prognosis
— id: 134891, year: 2011, vol: 78, page: 1310, stat: Journal Article,

Complications after robotic partial nephrectomy at centers of excellence: multi-institutional analysis of 450 cases
Spana, Gregory; Haber, Georges-Pascal; Dulabon, Lori M; Petros, Firas; Rogers, Craig G; Bhayani, Sam B; Stifelman, Michael D; Kaouk, Jihad H
2011 Aug;186(2):417-422, Journal of urology
PURPOSE: We evaluated the incidence of perioperative complications after robotic partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system. RESULTS: A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths. CONCLUSIONS: Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively
— id: 136501, year: 2011, vol: 186, page: 417, stat: Journal Article,

Comparison of Hand-Assisted Laparoscopy Versus Open and Laparoscopic Techniques in Urology Procedures: A Systematic Review and Meta-analysis
Wadstrom, Jonas; Martin, Amber L; Estok, Rhonda; Mercaldi, Catherine J; Stifelman, Michael D
2011 Jul;25(7):1095-1104, Journal of endourology
Abstract Background and Purpose: Hand-assisted laparoscopic surgery (HALS) is an integral part of the urologist's armamentarium. We aimed to perform a comprehensive meta-analysis comparing HALS renal surgery with open and laparoscopic techniques. Methods: A systematic review and meta-analysis of HALS renal procedures (donor nephrectomy, nephrectomy, or nephroureterectomy) from 1996 to 2007 was performed. Results: Sixty-two studies of 30 donor nephrectomy, 21 radical nephrectomy, and 14 nephroureterectomy procedures in 5446 patients were included in the analysis. In donor nephrectomy, estimated blood loss (EBL) was statistically significant for HALS vs the open and laparoscopic cohorts, -69.0 mL (95% confidence interval [CI], -129.7, -8.2) and -40.1 mL (95% CI, -68.2, -12.0), respectively. Length of stay (LOS) was shorter compared with the open group, -1.7 days (95% CI, -2.3, -1.1). For nephroureterectomy, EBL (-29.9 mL (95% CI, -242.3, 182.5)), and LOS (-1.5 d [95% CI, -2.8, -0.3]) again favored HALS vs open procedures. Operating room (OR) time and warm ischemia time (WIT) were statistically significant in favor of HALS donor nephrectomy vs the laparoscopic cohort; -36.8 minutes (95% CI, -61.3, -12.3) and -1.3 minutes (95% CI, -1.8, -0.7), respectively. For radical nephrectomy, both EBL -232.9 mL (95% CI, -383.6, -82.2) and LOS -2.4 days (95% CI, -3.5, -1.3) were statistically significant, favoring HALS vs the open group. Conclusion: We report the largest meta-analysis of HALS renal surgery to date. When compared with open surgery, HALS allows for a significant decrease in EBL and LOS. Compared with laparoscopic donor nephrectomy, HALS resulted in a significant decrease in blood loss, OR time, and WIT
— id: 136667, year: 2011, vol: 25, page: 1095, stat: Journal Article,

EARLY FUNCTIONAL OUTCOMES IN 102 UNSELECTED PATIENTS UNDERGOING ROBOTIC PARTIAL NEPHRECTOMY (RPN)
Berkman, D. S.; Dulabon, L. M.; Stifelman, M.
2010 SEP ;24(1):A48-A49, Journal of endourology
— id: 124117, year: 2010, vol: 24, page: A48, stat: Journal Article,

MULTIINSTITUTIONAL ANALYSIS OF ONCOLOGIC OUTCOMES OF PATIENTS WITH MICROSCOPIC POSITIVE MARGIN AFTER ROBOT ASSISTED PARTIAL NEPHRECTOMY
Bhayani, S.; Petros, F.; Haber, G. P.; Dulabon, L. M.; Rogers, C.; Stifelman, M.; Kaouk, J.
2010 SEP ;24(1):A259-A259, Journal of endourology
— id: 124124, year: 2010, vol: 24, page: A259, stat: Journal Article,

Laparoscopic and robotic assisted adrenal surgery
Bruhn, A M; Hyams, E S; Stifelman, M D
2010 Sep;62(3):305-318, Minerva urologica e nefrologica = The Italian journal of urology & nephrology
The aim of this paper is to review the current state of laparoscopic and robotic surgery in the mannagement of benign and malignant disease of the adrenal gland. Adrenal lesions can be adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, adrenal cysts, hematomas, adrenal cortical carcinomas, metastases from other cancers, or other rare causes. Laparoscopic adrenalectomy (LA) has become the new standard of care for benign adrenal neoplasms and is being increasingly utilized for malignant disease. Robotic assistance offers unique advantages in visualizing and dissecting the adrenal gland, especially considering its challenging vasculature. Series of robotic adrenalectomy (RA) and LA show that techniques are both safe and effective compared to open. There is also growing evidence in using minimally invasive approaches in adrenal sparing-surgery. Success in these procedures depends on a firm understanding of adrenal anatomy and in careful patient selection. Both LA and RA are offer advantages to patients and are comparable in outcomes. RA offers the potential for increased visualization and faster learning curve which may allow for both faster, and more precise dissection, as well as increased utilization of minimally invasive techniques. While LA remains the standard of care, RA is an excellent option in high volume robotic centers from standpoints of outcomes, feasibility, and cost
— id: 113813, year: 2010, vol: 62, page: 305, stat: Journal Article,

MULTI-INSTITUTIONAL ANALYSIS OF ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR VS NON-HILAR LESIONS IN 446 CONSECUTIVE CASES
Dulabon, L. M.; Kaouk, J.; Haber, G. P.; Rogers, C.; Petros, F.; Bhayani, S.; Stifelman, M.
2010 SEP ;24(1):A157-A159, Journal of endourology
— id: 124121, year: 2010, vol: 24, page: A157, stat: Journal Article,

MULTI-INSTITUTIONAL ANALYSIS OF COMPLICATIONS AFTER ROBOTIC PARTIAL NEPHRECTOMY IN 450 CONSECUTIVE CASES
Haber, G.; Bhayani, S.; Stifelman, M.; Dulabon, L. M.; Petros, F.; Rogers, C.; Kaouk, J.
2010 SEP ;24(1):A50-A51, Journal of endourology
— id: 124119, year: 2010, vol: 24, page: A50, stat: Journal Article,

COMPARISON OF POSITIVE SURGICAL MARGINS IN PATIENTS WITH PATHOLOGIC T3 DISEASE UNDERGOING ROBOTIC ASSISTED LAPAROSCOPIC PROSTATECTOMY OR OPEN RADICAL RETROPUBIC PROSTATECTOMY
Jain, R.; Berkman, D. S.; Taneja, S. S.; Huang, W. C.; Lepor, H.; Stifelman, M.
2010 SEP ;24(1):A45-A46, Journal of endourology
— id: 124116, year: 2010, vol: 24, page: A45, stat: Journal Article,

Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy
Kaag, Matthew G; O'Malley, Rebecca L; O'Malley, Padraic; Godoy, Guilherme; Chen, Mang; Smaldone, Marc C; Hrebinko, Ronald L; Raman, Jay D; Bochner, Bernard; Dalbagni, Guido; Stifelman, Michael D; Taneja, Samir S; Huang, William C
2010 Oct;58(4):581-587, European urology
BACKGROUND: Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. OBJECTIVE: Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. DESIGN, SETTINGS, AND PARTICIPANTS: We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. INTERVENTION: All patients underwent nephroureterectomy. MEASUREMENTS: All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. RESULTS AND LIMITATIONS: Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. CONCLUSIONS: eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens
— id: 134397, year: 2010, vol: 58, page: 581, stat: Journal Article,

ROBOTIC URETEROLYSIS AND OMENTAL WRAP: LESSONS LEARNED AFTER 23 RENAL UNITS
Keehn, A.; Mufarij, P.; Berkman, D.; Stifelman, M.
2010 SEP ;24(1):A389-A389, Journal of endourology
— id: 124128, year: 2010, vol: 24, page: A389, stat: Journal Article,

ROBOTIC URETEROLYSIS AND OMENTAL WRAP FOR RELIEF OF URETERAL OBSTRUCTION FROM RETROPERITONEAL FIBROSIS
Mufarij, P.; Hyams, E. S.; Facelle, T. M.; Shah, O.; Keehn, A.; Stifelman, M.
2010 SEP ;24(1):A242-A242, Journal of endourology
— id: 124122, year: 2010, vol: 24, page: A242, stat: Journal Article,

ROBOTIC VS LAPAROSCOPIC PYELOPLASTY: A TWO-CENTER INTERNATIONAL STUDY WITH LONG TERM SCINTIGRAPHIC FOLLOW-UP
Mufarrij, P. W.; Boudreau, L.; Mitchell, S.; Pouliot, F.; Audet, J.; Shah, O.; Dujardin, T.; Stifelman, M.
2010 SEP ;24(1):A254-A255, Journal of endourology
— id: 124123, year: 2010, vol: 24, page: A254, stat: Journal Article,

Robotic assisted partial nephrectomy for renal tumors greater than 4 cm: A multi-institutional analysis of perioperative outcomes in 445 patients
Petros F.; Haber G.-P.; Dulabon L.; Bhayani S.; Stifelman M.; Kaouk J.; Rogers C.
2010 ;9(5 SUPPL 3):513-513, European Urology Supplements
Objectives: Robotic Assisted Partial Nephrectomy (RAPN) has emerged as a viable approach to minimally invasive surgery for small renal tumors. There are few reports of RAPN for tumors >4 cm. We evaluate perioperative outcomes of RAPN for tumors >4cm in size compared to RAPN for tumors <=in a large multi-institutional study. Methods: Data for 445 consecutive patients who underwent RAPN at 4 institutions between June 2006 and April 2010 were reviewed. Patients were stratified into two groups according to tumor size on preoperative radiographic imaging: 83 with tumors >4cm (group 1) and 362 patients with tumors <= (group 2). Outcomes were compared between groups. Summary of Results: Mean radiographic tumor size was 6.0cm (4.1-11 cm) for group 1 and 2.0cm (0.7-4 cm) for group 2. Patients with tumors >4cm had a greater mean warm ischemia time (24 vs. 17 min, p < 0.001), blood loss (312 vs. 185 ml, p = 0.01) and rate of collecting system repair (72.2% vs. 51.6%, p = 0.006). There was no statistically significant difference in percent decrease in mean estimated GFR between groups at 1 month (9% vs. 4.5%, p = 0.09). There was no difference in overall complications between groups. Conclusions: In the largest multi-institutional series of RAPN for clinical stage T1b tumors to date, RAPN for tumors >cm is safe and feasible showing comparable outcomes to RPN for smaller tumors. Large tumors have greater warm ischemia times, blood loss and rate collecting system repair
— id: 112585, year: 2010, vol: 9, page: 513, stat: Journal Article,

ROBOTIC PARTIAL NEPHRECTOMY FOR RENAL TUMORS GREATER THAN 4
Petros, F.; Haber, G. P.; Dulabon, L. M.; Bhayani, S.; Stifelman, M.; Kaouk, J.; Rogers, C.
2010 SEP ;24(1):A49-A49, Journal of endourology
— id: 124118, year: 2010, vol: 24, page: A49, stat: Journal Article,

GUIDE TO INTRAOPERATIVE ULTRASOUND DURING PARTIAL NEPHRECTOMY
Stifelman, M.; Berkman, D.
2010 SEP ;24(1):A340-A340, Journal of endourology
— id: 124126, year: 2010, vol: 24, page: A340, stat: Journal Article,

ROBOTIC TRANSMESNTERIC PYELOPLASTY IN A PELVIC KIDNEY
Stifelman, M.; Shah, O.; Keehn, A.; Mufarij, P.
2010 SEP ;24(1):A362-A362, Journal of endourology
— id: 124127, year: 2010, vol: 24, page: A362, stat: Journal Article,

Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes
Benway, Brian M; Bhayani, Sam B; Rogers, Craig G; Dulabon, Lori M; Patel, Manish N; Lipkin, Michael; Wang, Agnes J; Stifelman, Michael D
2009 Sep;182(3):866-872, Journal of urology
PURPOSE: Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. MATERIALS AND METHODS: We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. RESULTS: The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). CONCLUSIONS: Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naive surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons
— id: 136669, year: 2009, vol: 182, page: 866, stat: Journal Article,

Effect of warm ischemia time during laparoscopic partial nephrectomy on early postoperative glomerular filtration rate
Godoy, Guilherme; Ramanathan, Vigneshwaran; Kanofsky, Jamie A; O'Malley, Rebecca L; Tareen, Basir U; Taneja, Samir S; Stifelman, Michael D
2009 Jun;181(6):2438-2443, Journal of urology
PURPOSE: We evaluated the effect of warm ischemia time on early postoperative renal function following laparoscopic partial nephrectomy. MATERIALS AND METHODS: Of 453 patients who were surgically treated for renal tumors between May 2001 and September 2007, and who were identified in our database 128 underwent laparoscopic partial nephrectomy. Of these 128 patients 101 who were evaluable had complete demographic, operative, preoperative and early postoperative data available. Renal function was estimated using the glomerular filtration rate. Warm ischemia time was stratified into 4 interval groups and also analyzed based on different time cutoffs. Ultimately we also tested the relationship between postoperative renal failure, and preoperative factors and warm ischemia time. RESULTS: Warm ischemia time interval analysis was not significant. However, when analyzing the effect of warm ischemia time cutoffs, patients with warm ischemia time greater than 40 minutes had a significantly greater decrease in the glomerular filtration rate (p = 0.03) and a lower glomerular filtration rate postoperatively. The incidence of renal function impairment was more than 2-fold higher in those with a warm ischemia time of greater than 40 minutes than in the other groups (p = 0.077). Warm ischemia time was significant on univariate analysis when only patients with a preoperative glomerular filtration rate of 60 ml per minute per 1.73 m(2) or greater were analyzed. However, this did not hold as an independent predictor of postoperative renal function impairment on multivariate analysis. The preoperative glomerular filtration rate was the only independent predictor of postoperative renal function impairment. CONCLUSIONS: A warm ischemia time of 40 minutes appears to be an appropriate cutoff, after which a significantly greater decrease in renal function occurs after laparoscopic partial nephrectomy. The preoperative glomerular filtration rate was the only independent predictor of an increased risk of renal insufficiency following laparoscopic partial nephrectomy
— id: 98898, year: 2009, vol: 181, page: 2438, stat: Journal Article,

The role of robotics for adrenal pathology
Hyams, Elias S; Stifelman, Michael D
2009 Jan;19(1):89-96, Current opinion in urology
PURPOSE OF REVIEW: This review assesses the role of robotic surgery in management of benign and malignant adrenal disease. RECENT FINDINGS: Laparoscopic adrenalectomy is considered the standard of care for benign adrenal neoplasms and has been increasingly considered for malignant disease. Robotic techniques have been considered for theoretical advantages in visualizing and dissecting the adrenal and its vasculature. Series of robotic adrenalectomy and limited comparisons with laparoscopic adrenalectomy have shown that robotic adrenalectomy is well tolerated and effective with subjective advantages compared with laparoscopic adrenalectomy. There has been growing interest in adrenal sparing-surgery using minimally invasive techniques and encouraging outcomes for selected benign lesions. SUMMARY: Robotic techniques for adrenalectomy have subjective advantages compared with laparoscopic adrenalectomy, but no objective superiority has been demonstrated. Surgical outcomes have been comparable with laparoscopic adrenalectomy though there have been no randomized controlled studies. Robotic adrenalectomy will be increasingly considered in lieu of laparoscopic adrenalectomy as robotic systems further disseminate and the cost disadvantages become less prohibitive. Although laparoscopic adrenalectomy remains the standard of care, robotic adrenalectomy is an acceptable option in high volume robotic centers from standpoints of outcomes, feasibility, and cost
— id: 94871, year: 2009, vol: 19, page: 89, stat: Journal Article,

Robot-assisted partial adrenalectomy for isolated adrenal metastasis
Kumar, Angelish; Hyams, Elias S; Stifelman, Michael D
2009 Apr;23(4):651-654, Journal of endourology
Adrenal-sparing surgery is an effective and safe alternative to total adrenalectomy for small, benign adrenal lesions and may decrease the risk of the development of adrenal insufficiency. While series of laparoscopic partial adrenalectomy have demonstrated safety and excellent long-term outcomes, there have been no reports of a complete robot-assisted partial adrenalectomy. We believe that robotic techniques may be useful for this procedure, given the complex vascularity and small size of the adrenal gland. Furthermore, there have been no reports of minimally invasive partial adrenalectomy for management of small, isolated adrenal metastasis. We report a case of robot-assisted partial adrenalectomy in a patient with a history of renal-cell carcinoma who had previously undergone contralateral adrenalectomy for metastasis. We report our surgical technique and short-term follow-up for our patient. To our knowledge, this is the first report of a complete robot-assisted partial adrenalectomy and the first report of minimally invasive partial adrenalectomy for an isolated adrenal metastasis
— id: 100422, year: 2009, vol: 23, page: 651, stat: Journal Article,

Bosniak category IIF designation and surgery for complex renal cysts
O'Malley, Rebecca L; Godoy, Guilherme; Hecht, Elizabeth M; Stifelman, Michael D; Taneja, Samir S
2009 Sep;182(3):1091-1095, Journal of urology
PURPOSE: We investigated whether adding the IIF categorization improved the accuracy of Bosniak renal cyst classification, as evidenced by a low rate of progression in IIF lesions and a high rate of malignancy in category III lesions. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with complex renal cysts categorized as a Bosniak IIF or III. Surveillance imaging and pathological outcomes of category IIF cysts were recorded to determine radiological predictors of progression. Pathological outcomes of category III cysts were recorded to determine the malignancy rate. RESULTS: A total of 112 patients met study inclusion criteria, of whom 81 were initially diagnosed with a category IIF cyst and 31 had a Bosniak category III cyst. At a median followup of 15 months 14.8% of Bosniak IIF lesions progressed in complexity with a median time to progression of 11 months (maximum greater than 4 years). There were no differences in tumor or patient characteristics between cysts that progressed and those that remained stable. In the 33 patients with Bosniak III lesions who underwent surgical extirpation the malignancy rate was 81.8%. Most patients had low stage, low grade disease and remained recurrence-free at a median followup of 6 months. CONCLUSIONS: Adding the IIF category has increased the accuracy and clinical impact of the Bosniak categorization system, as evidenced by a low rate of progression in category IIF cysts and an increased rate of malignancy in surgically treated category III lesions compared to those in historical controls
— id: 101448, year: 2009, vol: 182, page: 1091, stat: Journal Article,

Laparoscopic Doppler technology in laparoscopic renal surgery
Perlmutter, Mark A; Hyams, Elias S; Stifelman, Michael D
2009 Jul-Sep;13(3):406-410, Journal of the Society of Laparoendoscopic Surgeons
BACKGROUND AND OBJECTIVES: Laparoscopic Doppler technology has previously been reported to help identify vasculature during laparoscopy. Recently, we published our initial experience with this technology during laparoscopic radical nephrectomy, laparoscopic nephroureterectomy, laparoscopic partial nephrectomy, and robotic-assisted laparoscopic pyeloplasty. We now present a prospective, pilot evaluation of the Doppler probe for these procedures. METHODS: A laparoscopic Doppler probe was used in the above laparoscopic renal surgeries in 50 patients. Anatomic findings, Doppler survey time, dissection time, operative time, estimated blood loss, changes in management, subjective time saved/utility, technical difficulties, clinical complications, and ease of use were prospectively recorded. RESULTS: Mean Doppler survey time was 1.77 minutes. Mean hilar dissection time was 9.25 minutes. Eight accessory vessels were not seen on preoperative imaging in 7 patients (17%). In 3 cases of RALP, Doppler rectified preoperative imaging in detecting a crossing vessel. The probe altered management in 16% of patients, subjectively saved time in 78% of patients, and had 100% concordance with dissection. There were no complications but 2 technical failures. CONCLUSION: The probe is quick, safe, easy to use, and has perfect concordance with surgical dissection. Randomized comparison with and without Doppler assistance is necessary to confirm the utility of this technology
— id: 102939, year: 2009, vol: 13, page: 406, stat: Journal Article,

Renal artery pseudoaneurysm following laparoscopic partial nephrectomy
Shapiro, Edan Y; Hakimi, A Ari; Hyams, Elias S; Cynamon, Jacob; Stifelman, Michael; Ghavamian, Reza
2009 Oct;74(4):819-823, Urology
OBJECTIVES: To present our experience with the management of renal artery pseudoaneurysms following laparoscopic partial nephrectomy (LPN). METHODS: Our bi-institutional LPN database of 259 patients from July 2001 to April 2008 was queried for patients diagnosed with a postoperative renal artery pseudoaneurysm. Demographic data, perioperative course, complications, and follow-up studies in identified subjects were analyzed. Postembolization success was defined as symptomatic relief, resolution of hematuria, and a stable hematocrit and serum creatinine. RESULTS: We identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The mean age of our cohort was 61.2 years (49-76), mean operative time was 208 minutes (140-265), and mean estimated blood loss was 408 mL (50-800). Patients presented at a mean of 12.6 days (5-23) after the initial surgery. Five patients had gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. The sixth patient was incidentally diagnosed. The diagnosis of a renal artery pseudoaneurysm was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months all patients (100%) remained without any evidence of recurrence. CONCLUSIONS: Although pseudoaneuryms are a rare postoperative complication of LPN, they are potentially life-threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms. Our experience demonstrates the feasibility and supports the use of selective angioembolization as an excellent first-line option for patients who present with this form of delayed bleeding
— id: 136668, year: 2009, vol: 74, page: 819, stat: Journal Article,

Transperitoneal laparoscopic radical nephrectomy for large (more than 7 cm) renal masses
Berger, Aaron D; Kanofsky, Jamie A; O'Malley, Rebecca L; Hyams, Elias S; Chang, Carolyn; Taneja, Samir S; Stifelman, Michael D
2008 Mar;71(3):421-424, Urology
OBJECTIVES: To evaluate our laparoscopic radical nephrectomy (LRN) series to determine whether any significant increases have occurred in operative morbidity when resecting large (7 cm or greater) renal masses. LRN is becoming the reference standard for treating suspicious renal masses not amenable to nephron-sparing surgery. METHODS: We retrospectively reviewed the charts of 164 consecutive patients who had undergone laparoscopic radical nephrectomy performed for suspicious renal masses by two surgeons from February 2000 and December 2006. After institutional review board approval, we reviewed the patient charts to determine whether patients with 7-cm or larger lesions had significant differences in age, body mass index, American Society of Anesthesiologists class, operative time, estimated blood loss, conversion rate, positive margin rate, postoperative creatinine, and hematocrit compared with patients with lesions smaller than 7 cm. RESULTS: The data from 164 patients were reviewed. Of these 164 patients, 124 had less than 7-cm masses and 40 had lesions 7 cm or larger. The mean tumor size in the less than 7-cm group was 4.2 cm (range 1.8 to 6.9) and was 9.2 cm (range 7 to 14) in the 7-cm or larger group. The patients with large tumors had a significantly longer operative time, greater estimated blood loss, and increase in postoperative serum creatinine than those with smaller tumors but all other perioperative variables were similar. Two conversions to open radical nephrectomy occurred in both groups. CONCLUSIONS: Our data have clearly shown that larger tumors can safely be resected with transperitoneal laparoscopic nephrectomy. Open nephrectomy for large tumors can be associated with increased morbidity and the use of LRN could minimize this increased risk. Urologists with laparoscopic experience should consider expanding their indication for LRN
— id: 79155, year: 2008, vol: 71, page: 421, stat: Journal Article,

Laparoscopic Doppler technology: applications in laparoscopic pyeloplasty and radical and partial nephrectomy
Hyams, Elias S; Kanofsky, Jamie A; Stifelman, Michael D
2008 May;71(5):952-956, Urology
INTRODUCTION: The identification and isolation of vascular structures are crucial and technically demanding aspects of laparoscopic renal surgery. Doppler technology has been used for this purpose in laparoscopic varicocele repair, renal cryoablation, and adrenalectomy. However, it has not been formally described for use in laparoscopic radical nephrectomy, partial nephrectomy, or pyeloplasty. We report our initial experience with Doppler technology in 20 patients undergoing these procedures. TECHNICAL CONSIDERATIONS: A laparoscopic Doppler probe was used in laparoscopic radical nephrectomy (n = 6), partial nephrectomy (n = 8), nephroureterectomy (n = 3), and robotic-assisted pyeloplasty (n = 3). The Doppler system consisted of a disposable 8-MHz probe passed through a 5-mm port and a battery-powered transceiver. The probe was used to guide dissection/isolation of the renal hilum and aberrant vasculature in radical and partial nephrectomy, confirm parenchymal ischemia before resection in partial nephrectomy, and identify crossing vessels during pyeloplasty. Nine accessory vessels were detected in 6 (35%) of 17 patients undergoing radical/partial nephrectomy or nephroureterectomy. In 1 case of partial nephrectomy, persistent parenchymal flow despite renal artery clamping required clamp repositioning. In 1 case of pyeloplasty, the Doppler probe detected a crossing vessel despite negative preoperative imaging findings. Use of the probe altered management in 7 (35%) and saved time in 15 (75%) of 20 cases. No complications were associated with the use of the probe. CONCLUSIONS: Doppler ultrasound technology might have extended applications in laparoscopic renal surgery by facilitating the dissection and evaluation of vasculature. A prospective study with objective endpoints would be helpful in confirming the utility of this technology in these settings
— id: 79150, year: 2008, vol: 71, page: 952, stat: Journal Article,

Robotic renal and upper tract reconstruction
Hyams, Elias S; Mufarrij, Patrick W; Stifelman, Michael D
2008 Nov;18(6):557-563, Current opinion in urology
PURPOSE OF REVIEW: To evaluate the current role of robotic surgery in upper urinary tract reconstruction. RECENT FINDINGS: Robotic techniques have been increasingly adopted by urologists for reconstruction of the upper urinary tract. The improved dexterity, visualization, and ergonomics of robotic systems have applied naturally to reconstruction and have facilitated intracorporeal suturing compared with traditional laparoscopy. In particular, robotic techniques have been used for anastamotic suturing during minimally invasive pyeloplasty. Series of robotic pyeloplasty have demonstrated comparable long-term outcomes to laparoscopy, a shorter learning curve, subjective operator benefits, and potential advantages in operative time. Other robotic reconstructive procedures of the upper tract have included ureterocalicostomy, ureteroureterostomy, ureterolysis, and ureteral reimplantation with and without psoas hitch. SUMMARY: Robotic techniques provide clear advantages for minimally invasive upper tract reconstruction, though the objective benefits need further delineation. These procedures are in their early experience, and larger series with prospective randomized comparison with the standard of care are warranted. Low volume of upper tract reconstruction in general will likely require multi-institutional study. Continued study of cost-effectiveness is necessary to define the optimal role for robotic reconstruction in both medical and economic terms
— id: 91447, year: 2008, vol: 18, page: 557, stat: Journal Article,

Management of localized prostate cancer and an incidental ureteral duplication with upper pole ectopic ureter inserting into the prostatic urethra
Marien, Tracy P; Shapiro, Ellen; Melamed, Jonathan; Taouli, Bachir; Stifelman, Michael D; Lepor, Herbert
2008 Fall;10(4):297-303, Reviews in urology
Ectopic ureters are rare congenital malformations of the renal system that most commonly present in females. It is extremely rare to encounter an ectopic ureter in an older man undergoing radical prostatectomy. We report herein a case of a 66-year-old man with prostate cancer and a complete duplication of the left renal collecting system, with an upper pole ectopic ureter and associated normal functioning renal parenchyma entering into the prostatic urethra. This anomaly was incidentally discovered on preoperative magnetic resonance imaging of the prostate. Open radical retropubic prostatectomy and a left ureteroureterostomy were performed
— id: 94870, year: 2008, vol: 10, page: 297, stat: Journal Article,

Robot-assisted ureterolysis, retroperitoneal biopsy, and omental wrap: pilot series for the treatment of idiopathic retroperitoneal fibrosis
Mufarrij, Patrick W; Lipkin, Michael E; Stifelman, Michael D
2008 Aug;22(8):1669-1675, Journal of endourology
BACKGROUND AND PURPOSE: Retroperitoneal fibrosis (RPF) is an uncommon disease of vague cause distinguished by a chronic inflammatory response. Traditionally, RPF with ureteral involvement has been managed with open ureterolysis and transposition, with excellent success rates. More recently, laparoscopic ureterolysis has been described. Here, we report our experience of managing idiopathic RPF with robot-assisted ureterolysis, retroperitoneal biopsy, and ureteral omental wrapping. PATIENTS AND METHODS: We performed robot-assisted ureterolysis, retroperitoneal biopsy, and ureteral omental wrapping on five consecutive patients between April and October 2006. The same technique was used for all five patients, except for the omental wrapping. Initially, omental wrapping was performed laparoscopically, but in the last two patients, it was performed entirely robotically. We analyzed our patients' data retrospectively. RESULTS: The mean operative time was 220.5 minutes and 390 minutes for unilateral and bilateral cases, respectively; mean blood loss 33.4 mL; mean length of stay 2.8 days; and mean follow-up was 5.6 months. All patients have remained free of obstruction since surgery and no longer need pain medication. CONCLUSIONS: Our study suggests that robot-assisted ureterolysis with laparoscopic or robot-assisted omental wrapping is a feasible alternative to the more morbid open procedure and compares favorably to the purely laparoscopic technique with respect to operative times, estimated blood loss, length of stay, and postoperative relief of obstruction. This procedure can be performed entirely robotically, which provided several advantages over the other techniques
— id: 93345, year: 2008, vol: 22, page: 1669, stat: Journal Article,

Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience
Mufarrij, Patrick W; Woods, Michael; Shah, Ojas D; Palese, Michael A; Berger, Aaron D; Thomas, Raju; Stifelman, Michael D
2008 Oct;180(4):1391-1396, Journal of urology
PURPOSE: The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty. MATERIALS AND METHODS: A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups. RESULTS: Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts. CONCLUSIONS: To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney
— id: 86659, year: 2008, vol: 180, page: 1391, stat: Journal Article,

Endoscopic manipulation of upper tract urothelial carcinoma results in a higher risk of subsequent bladder recurrence
Perlmutter, M; Shah, O; Godoy, G; Stifelman, M; Taneja, S
2008 MAR ;7(3):77-77, European Urology Supplements
— id: 76434, year: 2008, vol: 7, page: 77, stat: Journal Article,

Minimally invasive management of retroperitoneal fibrosis
Stifelman, Michael D; Shah, Ojas; Mufarrij, Patrick; Lipkin, Michael
2008 Feb;71(2):201-204, Urology
OBJECTIVES: Ureteral obstruction is a common finding in retroperitoneal fibrosis (RPF). The management of ureteral obstruction in patients with RPF is challenging and controversial. To our knowledge we are the first to report on laparoscopic ureterolysis (LU) and robotic ureterolysis (RU) for the management of RPF to determine feasibility and success. METHODS: We reviewed the charts of all patients who have undergone laparoscopic ureterolysis with or without robotic assistance at our institution. RESULTS: Between 2001 and 2006, one surgical team performed laparoscopic ureterolysis with or without robotic assistance on 15 renal units in 10 patients. Mean age was 50.9 years (range, 28 to 71 years). Eight patients presented with back pain and all 15 renal units had radiographic evidence of obstruction. Five patients underwent LU, and 5 underwent RU. Mean operative times for bilateral and unilateral LU were 509.0 and 110 minutes, and the mean estimated blood loss was 362.5 and 50 mL. Mean operative times for bilateral and unilateral RU were 390 and 220.5 minutes, and the mean estimated blood loss was 25 and 35.5 mL. With a mean follow-up of 15.6 months, 90% of all patients were asymptomatic and 86.7% renal units had no signs of obstruction on imaging. CONCLUSIONS: Laparoscopic ureterolysis with or without robotics may be performed with minimal perioperative morbidity and provides excellent success rates for relief of symptoms and obstruction in RPF. RU appears to have better short-term outcomes and is now our technique of choice
— id: 76639, year: 2008, vol: 71, page: 201, stat: Journal Article,

Robot-assisted laparoscopic partial cystectomy and diverticulectomy: initial experience of four cases
Tareen, Basir U; Mufarrij, Patrick W; Godoy, Guilherme; Stifelman, Michael D
2008 Jul;22(7):1497-1500, Journal of endourology
PURPOSE: We report our initial experience with four cases of robot-assisted laparoscopic partial cystectomy and diverticulectomy performed between June 2005 and August 2007. PATIENTS AND METHODS: The series consisted of three male patients and one female with a mean age of 64 years (range 36-77 years). In each case, a transperitoneal laparoscopic approach was used to mobilize the bladder. Next the bladder lesion was scored circumferentially cystoscopically with a Collings knife. The remainder of the excision and bladder reconstruction was performed with the da Vinci robot. RESULTS: Mean operative time was 194 minutes with a mean blood loss of 35 mL. The urethral catheter was removed between 5 and 14 days following a normal cystogram. There were no significant complications. Postoperative hospital stay was 2 to 3 days. CONCLUSION: Robot-assisted laparoscopic partial cystectomy and diverticulectomy are technically feasible and represent an alternative to open and conventional laparoscopic approaches
— id: 93347, year: 2008, vol: 22, page: 1497, stat: Journal Article,

Use of haemostatic agents and glues during laparoscopic partial nephrectomy: a multi-institutional survey from the United States and Europe of 1347 cases
Breda, Alberto; Stepanian, Sevan V; Lam, John S; Liao, Joseph C; Gill, Inderbir S; Colombo, Jose R; Guazzoni, Giorgio; Stifelman, Michael D; Perry, Kent T; Celia, Antonio; Breda, Guglielmo; Fornara, Paolo; Jackman, Stephen V; Rosales, Antonio; Palou, Juan; Grasso, Michael; Pansadoro, Vincenzo; Disanto, Vincenzo; Porpiglia, Francesco; Milani, Claudio; Abbou, Claude C; Gaston, Richard; Janetschek, Gunter; Soomro, Naeem A; De la Rosette, Jean J; Laguna, Pilar M; Schulam, Peter G
2007 Sep;52(3):798-803, European urology
OBJECTIVES: Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure for the management of renal tumours. Major complications of LPN include bleeding and urine leakage. Haemostatic agents (HAs) and/or glues may reduce haemorrhage and urine leakage. We sought to examine the current practice patterns for urologists performing LPN with regard to HA use and its relationship with bleeding and urine leakage. MATERIALS AND METHODS: A survey was sent via e-mail to urologists currently performing LPN in centres in the United States and Europe. We queried the indications for HA/glue usage, type of HAs/glues used, and whether concomitant suturing/bolstering was performed. In addition, the total number of LPNs performed, laparoscopic tools used to resect the tumour, tumour size, and tumour position were queried. RESULTS: Surveys suitable for analysis were received from 18 centres (n=1347 cases). HAs and/or glues were used in 1042 (77.4%) cases. Mean tumour size was 2.8cm, with 79% of the tumours being defined as exophytic and 21% deep. The HAs and glues used included gelatin matrix thrombin (FloSeal), fibrin gel (Tisseel), bovine serum albumin (BioGlue), cyanoacrylate glue (Glubran), oxidized regenerated cellulose (Surgicel), or combinations of these. Sixteen centres performed concomitant suturing/bolstering. The overall postoperative bleeding requiring transfusion and urine leakage rates were 2.7% and 1.9%, respectively. CONCLUSIONS: The use of HAs and/or glues is routine in most centres performing LPN. The overall haemorrhage and urine leakage rates are low following LPN. More studies are needed to assess the potential role of HAs and/or glues in LPN
— id: 94872, year: 2007, vol: 52, page: 798, stat: Journal Article,

Laparoscopic doppler probe to aid in identifying aberrant vascular anatomy during renal surgery: Video
Hyams, ES; Stifelman, MD
2007 OCT ;21(1):A114-A114, Journal of endourology
— id: 75788, year: 2007, vol: 21, page: A114, stat: Journal Article,

Laparoscopic Doppler technology: Applications in laparoscopic pyeloplasty, radical and partial nephrectomy
Hyams, ES; Stifelman, MD
2007 OCT ;21(1):A136-A136, Journal of endourology
— id: 75790, year: 2007, vol: 21, page: A136, stat: Journal Article,

Malignant extrinsic ureteral obstruction: A survey of urologists and medical oncologists regarding treatment patterns and preferences
Hyams, ES; Stifelman, MD; Shah, O
2007 OCT ;21(1):A254-A254, Journal of endourology
— id: 75794, year: 2007, vol: 21, page: A254, stat: Journal Article,

Robotic-assisted laparoscopic ureterocalicostomy
Korets, Ruslan; Hyams, Elias S; Shah, Ojas D; Stifelman, Michael D
2007 Aug;70(2):366-369, Urology
INTRODUCTION: Ureterocalicostomy is a well-established treatment option for patients with recurrent ureteropelvic junction obstruction or proximal ureteral stricture refractory to endoscopic management in the setting of diminutive or intrarenal pelvis or significant peripelvic fibrosis. We report a case of robotic-assisted laparoscopic ureterocalicostomy using the da Vinci robotic system in a patient with proximal ureteral stricture refractory to endoscopic management. TECHNICAL CONSIDERATIONS: All techniques described to date for ureterocalicostomy have been either open or purely laparoscopic. We report a case of robotic-assisted laparoscopic ureterocalicostomy in a patient with refractory proximal ureteral stricture secondary to multiple interventions for stones. We used laparoscopy for the initial dissection and exposure and robotic techniques for lower pole amputation and ureterocaliceal anastomosis. Intraoperative nephroscopy was also performed through the lower pole calix. The patient had resolution of the obstruction at 10 weeks postoperatively with the stent out and radiographic confirmation of excretion and drainage. CONCLUSIONS: Robotic-assisted laparoscopic ureterocalicostomy is a feasible alternative to open or laparoscopic techniques for treating refractory proximal ureteral stricture or ureteropelvic junction obstruction. To our knowledge, this is the first described case of robotic-assisted laparoscopic ureterocalicostomy with intraoperative nephroscopy
— id: 73942, year: 2007, vol: 70, page: 366, stat: Journal Article,

Robotic pyeloplasty for secondary versus primary ureteropelvic junction obstruction
Mufarrij, P; Berger, A; Lipkin, M; Shah, O; Stifelman, M
2007 OCT ;21(1):A143-A143, Journal of endourology
— id: 75792, year: 2007, vol: 21, page: A143, stat: Journal Article,

Robotic reconstruction of the upper urinary tract
Mufarrij, P; Berger, A; Lipkin, M; Shah, O; Stifelman, M
2007 OCT ;21(1):A143-A143, Journal of endourology
— id: 75793, year: 2007, vol: 21, page: A143, stat: Journal Article,

Laparoscopic pyeloplasty with pyelolithotomy for treatment of concomitant ureteropelvic junction obstruction and kidney stones
Mufarrij, P; Berger, A; Lipkin, M; Stifelman, M; Shah, O
2007 OCT ;21(1):A143-A143, Journal of endourology
— id: 75791, year: 2007, vol: 21, page: A143, stat: Journal Article,

Robotic Reconstruction of the Upper Urinary Tract
Mufarrij, Patrick W; Shah, Ojas D; Berger, Aaron D; Stifelman, Michael D
2007 Nov;178(5):2002-2005, Journal of urology
PURPOSE: Reconstructive surgery of the upper urinary tract can be complicated. During the last 2 decades minimally invasive techniques have emerged as viable options for these complex procedures. We reviewed our experience with robotic surgery for upper urinary tract reconstruction. MATERIALS AND METHODS: Between May 2002 and December 2006, a single surgeon performed certain robotic reconstructions on the upper urinary tract in 26 males and 37 females (65 renal units), including dismembered pyeloplasty, dismembered pyeloplasty with stone extraction, ureteroureterostomy, ureterolysis with omental wrap, ureterocalicostomy, ureteral reimplantation and upper pole nephroureterectomy. We compared demographic, preoperative, intraoperative and postoperative data on patients undergoing these various procedures. RESULTS: Across all cases mean blood loss was 125 cc, mean operative time was 244.8 minutes and mean length of stay was 2.8 days. The rate of radiographic and symptomatic improvement was 97.3% and 100%, respectively. We observed 2 major complications during a mean followup of 18.7 months. CONCLUSIONS: Our data illustrate that robotics can be successfully and safely used for virtually any type of upper urinary tract reconstruction. Robotic techniques are a viable option for upper urinary tract reconstruction
— id: 73941, year: 2007, vol: 178, page: 2002, stat: Journal Article,

A matched-cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses
O'Malley, Rebecca L; Berger, Aaron D; Kanofsky, Jamie A; Phillips, Courtney K; Stifelman, Michael; Taneja, Samir S
2007 Feb;99(2):395-398, BJU international
OBJECTIVE: To compare the surgical outcomes of elderly patients with renal masses treated with laparoscopic partial nephrectomy (LPN) or laparoscopic cryoablation (LCA). PATIENTS AND METHODS: All 15 patients who had LCA at the authors' institution between May 2003 and July 2005 were included, and compared with a matched cohort of 15 patients selected by patient age and tumour size, from a pre-existing database of 104 patients who had LPN from July 2002 to July 2005. The two groups were compared for gender, number of comorbidities, American Society of Anesthesiologists status (ASA), body mass index (BMI), baseline renal function and haematocrit, location and size of lesion, length of stay, operative time, estimated blood loss (EBL), transfusion rate, number and type of complications, conversion rate, and postoperative renal function and haematocrit. RESULTS: The two groups were similar in age, sex, BMI, ASA, baseline renal function, haematocrit, size and side of tumour, the percentage of exophytic tumours, and the likelihood of more than one comorbidity. Surgical outcomes between the groups were also relatively similar. The length of stay, creatinine and haematocrit levels after surgery did not differ between the groups. The LPN group had a significantly longer operation (248 vs 152 min, P < 0.001) and higher EBL (222 vs 59 mL, P = 0.007) than the LCA group, but only one patient required a transfusion and there was no discernible difference in discharge haematocrit values. No recurrences were detected in either group, with a similar mean follow-up of 9.8 and 11.9 months, respectively. CONCLUSION: Although this matched-cohort comparison showed that LPN had a higher mean EBL, a longer operation and higher relative risk of open conversion, the overall clinical outcome was similar in terms of complication rates, length of stay and changes in creatinine and haematocrit after surgery. In this small retrospective evaluation, there was similar morbidity, treatment outcome and short-term efficacy with LCA and LPN. At present, although still experimental, LCA is a good choice for elderly patients with comorbidities precluding blood loss or renal ischaemia. However, in experienced hands, LPN is a preferred option for most elderly patients and should be considered when contemplating definitive treatment of renal masses
— id: 71143, year: 2007, vol: 99, page: 395, stat: Journal Article,

Does endoscopic manipulation of upper tract Urothelial Carcinoma result in higher risk of subsequent bladder recurrence?
Perlmutter, M; Taneja, S; Godoy, G; Stifelman, M; Shah, O
2007 OCT ;21(1):A80-A80, Journal of endourology
— id: 75787, year: 2007, vol: 21, page: A80, stat: Journal Article,

Laparascopic transperitoneal partial nephrectomy: Tips and tricks in managing complex lesions
Robbins, D; Stifelman, M
2007 OCT ;21(1):A117-A117, Journal of endourology
— id: 75789, year: 2007, vol: 21, page: A117, stat: Journal Article,

CT and MR imaging findings following laparoscopic and open nephron sparing surgery
Stifelman, M; Brown, K; Hyams, E; Lipkin, M; Hecht, E; Taneja, S
2007 OCT ;21(1-2):A274-A274, Journal of endourology
— id: 98150, year: 2007, vol: 21, page: A274, stat: Journal Article,

Robot assisted laparoscopic partial nephrectomy: initial experience
Caruso, Robert P; Phillips, Courtney K; Kau, Eric; Taneja, Samir S; Stifelman, Michael D
2006 Jul;176(1):36-39, Journal of urology
PURPOSE: Advances in laparoscopy have made laparoscopic partial nephrectomy a technically feasible procedure but it remains challenging to even experienced laparoscopists. We hypothesized that robotic assisted laparoscopic partial nephrectomy may make this procedure more efficacious than the standard laparoscopic approach. MATERIALS AND METHODS: Ten patients with a mean age of 58 years and mean tumor size of 2.0 cm underwent robotic assisted laparoscopic partial nephrectomy and another 10 with a mean age of 61 years and mean tumor size of 2.18 cm underwent laparoscopic partial nephrectomy, as performed by a team of 2 surgeons (MS and ST) between May 2002 and January 2004. Demographic data, intraoperative parameters and postoperative data were compared between the 2 groups. RESULTS: There were no significant differences in patient demographics between the 2 groups. Intraoperative data and postoperative outcomes were statistically similar. In the 10 patients who underwent robotic assisted laparoscopic partial nephrectomy there were 2 intraoperative complications. There was 1 conversion in the laparoscopic partial nephrectomy group. CONCLUSIONS: Robotic assisted laparoscopic partial nephrectomy is a safe and feasible procedure in patients with small exophytic masses. The robotic approach to laparoscopic partial nephrectomy does not offer any clinical advantage over conventional laparoscopic nephrectomy
— id: 66462, year: 2006, vol: 176, page: 36, stat: Journal Article,

Impact of discordant radiologic and pathologic tumor size on renal cancer staging
Kanofsky, Jamie A; Phillips, Courtney K; Stifelman, Michael D; Taneja, Samir S
2006 Oct;68(4):728-731, Urology
OBJECTIVES: To determine whether the discrepancy in the radiologic and pathologic size of renal cell carcinoma influences the final cancer stage. METHODS: Renal masses resected from December 1999 to September 2004 were identified using a pathologic database and compared by surgical accession number to an existing clinical renal tumor database to identify those T1 and T2 tumors for which radiologic and pathologic data were available. The tumor histologic features, maximal pathologic diameter, and maximal radiologic diameter were recorded. The percentage of tumor size reduction was then calculated using these data. RESULTS: Of the 236 renal cancers evaluated, 52% had regressed in size when comparing the pathologic and radiologic sizes. When stratified by histologic subtype, clear cell tumors regressed more often and to a greater degree than those that were chromophobe or papillary. Also, 15 organ-confined tumors were downstaged when comparing the maximal radiologic diameter and the maximal pathologic diameter, and 13 of these were clear cell tumors. CONCLUSIONS: A reduction in kidney tumor size is commonly observed at surgical resection because of a loss of blood flow to the tumor. This tumor size reduction has an impact on the final pathologic stage in organ-confined tumors for which size is the only criterion. The greatest tumor size reduction, and most frequent downstaging, was observed for conventional (clear cell) tumors. We believe this may explain, in part, the worse stage-stratified outcomes for clear cell tumors compared with other tumor types. We propose that renal cancer staging should be determined from accurate measurement of the radiologic size, rather than the pathologic size
— id: 69087, year: 2006, vol: 68, page: 728, stat: Journal Article,

Robotic ureterolysis, retroperitoneal biopsy, and omental wrap for the treatment of ureteral obstruction due to idiopathic retroperitoneal fibrosis
Mufarrij, Patrick W; Stifelman, Michael D
2006 Fall;8(4):226-230, Reviews in urology
Retroperitoneal fibrosis (RPF) is a rare disorder of unclear etiology characterized by chronic inflammation of the retroperitoneum, which can involve any of the retroperitoneal structures, most notably the ureters, aorta, and vena cava. Historically, open biopsy, ureterolysis, and transpositioning or omental wrapping of the involved ureter(s) have been the preferred surgical treatments of RPF, with success rates greater than 90%. More recently, successful laparoscopic biopsy, ureterolysis, and ureteral omental wrapping and intraperi-tonealization have been described. We report the first case in the literature of idiopathic RPF managed with robotic ureterolysis and laparoscopic omental ureteral wrapping
— id: 94873, year: 2006, vol: 8, page: 226, stat: Journal Article,

The learning curve for robotic-assisted laparoscopic radical prostatectomy: A multiinstitutional experience of laparoscopic and oncologic trained urologists
Munver, R; Hwang, JJ; Phillips, JL; Palese, MA; Dinlenc, CZ; Badillo, FL; Stifelman, MD; Eastham, JA; Samadi, A; Bhalla, RS; Kim, IY; Scherr, DS; Somadi, DB; Hassen, WA; Tewari, AK; Sawczuk, IS
2006 AUG ;20(10):A220-A220, Journal of endourology
— id: 69629, year: 2006, vol: 20, page: A220, stat: Journal Article,

Left renal vein reconstruction after right nephrectomy and inadvertent left renal vein ligation: a case report and review of the literature
Powell, Anathea C; Plitas, George; Muhs, Bart E; Stifelman, Michael; Maldonado, Thomas S
2006 Oct-Nov;40(5):421-424, Vascular & endovascular surgery
Left renal vein ligation has been used as a technical aid to gain exposure to the perirenal aorta and to control bleeding in abdominal aortic operations. Left renal vein ligation is considered to be well tolerated in patients with 2 functioning kidneys, but has rarely been described in the setting of concomitant right nephrectomy and presents a management challenge. Some reports suggest recovery of renal function may be possible after left renal vein ligation during right nephrectomy, but other suggest that a delay in revascularizing the left renal venous drainage may result in irreversible nephropathy. This article reports the inadvertent division of the left renal vein during right nephrectomy. Renal failure ensued postoperatively. The left renal vein was reconstructed, and renal function was recovered. The inability to reliably predict which patients will have adverse outcome after left renal vein ligation in the setting of a right nephrectomy may necessitate preemptive intervention
— id: 69694, year: 2006, vol: 40, page: 421, stat: Journal Article,

Robot-assisted laparoscopic dismembered pyeloplasty
Palese, Michael A; Munver, Ravi; Phillips, Courtney K; Dinlenc, Caner; Stifelman, Michael; DelPizzo, Joseph J
2005 Jul-Sep;9(3):252-257, Journal of the Society of Laparoendoscopic Surgeons
OBJECTIVE: Advanced laparoscopic skills limit the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the da Vinci Robotic Surgical System at 3 New York City medical centers. METHODS: A review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 38 patients (21 females, 17 males) between April 2001 and January 2004 was performed. All patients had symptoms or radiographic evidence of ureteropelvic junction obstruction. Robotic assistance with the da Vinci Robotic Surgical System was used after preparation of the ureteropelvic junction with a standard laparoscopic approach. RESULTS: The average patient age was 39.3 years (range, 15 to 69). The mean operative time and suturing time were 225.6+/-59.3 minutes and 64.2+/-14.6 minutes. The average estimated blood loss was minimal at 77.3+/-55.3 mL. The mean length of hospitalization was 69.6 hours (range, 28 to 310). The average use of intravenous morphine was 26.5 mg (range, 0 to 162). No intraoperative complications occurred, and open conversions were not necessary. A mean follow-up of 12.2 months revealed a success rate of 94.7% with 2/38 patients requiring further treatments. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the da Vinci Surgical System is safe and reproducible. These intermediate results appear comparable to results with open and laparoscopic pyeloplasty repairs
— id: 136670, year: 2005, vol: 9, page: 252, stat: Journal Article,

Robot-assisted laparoscopic dismembered pyeloplasty: a combined experience
Palese, Michael A; Stifelman, Michael D; Munver, Ravi; Sosa, R Ernest; Philipps, Courtney K; Dinlenc, Caner; Del Pizzo, Joseph J
2005 Apr;19(3):382-386, Journal of endourology
BACKGROUND AND PURPOSE: The need for advanced laparoscopic skills limits the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the daVinci Surgical System at three New York City medical centers. PATIENTS AND METHODS: A retrospective review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 18 female and 17 male patients between April 2001 and January 2004 was performed. The average patient age was 39.0 years (range 15-69 years). All patients had symptoms or radiographic evidence of ureteropelvic junction (UPJ) obstruction. Robotic assistance with the daVinci Surgical System was employed after preparation of the UPJ with a standard laparoscopic approach. RESULTS: The mean operative time and suturing time was 216.4 +/- 52.9 minutes and 63.0 +/- 14.2 minutes, respectively. The average estimated blood loss was minimal at 73.9 +/- 58.3 mL. The mean length of hospitalization was 69.4 hours (range 28-310 hours). The average use of intravenous morphine was 28.4 mg (range 0-162 mg). There were no intraoperative complications or open conversions. A mean follow-up of 7.9 months revealed a success rate of 94%, with two patients requiring further treatment. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the daVinci Surgical System is safe and reproducible. These intermediate results appear comparable to those of open and laparoscopic pyeloplasty repairs
— id: 94874, year: 2005, vol: 19, page: 382, stat: Journal Article,

Robot-assisted laparoscopic partial nephrectomy: the NYU technique
Phillips, Courtney K; Taneja, Samir S; Stifelman, Michael D
2005 May;19(4):441-445, Journal of endourology
The introduction of the daVinci surgical system has changed the way both surgeon and patient view radical prostatectomy. We hypothesized that the same theoretical and tangible benefits may be realized when employing the system for partial nephrectomy. This paper reviews our technique of robot-assisted laparoscopic partial nephrectomy (RALPN) utilizing the daVinci surgical system. Intraoperative hilar clamping is utilized in all cases. With the daVinci system, the tumor is excised with cold scissors, biopsies are taken from the base for frozen-section study, sutures are placed at the base, Gelfoam/fibrin glue is activated in the defect, a Surgicel bolster is laid in the defect, and mattress sutures are placed prior to releasing the clamp. After performing 12 RALPNs, it appears this technique is safe, feasible, and reproducible both for small exophytic masses and for deeper lesions involving the collecting system. A RALPN requires two surgeons, both well versed in laparoscopic and robotic techniques
— id: 56167, year: 2005, vol: 19, page: 441, stat: Journal Article,

Robot-assisted laparoscopic partial nephrectomy
Stifelman, Michael D; Caruso, Robert P; Nieder, Alan M; Taneja, Samir S
2005 Jan-Mar;9(1):83-86, Journal of the Society of Laparoendoscopic Surgeons
The indications for nephron-sparing surgery and for minimally invasive surgery are continually expanding. Nephron-sparing surgery, also known as partial nephrectomy, presents a challenge to the minimally invasive surgeon. Herein, we describe our technique of robot-assisted laparoscopic partial nephrectomy. This approach may have potential advantages of including easier excision and suturing. Moderate training is required
— id: 56168, year: 2005, vol: 9, page: 83, stat: Journal Article,

Work-up of the functional adrenal mass [Review, Tutorial]
Stifelman, Michael D; Fenig, David M
2005 Feb;6(1):63-71, Current urology reports
Evaluation of a functional adrenal mass may be initiated based on symptomatic presentation or the detection of an incidental adrenal mass. Recent literature suggests that 10% to 20% of adrenal incidentalomas demonstrate subclinical hormonal dysfunction, which may place patients at a higher risk for metabolic or cardiovascular disorders. Many diagnostic algorithms have been proposed for the evaluation of pheochromocytoma, Cushing's adenoma, aldosteronoma, and hormonally active adrenal cortical carcinoma. In this article, the available literature on functional adrenal masses is reviewed and up-to-date methods of efficient diagnosis are proposed
— id: 50285, year: 2005, vol: 6, page: 63, stat: Journal Article,

Hand-assisted laparoscopic devices: the second generation
Patel, Rupa; Stifelman, Michael D
2004 Sep;18(7):649-653, Journal of endourology
BACKGROUND AND PURPOSE: Hand-assisted laparoscopic (HAL) nephrectomy is an increasingly popular surgical modality. Within the last year, three newly designed second-generation hand-assist devices have emerged with the intention to improve efficacy and ease of use. We prospectively evaluated and compared these with each other and with the first-generation devices. MATERIALS AND METHODS: A total of 130 urologists performed two HAL nephrectomies in a porcine laboratory using two different hand devices at an American Urological Association-sponsored learning course. Sixty-three urologists utilized the second-generation devices (Gelport, Omniport, LapDisc), while 67 urologists used the first-generation devices (Handport, Intromit, PneumoSleeve). Each surgeon completed a 12-question survey evaluating the devices. RESULTS: Evaluation of the second-generation devices revealed that Gelport was statistically significantly superior in all parameters to the Omniport and in 5 of 10 parameters to the LapDisc. Comparison of the first- and second-generation devices revealed that only the Gelport achieved a significant increase in all ratings. Among the first-generation devices, no device scored better than 8.27 of 10 in any category. Analysis of the second-generation devices demonstrated that the Gelport scored a rating above 8.25 in all parameters with an overall satisfaction score of 8.59. Both the Omniport and the LapDisc attained ratings comparable to those of the first-generation devices. CONCLUSION: The HAL procedure relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The Gelport, when evaluated in a porcine model by training laparoscopic urologists, appears to be significantly better than other devices available to date. Further testing with larger cohorts and human clinical trials are required to confirm these findings
— id: 48725, year: 2004, vol: 18, page: 649, stat: Journal Article,

HALS devices and operating room set-up: pearls and pitfalls
Stifelman, Michael; Patel, Rupa
2004 May;18(4):315-318, Journal of endourology
Although some surgeons maintain that such devices are not necessary, most prefer a hand-assist device for the performance of hand-assisted laparoscopy. The three devices now available are the Gelport, LapDisc, and Omniport. None is perfect, and the choice depends in part on surgeon preference and patient body habitus. Each has advantages and disadvantages, and there is room for improvement, especially in the ease of hand removal and reinsertion, sturdiness and reliability, and ability to maintain the pneumoperitoneum. Beginning laparoscopic surgeons are advised to try all three devices and formulate their own opinions. As important as the hand-assist device is the operating room set-up. The authors provide a checklist covering the imaging system, insufflation equipment, hemostatic generators, and instrumentation
— id: 49298, year: 2004, vol: 18, page: 315, stat: Journal Article,

Laparoscopic radical nephrectomy: oncologic efficacy
Ogan, Kenneth; Cadeddu, Jeffrey A; Stifelman, Michael D
2003 Aug;30(3):543-550, Urologic clinics of North America
Laparoscopic radical nephrectomy has evolved tremendously over the past decade to the point where it should be considered the standard of care for localized renal tumors not amenable to nephron-sparing surgery. The benefits of decreased postoperative pain, shortened hospital stay, quicker convalescence, and improved cosmesis have been proved in numerous studies. Long-term oncologic results of LRN have demonstrated equivalent outcomes to ORN
— id: 136671, year: 2003, vol: 30, page: 543, stat: Journal Article,

Use of fibrin glue and gelfoam to repair collecting system injuries in a porcine model: implications for the technique of laparoscopic partial nephrectomy
Patel, Rupa; Caruso, Robert P; Taneja, Samir; Stifelman, Michael
2003 Dec;17(9):799-804, Journal of endourology
BACKGROUND AND PURPOSE: One of the challenges of laparoscopic partial nephrectomies is the repair of a collecting system injury. We hypothesized that fibrin glue plus Gelfoam could be sufficient to repair such injuries. MATERIALS AND METHODS: Four pigs (eight kidneys) underwent collecting system injuries of various lengths (3, 5, and 10 mm) (N = 8 each) during partial nephrectomy. Gelfoam soaked in the fibrin glue was applied to seal the collecting system and parenchymal defects. After 1 hour of passive filling, the renal pelvis was distended at supraphysiologic pressure to the point of leakage. Each repair site was examined for urinary extravasation during the physiologic and active phases of filling. RESULTS: Hemostasis was achieved, and all collecting system injuries, regardless of size, were free of urinary leakage at physiologic pressures. Moreover, all defects maintained a seal at supraphysiologic pressures of at least 50 cm H(2)O. CONCLUSION: The combined use of fibrin glue and Gelfoam is an effective means to obtain hemostasis and seal collecting system injuries up to 10 mm at physiologic pressures and up to 50 cm H(2)O in the acute setting. Our hope is that this technique can facilitate both laparoscopic and open partial nephrectomies. New technologies will be employed in an attempt to obtain better seating of the sealant plug in the future. Survival studies are in progress
— id: 46184, year: 2003, vol: 17, page: 799, stat: Journal Article,

Hand-assisted laparoscopy for large renal specimens: a multi-institutional study
Stifelman, Michael D; Handler, Toby; Nieder, Alan M; Del Pizzo, Joseph; Taneja, Samir; Sosa, R Ernest; Shichman, Steven J
2003 Jan;61(1):78-82, Urology
OBJECTIVES: To present our experience with hand-assisted laparoscopy (HAL) for larger renal specimens. One of the theoretical benefits of HAL is the ability to manage large renal specimens, which we defined as tumors greater than 7 cm, and tumors in obese patients. METHODS: Between March 1998 and October 2000, 106 HAL radical nephrectomies were performed for enhancing renal masses, for which 95 patients had complete preoperative, intraoperative, and postoperative data. Of the 95 patients, 32 underwent HAL for large tumors (7 cm or greater) and 41 had a body mass index of 31 or greater. The demographic and outcome data of these two groups were compared with 63 patients who underwent HAL for tumors less than 7 cm and 54 patients with a body mass index of less than 31. RESULTS: When comparing cohorts by tumor size, the only statistically significant differences were in convalescence and specimen weight. Patients with lesions 7 cm or greater required 21 days to recover compared with 18 days for patients with lesions less than 7 cm. Obese patients had statistically significantly higher American Society of Anesthesiologists classifications, longer operative times (214 versus 176 minutes), and longer convalescences (21 versus 17.5 days) compared with nonobese patients. The estimated blood loss and conversion rate was not different between the groups. Furthermore, no difference was noted between the groups in the incidence of positive margins, local recurrence, or metastatic recurrence at a mean follow-up of 12.2 months. CONCLUSIONS: HAL provides a safe, reproducible, and minimally invasive technique to remove large renal tumors and renal tumors in the obese
— id: 68183, year: 2003, vol: 61, page: 78, stat: Journal Article,

Prospective comparison of hand-assisted laparoscopic devices
Stifelman, Michael; Nieder, Alan M
2002 May;59(5):668-672, Urology
OBJECTIVES: To evaluate and compare the three commercially available first-generation hand-assisted laparoscopic (HAL) devices in a prospective, randomized fashion. HAL nephrectomy has become an increasingly popular surgical modality. METHODS: Sixty-seven board-certified urologists each performed two HAL nephrectomies in a porcine laboratory, using two different hand devices, at a learning course sponsored by the American Urological Association. At the completion of the laboratory session, each surgeon was asked to complete a 12-question survey designed to evaluate the different hand-assist devices. RESULTS: Thirty-nine surgeons used the HandPort, 47 used the Intromit, and 47 used the Pneumosleeve. No statistical differences were found in the ratings among the three devices within any category. No device scored better than 8.1 in any category, and the overall satisfaction was less than 7.7 in all three groups. Although not statistically significant, the Intromit device had the highest ratings in the following categories: instructions, maintenance of pneumoperitoneum, exchange of laparotomy pads, retrieval of specimens, sturdiness, and overall satisfaction. The HandPort had the highest failure rate. CONCLUSIONS: HAL relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The three available devices are all effective, yet each have their specific advantages and disadvantages. In terms of overall satisfaction, no device scored greater than 7.7. The results of this study suggest that the need for improvement by all three manufacturers is significant and have helped to better identify these areas
— id: 27567, year: 2002, vol: 59, page: 668, stat: Journal Article,

Hand assisted laparoscopic donor nephrectomy: a comparison with the open approach
Stifelman MD; Hull D; Sosa RE; Su LM; Hyman M; Stubenbord W; Shichman S
2001 Aug;166(2):444-448, Journal of urology
PURPOSE: Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods. MATERIALS AND METHODS: In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups. RESULTS: Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups. CONCLUSIONS: Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted
— id: 20794, year: 2001, vol: 166, page: 444, stat: Journal Article,

Hand-assisted laparoscopic nephroureterectomy versus open nephroureterectomy for the treatment of transitional-cell carcinoma of the upper urinary tract
Stifelman MD; Hyman MJ; Shichman S; Sosa RE
2001 May;15(4):391-395, Journal of endourology
BACKGROUND AND PURPOSE: For patients with upper tract transitional-cell carcinoma (TCC), nephroureterectomy with removal of a bladder cuff is the standard of care. Historically, it has been performed using two incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative using endoscopic management of the bladder cuff combined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compared our results using these minimally invasive advances with those of a contemporary open nephroureterectomy series. PATIENTS AND METHODS: Between May 1998 and June 1999, we performed 11 HAL nephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a contemporary series of 11 patients undergoing the traditional open operation at our institution. The patient age, male:female ratio, and ASA classification were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and the status of the surgical margins. Postoperative endpoints were time to sustained fluid intake; epidural, parenteral, and oral narcotic requirements; length of stay; and complications. Follow-up, specifically disease recurrence and overall survival, was recorded. RESULTS: The mean operative time was 291 minutes for HAL v 232 minutes for the open operation (P = NS). The average blood loss was 144 v 311 mL (P = 0.04), the mean specimen weight 368 v 392 g (P = NS), and the mean specimen volume was 630 v 693 cc (P = NS). No patient in the HAL group had a positive surgical margin, but one patient in the open surgery group did. The time to sustained fluid intake postoperatively averaged 1.4 v 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requirement was 0 v 2.7 days (P < 0.001), the mean parenteral narcotic requirement was 45 v 44 mg of morphine sulfate equivalent (P = NS), and the oral narcotic requirement was 5.8 v 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group v 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surgery. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pain medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progress
— id: 20795, year: 2001, vol: 15, page: 391, stat: Journal Article,

Hand-assisted laparoscopic partial nephrectomy
Stifelman MD; Sosa RE; Nakada SY; Shichman SJ
2001 Mar;15(2):161-164, Journal of endourology
BACKGROUND AND PURPOSE: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. PATIENTS AND METHODS: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. RESULTS: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway
— id: 20701, year: 2001, vol: 15, page: 161, stat: Journal Article,

Hand assisted laparoscopy in urology
Stifelman MD; Sosa RE; Shichman SJ
2001 ;3(2):63-71, Reviews in urology
— id: 20820, year: 2001, vol: 3, page: 63, stat: Journal Article,

Detrusor contraction duration may predict response to alpha-blocker therapy for lower urinary tract symptoms
Kaplan SA; Stifelman M; Avillo C; Reis RB; Te AE
2000 Mar;37(3):314-317, European urology
OBJECTIVES: Baseline pressure/flow parameters have not correlated well with response to medical therapy for lower urinary tract symptoms (LUTS). This open-label, nonrandomized retrospective study was designed to evaluate whether the urodynamic parameter duration (in seconds) of the detrusor contraction (DCD) correlates better with alpha-blocker response than previously described urodynamic parameters. METHODS: 93 men (mean age 62.6+/-8.5) with LUTS underwent urodynamic evaluation prior to initiating therapy with doxazosin titrated to 8 mg and followed for 6 months. Parameters of evaluation included the AUA symptom score (AUASx), peak urinary flow rate (Q(max)), maximal detrusor pressure (P(max)), detrusor pressure at maximal flow (P(det)) and DCD. The correlation and predictive value of therapeutic response and baseline urodynamic parameters were assessed. RESULTS: 85 patients were evaluable at 6 months. For the entire group, AUASx decreased from 15.1+/-6.9 to 9.7+/-5.1 (-36%) and Q(max) increased from 9.3+/-3.7 to 11.9+/-5.7 ml/s (+28%). Baseline P(max) was 74.8+/-19.6 cm H(2)O, P(det) was 61.6+/-18.9 cm H(2)O and DCD was 107.6+/-28.6 s. There was weak correlation between either baseline P(max) or P(det) and therapeutic response (defined as a decrease in AUASx of 40% and an increase in Q(max) of 30%). Utilizing a baseline DCD of 90 s or more, there was a significant correlation to therapeutic response (r = 0.48, p = 0.002). CONCLUSIONS: These preliminary data suggest that DCD may be a useful urodynamic parameter to predict and optimize therapy with a-blockade. The potential utility and cost-effectiveness of DCD remains to be determined
— id: 20810, year: 2000, vol: 37, page: 314, stat: Journal Article,

Simple nephrectomy: hand-assisted technique
Stifelman M; Andrade A; Sosa RE; Shichman S
2000 Dec;14(10):793-798, Journal of endourology
Chronic inflammation or prior surgical procedures may complicate the laparoscopic performance of simple nephrectomy. In these difficult cases, hand-assisted laparoscopy may be useful. The position of the hand port depends on the particular situation, but the port must allow flexion of the wrist and access to the entire surgical field. The hand-assisted procedure is similar to standard laparoscopy in analgesic use, time to oral intake, length of stay, and time to full recovery. Hand-assisted laparoscopy allows the inexperienced surgeon to perform laparoscopy with the aid of tactile sensation and three-dimensional spatial orientation. For the experienced surgeon, the technique offers an alternative to open conversion when the laparoscopic procedure fails to progress
— id: 20809, year: 2000, vol: 14, page: 793, stat: Journal Article,

Hand assisted laparaoscopy
Stifelman MD; Shichman S; Sosa SE
2000 ;12(2):1-7, Current surgical techniques in urology
— id: 20821, year: 2000, vol: 12, page: 1, stat: Journal Article,

Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract
Stifelman MD; Sosa RE; Andrade A; Tarantino A; Shichman SJ
2000 Nov 1;56(5):741-747, Urology
OBJECTIVES: Nephroureterectomy with removal of the bladder cuff is the standard of care for patients with upper tract transitional cell carcinoma. Historically, it has been performed using two separate incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative technique using endoscopic and hand-assisted laparoscopic techniques and present our experience. METHODS: During the past 18 months, 22 patients at two institutions underwent hand-assisted laparoscopic nephroureterectomy. In 19 patients, the distal ureter and bladder cuff were managed endoscopically. In 3 patients, the distal ureter and the bladder cuff were removed by an extravesical, laparoscopic technique. The intraoperative parameters assessed included operative time, estimated blood loss, specimen weight, surgical margin status, pathologic grade and stage, and acute complications. Postoperative endpoints included the time to sustained fluid intake, parenteral narcotic requirement (milliequivalents of morphine sulfate), oral narcotic requirement (number of tablets), length of stay, time until return to normal activity, and rate of tumor recurrence. RESULTS: The average age of our patient population was 65 years (range 42 to 86), 10 patients were men and 12 were women, and the average American Society of Anesthesiologists classification was 2.2. All but 2 patients had their specimens removed en bloc. No intraoperative complications occurred. The average operative time was 272 minutes (range 190 to 440), and the average blood loss was 180 mL (range 50 to 400); no patient required a transfusion. The mean specimen weight was 457 g (range 190 to 1420). All 22 patients had negative surgical margins. Postoperatively, the time to sustained fluid intake averaged 2.1 days (range 1 to 7), the mean parenteral narcotic requirement was 55 mEq (range 12 to 107.8) of morphine sulfate, the mean oral narcotic requirement was 5.8 tablets (range 1 to 14), and the average length of stay was 4.1 days (range 3 to 14). One patient developed thrombophlebitis of the right external jugular vein from a central line and required 2 weeks of intravenous antibiotics. The mean time to return to normal activity was 19 days; the mean follow-up was 13 months. Six patients had disease recurrence: four low-grade, low-stage bladder tumors and two metastatic tumors. All patients were alive at 18 months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is a viable and efficacious alternative to open nephroureterectomy. The technique allows the surgeon to perform an en bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients benefit from a decrease in pain and hospital stay and quicker convalescence. Longer follow-up and comparative studies to standard open techniques are underway
— id: 20796, year: 2000, vol: 56, page: 741, stat: Journal Article,

The detection of renal carcinoma cells in the peripheral blood with an enhanced reverse transcriptase-polymerase chain reaction assay for MN/CA9
McKiernan JM; Buttyan R; Bander NH; de la Taille A; Stifelman MD; Emanuel ER; Bagiella E; Rubin MA; Katz AE; Olsson CA; Sawczuk IS
1999 Aug 1;86(3):492-497, Cancer
BACKGROUND: Using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay, the authors previously determined the expression of MN/CA9 mRNA in renal cell carcinoma (RCC) and its absence in benign renal tissue. In the current study, the utility of an enhanced RT-PCR assay in the detection of renal carcinoma cells in the peripheral blood was assessed. METHODS: An enhanced MN/CA9 RT-PCR assay was applied to peripheral blood samples from a total of 96 patients. Forty-two patients had renal tumors, including 5 with benign renal lesions, 28 with localized RCC, and 9 with metastatic RCC. Fifty-four control patients without renal tumors were similarly tested. Pathologic staging for patients with localized cancer was T1N0M0 for 5, T2N0M0 for 9, and T3N0M0 for 14 patients. RESULTS: Cells expressing MN/CA9 were detected in 1 of 54 controls (1.8%) and in 18 of 37 cancer patients (49%). Thirteen of twenty eight patients (46%) with localized RCC and 5 of 9 (56%) with metastatic disease tested positive with the assay. No patient with a benign renal tumor exhibited MN/CA9 expression. All blood test results for patients with clear cell RCC were noted to be positive. No correlation was noted between MN/CA9 results and age, gender, or tumor grade. The differences in MN/CA9 results according to T classification were not statistically significant. CONCLUSIONS: The enhanced RT-PCR assay for MN/CA9 is a highly specific technique for detecting circulating renal carcinoma cells in the peripheral blood, and it may prove useful in the diagnosis and monitoring of RCC
— id: 20798, year: 1999, vol: 86, page: 492, stat: Journal Article,

Prostrate specific antigen
Stifelman MD; Benson MC
Urology for primary care physicians Philadelphia : WB Saunders, 1999,
— id: 2634, year: 1999, vol: , page: 273, stat: Chapter,

Ureteral tissue expansion for bladder augmentation
Ikeguchi EF; Stifelman MD; Hensle TW
1998 May;159(5):1665-1668, Journal of urology
PURPOSE: Ureteral augmentation is an effective method of bladder reconstruction using the native urothelium of a megaureter. Clinically this procedure is contingent on the presence of an enlarged ureter. We have iatrogenically produced a segmental megaureter, while preserving renal function in a pig model. The urothelium of the enlarged ureter was then used for augmentation cystoplasty. MATERIALS AND METHODS: A tissue expander suitable for insertion into the lumen of the ureter was constructed. The tissue expander was passed antegrade through a flank incision of 8 pigs, and a separate nephrostomy tube was left in place. During the ensuing 1 to 4 weeks the pigs underwent daily dilation of the tissue expander without anesthesia. After dilation the pigs underwent ureteral augmentation of the bladder. The segment of expanded ureter was isolated from the native ureter, opened and anastomosed to the bladder. The continuity of the left ureter was restored by primary ureteroureterostomy. The animals underwent cystograms at 1 and 4 weeks and were sacrificed 4 weeks after augmentation. Tissue was harvested for gross and microscopic histology. RESULTS: Of the 8 pigs starting the protocol 5 underwent successful ureteral tissue expansion followed by bladder augmentation. Tissue expansion was performed from 1 to 4 weeks, and volumes of 150 to 1,000 cc were obtained. Two to 3 weeks of dilation was optimal to achieve ease of dilation, and no animal showed evidence of discomfort or failure to thrive. All 5 animals underwent successful ureteral augmentation with primary ureteroureterostomy. Tissue expansion volumes of approximately 250 cc were optimal for tissue management and ease of augmentation. Cystograms of all augmented animals showed increased bladder capacity with filling of the ureteral segment. Histological examination of the ureteral augmentation revealed preservation and regeneration of the urothelial mucosa. CONCLUSIONS: The use of a tissue expander in the lumen of the ureter is a novel method of generating urothelium for use in bladder augmentation. It may provide an alternative to bowel in patients who require bladder augmentation. Long-term studies are currently under way
— id: 20801, year: 1998, vol: 159, page: 1665, stat: Journal Article,

Early catheter removal decreases incidence of urinary tract infections in renal transplant recipients
Rabkin DG; Stifelman MD; Birkhoff J; Richardson KA; Cohen D; Nowygrod R; Benvenisty AI; Hardy MA
1998 Dec;30(8):4314-4316, Transplantation proceedings
— id: 20799, year: 1998, vol: 30, page: 4314, stat: Journal Article,

Ureteral tissue expansion for bladder augmentation: a long-term prospective controlled trial in a porcine model
Stifelman MD; Ikeguchi EF; Hensle TW
1998 Nov;160(5):1826-1829, Journal of urology
PURPOSE: We recently described a technique that iatrogenically produces segmental megaureter while preserving renal function. In our initial report in 5 of 8 pigs that underwent this procedure bladder augmentation with the expanded ureter was successful. Throughout the expansion and reconstructive process renal function was preserved and all 5 animals that underwent augmentation had increased bladder capacity at sacrifice 1 month postoperatively. In the present study we evaluated the long-term durability and performance of the ureteral segment used for augmentation. MATERIALS AND METHODS: We performed a prospective, controlled, double armed study in 8 pigs, including 4 control animals that underwent subtotal cystectomy only (group 1) and 4 animals that underwent subtotal cystectomy followed by bladder augmentation using the expanded ureteral segment (group 2). End point measurements included cystography, and measurement of bladder capacity, serum creatinine and random bladder residual urine volumes. All cystograms were performed using passive filling conditions at a standard filling pressure of 32 cm. water. RESULTS: Bladder capacity throughout the study revealed consistently higher volumes in group 2 than in group 1. In 3 of the 4 group 1 subjects vesicoureteral reflux developed compared to no reflux in group 2. Creatinine levels were elevated at sacrifice in 50% of the animals in group 1 compared to none in group 2. Random bladder residual urine was less than 150 cc in 3 of the 4 group 2 subjects. CONCLUSIONS: Serial cystograms in pigs after ureteral augmentation suggest that the tissue does not contract with time. Animals that underwent ureteral augmentation had significantly greater bladder capacity than controls. Random bladder residual urine volume remained low throughout the study period. Ureteral tissue expansion for bladder augmentation appears to be feasible and durable in this animal model. In addition, it may be protective against the deleterious effects associated with small capacity bladders
— id: 20800, year: 1998, vol: 160, page: 1826, stat: Journal Article,

Expression of the tumor-associated gene MN: a potential biomarker for human renal cell carcinoma
McKiernan JM; Buttyan R; Bander NH; Stifelman MD; Katz AE; Chen MW; Olsson CA; Sawczuk IS
1997 Jun 15;57(12):2362-2365, Cancer research
MN is a novel cell surface antigen originally detected in human HeLa cells. Although it is also expressed in normal gastric mucosa, this antigen was previously found to be expressed in cells with a malignant phenotype in certain tissues of the female genital tract (cervix and ovary). Using an oligonucleotide primer set specific for MN-complimentary DNA, we performed reverse transcription-PCR assays on RNAs extracted from human cell lines and tissues to evaluate whether this marker might be expressed at other sites. RNA libraries extracted from normal human heart, lung, kidney, prostate, peripheral blood, brain, placenta, and muscle were negative for MN expression. RNAs extracted from liver and pancreatic tissue were positive for MN expression. Three of six renal cancer cell lines tested revealed MN expression. In addition, 12 of 17 samples of human renal cell carcinoma tissue tested positive for MN, all 12 of which were clear cell adenocarcinomas. This survey identified a unique association of MN expression with renal cell cancers, especially those of the clear cell variety, suggesting that MN is a potential marker for the diagnosis, staging, and therapeutic monitoring of renal cell carcinoma in humans
— id: 20802, year: 1997, vol: 57, page: 2362, stat: Journal Article,

Enhanced Reverse Transcriptase Polymerase Chain Reaction for Prostate-specific Antigen Combined With Needle Biopsy Results: A Superior Predictor of pT3 Disease
Rubin MA; Fang M; Stifelman MD; De VRIES GM; Buttyan R; Benson MC; Katz AE; Olsson CA; O'Toole K
1997 Jun;2(2):135-145, Molecular diagnosis
Background: Preoperative staging for prostate cancer underestimates the final pathology stage in approximately 40-50% of the cases. Previous work from our institution demonstrated that an enhanced reverse transcriptase polymerase chain reaction (RT-PCR) assay for prostate-specific antigen (PSA) enabled more accurate staging of presumably localized prostate cancer. The goal of the current study is to determine if needle biopsy results when combined with the RT-PCR for PSA assay are a better predictor of final pathology stage. Methods and Results: One hundred sixty-two men with needle biopsy-diagnosed prostate cancer had blood drawn for the RT-PCR for PSA assay before undergoing radical prostatectomy. Polymerase chain reaction primers specific for the PSA gene were run, along with appropriate controls. Tumor was characterized using the TMN staging system: organ confined (pT2a-c), capsular penetration (pT2a-b), seminal vesicle involvement (pT3c). Surgical margins and lymph nodes were also evaluated. Of the 162 patients, the majority had localized disease by digital rectal examination: T2 = 97%, and T3 = 3%. On needle biopsy, 48 cases (30%) had a Gleason score >/=7 and 35 cases (22%) had perineural involvement (PNI). The RT-PCR for PSA assay was positive in 50 patients (31%). Final pathology revealed 39% of patients had pT3 disease; none of the 162 patients had lymph node involvement. Statistical analysis revealed that a Gleason score >/=7 had 81% specificity and 46% sensitivity in predicting pT3 disease (odds ratio 3.6). The presence of PNI on needle biopsy was 89% specific and 38% sensitive in predicting pT3 disease (odds ratio, 4.9). The RT-PCR for PSA assay was 89% specific and 62% sensitive in predicting pT3 disease (odds ratio, 13.0). All 14 cases with both RT-PCR for PSA and PNI positivity had pT3 disease. Logistic regression analysis demonstrated the independent predictive strength of PNI on needle biopsy, Gleason score >/=7, and RT-PCR for PSA positivity for identifying pT3 disease; their combined odds ratio was more than 180. Conclusions: Using the RT-PCR for PSA assay in conjunction with needle biopsy results increases the predictive strength for pT3 disease in patients with presumed organ-confined prostate carcinoma
— id: 20797, year: 1997, vol: 2, page: 135, stat: Journal Article,

The role of the reverse-transcriptase polymerase chain reaction assay for prostate-specific antigen in the selection of patients for radical prostatectomy
Katz AE; de Vries GM; Benson MC; Buttyan RE; O'Toole K; Rubin MA; Stifelman M; Olsson CA
1996 Nov;23(4):541-549, Urologic clinics of North America
Prostate cells present in the peripheral circulation can be detected using an enhanced reverse-transcriptase polymerase chain reaction (RT-PCR) for prostate-specific antigen (PSA) assay. In one study, preoperative enhanced RT-PCR for PSA status was a significant predictor of surgical pathology and postoperative biomechanical recurrence. The use of RT-PCR may enhance the urologist's ability to stage potential candidates for radical prostatectomy, as the assay is a more sensitive and specific predictor of microscopic extracapsular extension than conventional staging modalities. This highly adaptable assay also may have roles in screening for recurrence and in staging other solid tumors
— id: 20811, year: 1996, vol: 23, page: 541, stat: Journal Article,

Ejaculatory duct obstruction in the infertile male
Goluboff ET; Stifelman MD; Fisch H
1995 Jun;45(6):925-931, Urology
— id: 20803, year: 1995, vol: 45, page: 925, stat: Journal Article,

[Celioscopic lymphatic excision and perineal radical prostatectomy: a strategy for the treatment of prostatic cancer]
Melman A; Gladshteyn M; Stifelman M
1993 Apr;3(2):197-204, Progres en urologie
Radical perineal prostatectomy despite its many advantages over the past decade had decreased in popularity compared with the retropubic approach and was limited to a few specific indications. The primary reason for this trend was in the ability to first evaluate pelvic lymph node metastases by frozen section using only one retropubic incision. Recently our institution has developed an alternative method which combines laparoscopic lymph node dissection (LLND) with radical perineal prostatectomies (RPP). From January 1990 to January 1992, 30 patients with a mean age of 64 were identified as having clinical stage B prostatic carcinoma. From this population a total of 36 procedures were performed by the senior author. 9 patients underwent LLND alone (group 1), 13 patients underwent RPP alone (group 2) and 14 patients underwent combination LLND and RPP (group 3). The mean EBL for groups 1, 2 and 3 were 1.2, 5 and 5.6 days respectively. Number of transfusions for patients requiring blood in groups 2 and 3 were 1.2 units and 1.5 units respectively. There were no significant differences in post-operative stay, post-operative complications, day tolerating diet or days of analgesia despite the difference in operating room and anesthesia time: group 2 (2:25) and group 3 (5:29). All levels of PSA in groups 2 and 3 remain trace at 1, 3, 6 and 12 months post operatively except for one patient.(ABSTRACT TRUNCATED AT 250 WORDS)
— id: 20812, year: 1993, vol: 3, page: 197, stat: Journal Article,