Smith Blog

Recently, one of our faculty, Dr. Lee Richstone was honored to be involved as a faculty member at two advanced laparoscopy courses, one in India and the other in Los Angeles. Both courses were held for other physicians who wanted to learn advanced laparoscopic skills. In particular, they wanted to learn more about LESS surgery. LESS stands for Laparoendoscopic Single Site (LESS) surgery. This is a new approach to laparoscopic surgery, where the entire surgery is completed through the umbilicus (belly-button, or navel). The result is nearly scar-less surgery!

Dr. Richstone is one of the few who are leading the way in this exciting field. In fact, we have been pioneers in LESS donor nephrectomy, LESS pyeloplasty for obstructed kidneys, and LESS partial and complete nephrectomy. In particular, our experience with LESS partial nephrectomy is exciting. When patients have small kidney tumors that need to be surgically removed, a partial (not complete) kidney removal is required. This is called a partial nephrectomy. Dr. Richstone’s experience with performing this surgey ONLY through the belly-button may be the largest experience worldwide with this technique.  With time, there’s hope that this technique will offer the best possible cosmetic outcomes while sparing the majority of the remaining kidney, which is so vital.

In December Dr. Richstone was asked to travel to Nadiad, in India, to teach these techniques by giving lectures and performing live LESS surgery. It was a fascinating trip!  Surgeons came from all over the world, including Africa, India, Singapore, Japan, among other nations, to learn. It was a great “meeting of minds”! He performed 2 LESS operations over the 3 day course that helped many patients and their families. Medicine is an amazing occupation, rich with patient experiences, research opportunities, as well as incredible opportunities to work with collegues from across the globe. It is amazing how new technology “diffuses” so quickly to far corners of the world so rapidly! Dr. Manesh Desai was the organizer of the meeting, and the host. To him we are very grateful. More recently, Dr. Richstone was invited to participate in a similar course for the American Urological Association at a course held at the University of Southern California, with doctors from all over the United States, and as far as Korea, in attendance.

When it comes to new surgical approaches in surgery and urology, we need to do a better job of getting advanced techniques “out there” to the community.  For example, far too many patients get their entire kidney taken out when only part of it needs to be removed, and far too few patients are offered the advantages of a laparoscopic approach to surgery (ref 1). This is particularly for kidney surgery where the recovery is considerable shortened, with less pain. It is worthwhile to continue to strive to offer the same success rates for surgery, but strive for a “scarless” approach to improve patient sense of well-being, and cosmetic outcome (ref 2).  We at the Smith Institute for Urology have a long track record on the “cutting edge” of patient care and research, and will continue to do so with passion and vision.

Reference:
1) Richstone L, Kavoussi LR. Barriers to the diffusion of advanced surgical techniques. Cancer. 2008 Apr 15;112(8):1646-9.
2) Richstone L, Kavoussi L.”Less” is more. J Urol. 2007 Sep;178(3 Pt 1):752.

As many of our patients know, Dr. Barbara Shorter, EdD, RD, CDN Associate Professor of Nutrition and  Director of the undergraduate Nutrition Program at Long Island University, has been volunteering her time every other Friday to counsel IC patients.

Well…we are very happy to report that Dr. Shorter has now joined our faculty! She’ll be giving expert advice on the nutritional aspects of many other urological conditions such as kidney disease, kidney stones, interstitial cystitis, prostatitis, and urological cancers.

Barbara Shorter received her Doctorate in Nutrition Education from Teachers College, Columbia University.  She is a registered dietitian with the American Dietetic Association and is a Certified Dietitian/Nutritionist NYS.  Dr. Shorter is an Associate Professor in the Department of Nutrition at the CW Post Campus of Long Island University (LIU) and Director of the Didactic Program in Dietetics.  She recently joined the faculty of the Smith Institute for Urology where she provides nutritional counseling in facets of urology including, pelvic pain, prostate cancer, kidney stone disease, and renal failure.

Prior to Dr. Shorter’s positions in the Academic arena, she was Chief Dietitian for the Catholic Medical Center, and, Senior Nutritionist at the NYU Medical Center Hospital, NYC.

Welcome aboard Barbara!!

Men treated for inflammatory bowel disease with Sulfazalazine have drug related impairment in sperm quality that often persists after cessation of the drug. This had prompted pharmaceutical companies to develop other “sperm friendly” treatment options. The most frequent age of onset of the inflammatory bowel diseases including idiopathic chronic inflammatory bowel disease (IBD), Crohn’s disease (CD) and Ulcerative Colitis (UC) is between 15 to 30 years of age. This range, of course, coincides with the peak reproductive years. Therefore, it makes good sense that the effect on male fertility of any drug treatment should be known. Azathioprine and 6-Mercaptopurine (6-MP) are effective immunosuppressive agents commonly used for the long term control of UC and CD in the steroid dependent patient and are focus of this article.

Azathioprine is converted to 6-mercaptopurine which acts to decrease cell metabolism and DNA biosynthesis. A study by Russell and Hunsicker (Study of the base analog 6-mercaptopurine in the mouse specific-locus test., Mutat Res. 1987 Jan;176(1):47-52.) found that in mice 6-Mercaptopurine caused chromosomal damage (both structural and numerical) in all stages of development of the male germ-cell. This data was again confirmed by Witt and Bishop (Mutagenicity of anticancer drugs in mammalian germ cells., Mutat Res. 1996 Aug 17;355(1-2):209 34). In a study in rats, a dose dependent decrease in sperm concentration, damage to the seminiferous tubules and a lowering of testosterone was found with Azathioprine therapy (Iwasaki M, Fuse H, Katayama T., The effects of cyclosporine azathioprine and mizoribine on male reproduction in rats, Nippon Hinyokika Gakkai Zasshi. 1996 Jan;87(1):42-9). In addition, in a study in mice, spermatogenesis and fertility was also decreased (Sykora I. Dominant-lethal test of 6-mercaptopurine: dependence on dosage, duration and route of administration. Neoplasma. 1981;28(6):739-46).

There is some, but unfortunately not much, data available on the effect of these agents on sperm production and sperm function in man. A study by Dejaco et al suggested that men treated with Azathioprine have no change in semen quality and
implied that fertility was also unaffected (Gastroenterology. 2001 Nov;121(5):1048 53. Azathioprine treatment and male fertility in inflammatory bowel disease. Comment in: Inflamm Bowel Dis. 2002 May;8(3):234-5). In this study, paired data wasn’t examined. In contrast, a case study by Sills and Tucker found markedly impaired semen parameters in a single patient who had conceived twice with his partner prior to three months of therapy with 6-MP (First experience with intracytoplasmic sperm injection for extreme oligozoospermia associated with Crohn’s disease and 6-mercaptopurine chemotherapy. Asian J Androl. 2003 Mar;5(1):76-8).

Much more data is needed in humans. Many questions remain unanswered; Are the effects of these drugs in man similar to those found in rodents? Is it the medication used or the underlying disease that has a greater effect on sperm? Are the effects seen reversible, and if so over what time period? Additional research is needed to define the effect of these (and other) drugs used in the treatment of inflammatory bowel disease in reproductive-aged men. Until these studies are done, I feel it is advisable to discuss the potential for impairment in fertility and offer sperm banking to reproductive aged men prior to long term treatment with Azathioprine or 6-Mercaptopurine.

Bruce R. Gilbert, MD, PhD
Director, Reproductive and Sexual Medicine
The Smith Institute for Urology
North Shore LIJ Health System
7/26/09

The American Urological Association Annual meeting in Chicago (April 25th – April 30th) was a huge success for patients suffering from pelvic pain. Some of the latest news…

1.    Various differences may exist in urinary protein expression between interstitial cystitis (IC) patients and those without IC. This suggests that “urinary proteomics” may provide insight into the cause of IC and/or aid in the development of new “markers” for this condition.
2.    Nerve growth factor was found to be elevated in the urine of IC patients and in patients with overactive bladder and even in patients with varied lower urinary tract symptoms.
3.    Patients with IC appear to have significant biosocial impairment as compared to the population at large. Also, conditions such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome were more frequently seen in the IC population.
4.    The Rand Interstitial Cystitis Epidemiology study evaluated almost 100,000 US households and found the prevalence of IC type symptoms in women to be 3-6%, a significantly higher prevalence than previous studies. This suggests that IC symptoms may exist in over 4 million women in the United States!
5.    Botulinum toxin A (100 units) into the bladder base (trigone) improved the symptoms of all 17 patients in one study. At 9 months follow up, 7 patients requested another injection due to return of symptoms.
6.    In another Botulinum toxin A related study, Botulinum toxin A appeared to enhance the clinical effect of bladder hydrodistention.
7.    Antiproliferative factor (APF) is a chemical found in the urine of most IC patients and may be a cause of symptoms. Two new agents have shown promise as APF inhibitors in the laboratory setting.
8.    Both IC patients and patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) had a high prevalence of food sensitivities, but IC patients still had about twice the prevalence as the CP/CPPS patients.
9.     A clinical phenotyping system termed “UPOINT” (Urinary, Psychosocial, Organ specific, Infection, Neurologic/Systemic, Tenderness of pelvic floor muscles) was developed to better understand the cause of and best therapies for CP/CPPS.
10.    In a randomized, double blinded study, pregabalin (Lyrica®)  was not found to be better than a placebo group in the treatment of CP/CPPS…BUT..when evaluating “secondary endpoints” such as global improvements, significant differences where found, suggesting a role for this medication in the treatment of CP/CPPS.

For this information and more, please visit the Pelvic Pain section of this website.

Robert Moldwin, MD
Associate Professor of Clinical Urology
Hofstra University School of Medicine
Director, Pelvic Pain Center
The Arthur Smith Institute for Urology
Long Island Jewish Medical Center

In 1953, John Hunt led a British expedition to climb Mount Everest that unfortunately had to turn around within 300 feet of the summit.  Although the group failed its task, they defined a route and introduced a technique for carrying extra oxygen that allowed the New Zealander Edmund Hillary to reach the summit a few days later. Hillary became Sir Hillary and the accomplishment was celebrated around the globe.

Several steps have been taken in the climb towards a true Natural Orifice Transluminal Endoscopic Surgery (NOTES) nephrectomy. This means removing organs through a natural orifice such as the mouth, rectum, urethra or vagina.  Previous reports demonstrate that kidney removal through the vaginal vault is feasible.

Is NOTES the summit of “Everest” or is it Base Camp? The answer is both. NOTES has fulfilled the dream of eliminating a visable incision for extirpative renal surgery. However, there are growing series of Laparoendoscopic Single-Site Surgery (LESS) nephrectomies that have shown only cosmesis as the advantage to minimizing the incision. Until a series of NOTES nephrectomies is evaluated it is uncertain whether there will be any additional benefit to the patient. The major issues of surgery still remain with postoperative ileus, fatigue and discomfort coming from the actual renal dissection which does not change based on location of trocar placement.

This kind of surgical exploration needs to be supported.  However, the real surgical “Everest” will be a quantum leap, a total replacement of our current notion of invasive extirpative surgery.  We should never take our eyes off this ultimate prize.

Louis R. Kavoussi, M.D.
Professor and Chairman
Smith Institute for Urology
Hofstra School of Medicine
North Shore-LIJ Health System
Long Island, NY

Dr. Moldwin was an invited panelist for the National Institute’s of Health’s (NIH) Office of Research on Women’s Health (ORWH) held March 4-6th, 2009. The meeting was entitled “Moving into the Future: New Dimensions and Strategies for Women’s Health Research.” It was designed to help the NIH formulate its research priorities for the next 10-20 years. The meeting covered all areas of women’s health. Dr. Moldwin was present to plead for more dollars for research projects that would help interstitial cystitis patients. Also present representing the interests of IC patients was Barbara Gordon, the Executive Director of the ICA.

Some suggestions that came from the “Chronic Pain Syndromes” panel that Dr. Moldwin attended included:

1. Developing research strategies to investigate chronic pain syndromes as a “systemic” problem (that has manifestations in multiple systems in the body). This may help better establish why so many patients with IC also have problems like fibromyalgia, irritable bowel syndrome, migraine headaches, Sjögren’s Syndrome, vulvodynia, chronic fatigue syndrome, etc. This topic received the most attention and discussion.
2. Developing better ways to conduct trials for new therapies.
3. Developing better animal models for chronic pain syndromes. We had a very long discussion about this very complex topic.
4. Exploring issues related to clinician- patient interactions in the chronic pain patient. Differences in how people describe their difficulties which may vary on the basis of previous experiences, social environment, or sex.
5. The effect that factors such as hormones and diet may have on these pain syndromes.
6. The great need for the development of a database system where clinical data from patients can be pooled together from multiple institutions.

Other topics that were discussed included:

1. The need for chronic pain syndromes (including IC) to be included in the curriculum of medical schools. Currently, medical students typically graduate without even hearing of fibromyalgia, IC, vulvodynia, etc… no less being taught to manage such patients. Without a basic understanding of these conditions from their basic training, how do we expect any of these bright people to treat or become researchers in this area? We suggested that the ORWH take a role in mandating discussion of these topics in medical school curricula.
2. Pharmaceutical companies apparently have lots of data on various medications which may show promise as future treatments for patients in pain. We would like to see some of these data voluntarily released, thereby giving researchers some groundwork for the development of future therapies.

A common question asked by couples considering a vasectomy reversal is “What is the success rate”. There is no precise way to determine success (which we will define as return of sperm to the ejaculate) prior to a procedure. There is certainly good data demonstrating a direct relationship between the time since the vasectomy and the success of the procedure.  However, many patients have a normal semen analysis after a vasectomy reversal, even when the reversal was done greater than 20 years after the vasectomy. Success is also a function of other factors besides the time from a vasectomy. For instance: site where sperm is found (vas deferens or epididymis) at the time of procedure, testicular size and function, length of viable vas deferens present…and of course the experience of the Surgeon.  In addition, if you define success as pregnancy then female factors must also be considered.  Oftentimes, many factors can be identified prior to the procedure by a comprehensive physical examination and review of the medical history. This will allow the Urologist to discuss the realistic expectations. Also, sperm banking of vasal/epididymal or testicular sperm done at the time of the procedure will assure that IVF (in vitro fertilization) can be done without the need for any additional procedures.

Bruce R. Gilbert, M.D., Ph.D., FACS
Director, Reproductive and Sexual Medicine
Smith Institute for Urology

Surgery was born centuries ago out of a raw necessity to cure in the context of a limited medical armamentarium. Early surgeons were pioneers in demonstrating the now obvious reality that the extirpation of tumors, drainage of infected kidneys, and removal of stones could alleviate pain and suffering. Initial focus addressed the disease and how to perform procedures with reasonable patient survival. With the 20th century came rapid advances in anesthetic techniques, perioperative care, antibiotics and organized surgical education, resulting in reliable surgical methods.Society has charged the modern era of surgery with an additional agenda.  Patients want and expect less: less pain, less incisions, less recuperation and less expense all with a classically successful surgical outcome.  The focus upon issues such as function and lifestyle has challenged our specialty to better understand the human body, diseases and surgical processes.  These requirements have engendered several novel minimally invasive techniques, radically different than traditional open surgery.  These approaches require a different set of surgical skills, collaborative efforts with disciplines outside of traditional surgical sciences and a creative spirit.

Over the past 30 years there has been acceleration in minimally invasive surgery that has indelibly changed the landscape of urologic practice.  Endoscopic and transcutaneous surgery for stone disease has supplanted open techniques.  Laparoscopic approaches to adrenal and renal pathology have evolved into not only acceptable alternatives but indeed the preferred surgical technique at qualified centers. Society will continue to push us to reevaluate the approach to every urologic pathologic condition, both benign and malignant.  Moreover what is minimally invasive today may not be minimally invasive by morning.

As “less” is expected by patients, our duty as surgeons continues to become more complex. Even the monumental accomplishment of removing a stone through a keyhole incision, halving the hospital stay associated with a partial nephrectomy, or slashing recovery time following RPLND is not enough. We must continue to analyze and refine all aspects of surgery.  This will require an ongoing investment in scientific inquiry, a tolerance for seemingly counterintuitive approaches and a continuous postgraduate learning process.

Lee Richstone MD

Louis Kavoussi MD

The Smith Institute for Urology
North Shore-LIJ Health System
Long Island, NY

The “Miracle on the Hudson” of US Airways flight 1549, with the survival of all 155 aboard, caused us to pause and think about the events that led to the happy outcome. We must all realize that careful planning and extensive training played a large part in this miraculous outcome.  First there are safety checklists.  Every aspect of mechanical soundness and procedural steps are reviewed.  Even the passengers are involved through the educational safety instructions prior to takeoff.  In the vast majority of air flights, safety measures help avoid situations that can lead to disaster.  Moreover, the pilots are experienced and train for hours on simulators that can reproduce any imaginable equipment failure.  Finally there was the “luck factor”: weather, empty river and nearby help.

Over the past several years, surgeons have been looking to adopt some of these practices from the airline industry to minimize complications.  Indeed a recent study by the Harvard School of Public Health in conjunction with the World Health Organization demonstrated that a simple 19 point checklist could considerably decrease complications and even death*.  Some of the items are as simple as identifying the correct side of the operation, having team members identify themselves, and checking equipment prior to surgery.  Patient education prior to surgery is also important to help assure a good outcome.  Instructing patients to avoid certain medications preoperatively, to bring films to the operating room and clean out the bowels all are important safety measures.

Unfortunately many important measures are not as easy to transfer from the airline industry to the operating room.  Although surgical simulators do exist, they are limited in their ability to truly re-create the surgeon’s experience, the precision of the procedure, and of course, the varying anatomy  that is seen with a real patient.  As such, normal routine procedures, let alone the given patient pathology, cannot be practiced for a given patient.  This differs markedly from the airline industry where planes of each manufacturer all are constructed and function in a predictable manner.  Medicine realizes that surgeon experience is important, however, there are no simulators or required mechanical exercises that surgeons must pass.  Indeed most hospitals do not set a limit on the minimal number of a case a surgeon must do to be considered competent.

Surgery must be made safer for our patients, and this is a major research initiative at the Smith Institute for Urology.  In fact, we have embarked on several initiatives that reach toward this goal. Credentialing requires documentation of experience.  Minimum volumes are required to grant privileges for high risk or robotic procedures.  Moreover, we are truly at the cutting edge of simulation and skill-assessment.  We are involved in the development of novel surgical simulators that one day may allow surgeons to practice an operation prior to coming to the operating room.  In a truly groundbreaking set of experiments, we have shown for the first time ever that surgeon’s eye and pupil function can predict surgeon skill in an objective and reproducible way.  Taking this concept even further, we have demonstrated that the brain function of novice vs. expert surgeons actually function differently based on MRIs!

Reducing the risks of human errors is critically important in high-stakes enterprises such as air-flight and surgery.  At the Smith Institute we pride ourselves at being at the cutting edge of this process, in order to make surgery safer for our patients.

*”A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” (N Engl J Med 2009;360:491-9)

Some good press on our telerounding work!

http://www.queenstribune.com/news/1174814933.html

 http://www.northshorelij.com/body.cfm?id=15&action=detail&ref=881

 http://www.brunoandtheprofessor.com/2007/03/i_am_your_robot_and_im.php