Extensive bladder and urethral calculi detected with computerized tomography: diagnosis and management.
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Humans↗
Biomedical subjects
D G Skinner
Publications and source records attributed to D G Skinner.
Mixed germ cell tumor of the testicle presenting with a sacrococcygeal mass and no evidence of retroperitoneal adenopathy.
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Adult↗
Orthotopic urinary diversion with preservation of erectile and ejaculatory function in men requiring radical cystectomy for nonurothelial malignancy: a new technique.
PURPOSE: Nerve sparing techniques to preserve sexual function in men undergoing cystoprostatectomy have been well documented. The patient who desires to remain fertile with ejaculatory function poses an additional challenge. We describe a new technique for radical cystectomy and orthotopic diversion with preservation of the vasa deferentia, seminal vesicles, posterior prostate and neurovascular bundles. MATERIALS AND METHODS: Four men with a median age of 26 years presented with bladder pathology necessitating cystectomy, including signet ring carcinoma of the bladder dome, leiomyosarcoma of the anterior bladder wall, leiomyosarcoma of the lateral bladder wall, and extensive polypoid cystitis glandularis of the trigone and posterior wall refractory to conservative and transurethral management. All patients wished to maintain fertility and ejaculatory function. We detail the surgical technique of extirpation of the bladder and anterior proximal prostate en bloc with preservation of the vasa deferentia, seminal vesicles, posterior prostate and neurovascular bundles as well as construction of an orthotopic reservoir. RESULTS: Followup ranges from 4 months to 5 years. All patients remain completely continent and void to completion without difficulty. Erectile function is normal in all cases. Of 3 patients who ejaculate antegrade 1 has fathered a child. The remaining patient ejaculates retrograde. There has been no tumor recurrence. CONCLUSIONS: The technique of cystectomy with preservation of the vasa deferentia, seminal vesicles, posterior prostate and neurovascular bundles is an excellent option in men with nonurothelial malignancy or another pathological condition that necessitates cystectomy, and in whom preservation of fertility and potency is desirable. All of our patients are fully potent and achieve ejaculation. Even the patient with retrograde ejaculation remains fertile. In terms of practicality semen retrieval from urine is much simpler than epididymal sperm aspiration and in vitro fertilization.
Adult↗
Effect of p21WAF1/CIP1 expression on tumor progression in bladder cancer.
BACKGROUND: Altered expression of p53 protein is an important predictor of progression in bladder cancer. The action of p53 on cell cycle regulation is mediated, in part, through expression of the cyclin-dependent kinase inhibitor p21WAF/CIP1 (p21). Loss of p21 expression may, therefore, contribute to tumor progression. We sought to determine the relationship between p21 expression in bladder cancer and disease progression. METHODS: Tumor specimens were obtained from 242 patients who underwent cystectomy for bladder cancer. Median follow-up was 8.5 years (range, 0.1-11.8 years). Nuclear p21 status was determined by immunohistochemistry and was then analyzed in relationship to the probability of tumor recurrence, overall survival, and tumor p53 status. Reported P values are two-sided. RESULTS: Nuclear p21 expression was detected in the tumors of 156 (64%) of the 242 patients. Patients with p21-positive tumors had a decreased probability of tumor recurrence (P<.00001) and an increased probability of overall survival (P<.00001) in comparison with patients with p21-negative tumors. In a multivariable analysis, p21 expression was an independent predictor of tumor recurrence (P = .0017) and of survival (P = .006) when assessed with tumor grade, tumor stage, lymph node status, and p53 status. p21 expression was associated with p53 status (P<.001); 56% of tumors with p53 alterations showed loss of p21 expression, whereas 79% of tumors expressing wild-type p53 were p21 positive. Patients with p53-altered/p21-negative tumors demonstrated a higher rate of recurrence and worse survival compared with those with p53-altered/p21-positive tumors (P<.0001). Patients with 53-altered/p21-positive tumors demonstrated a similar rate of recurrence and survival as those with p53-wild type tumors. CONCLUSION: Loss of p21 expression is a statistically significant and independent predictor of bladder cancer progression. Maintenance of p21 expression appears to abrogate the deleterious effects of p53 alterations on bladder cancer progression.
Aged↗
Radical cystectomy for elderly patients with bladder carcinoma: an updated experience with 404 patients.
BACKGROUND: The authors evaluated the experiences at their institution with radical cystectomy and urinary diversion performed on elderly bladder carcinoma patients to determine whether age had an impact on the clinical or functional results for this group of patients. METHODS: Between August 1971 and December 1996, 404 patients age 70 years or older (median age, 74 years) underwent radical cystectomy and urinary diversion for invasive bladder carcinoma: 352 (87%) were ages 70-79 years and 52 (13%) were age 80 years or older. Data analyzed included the following: perioperative mortality; early (within 90 days after surgery) and late (more than 90 days after surgery) postoperative complications, related and unrelated to the urinary diversion; length of hospital stay; pathologic staging; and clinical outcome. These data were then compared with those for 762 patients younger than 70 years (median age, 61 years) who underwent the same procedure during the same time period. RESULTS: The overall mortality rate for patients age 70 years or older was 2.8% (3.2% for those ages 70-79 years, 0% for those age 80 years or older), compared with 2% for patients younger than 70 years. The early complication rate for patients age 70 years or older was 32%, compared with 25% for patients younger than 70 years. Patients age 80 years or older had a similar early complication rate of 29%. Late postoperative complications occurred in 12.4% of patients age 70 years or older, compared with 22.8% of patients younger than 70 years. There was no significant difference between the two groups with regard to pathologic stage or length of hospital stay. The 3-year and 5-year overall survival rates for patients age 70 years or older were 60% and 53%, respectively, compared with 68% and 63%, respectively, for patients younger than 70 years (P=0.001). There was no statistical difference between the groups when rates of disease recurrence were compared (P=0.3627). The 5-year recurrence rate for patients age 70 years or older was 35%, compared with a 5-year recurrence rate of 31% for patients younger than 70 years. CONCLUSIONS: These data suggest that an aggressive, curative, radical surgical approach and urinary diversion may be a viable treatment strategy for properly selected elderly patients who are in generally good health and require definitive therapy for invasive bladder carcinoma.
Aged↗
Elevated and absent pRb expression is associated with bladder cancer progression and has cooperative effects with p53.
Rb protein (pRb) expression was evaluated in 185 cases of transitional cell carcinoma of the bladder from patients that underwent radical cystectomy. Tumors were stratified into three categories based on the percentage of nuclei expressing pRb: (a) 0, 0% of tumor cells showing nuclear reactivity; (b) 1+, 1-50% of tumor cells showing nuclear reactivity; and (c) 2+, >50% of tumor cells showing nuclear reactivity. Cases with undetectable (pRb 0) and high (pRb 2+) pRb reactivity had identical rates of recurrence. These cases had significantly higher recurrence (P = 0.0001) and lower survival rates (P = 0.0002) compared to cases with moderate (pRb 1+) pRb reactivity, indicating that high levels of pRb expression may reflect a dysfunctional (altered) Rb pathway. The tumors were also examined for alterations in p53 expression; patients with tumors altered in both p53 and pRb had significantly increased rates of recurrence (P < 0.0001) and survival (P < 0.0001) compared to patients with no alterations in either p53 or pRb; patients with alterations in only one of these proteins had intermediate rates of recurrence and survival. These results suggest that: (a) bladder cancers with high pRb expression do not show the tumor suppressor effects of the protein; and (b) alteration in both p53 and pRb may act in cooperative or synergistic ways to promote tumor progression.
Carcinoma, Transitional Cell↗
Radical prostatectomy and postoperative irradiation in patients with pathological stage C (T3) carcinoma of the prostate.
PURPOSE: Adenocarcinoma of the prostate is the most common human cancer of internal organs. Radical surgery is regarded by many to be the treatment of choice for capsule confined disease. Since accurate preoperative assessment of tumor stage is difficult to define, many patients are subsequently found to have pathological stage C (T3) disease. These patients should be considered for adjuvant radiotherapy. METHODS AND MATERIALS: A group of 201 PS C (T3) unselected patients, treated with radical prostatectomy and limited pelvic lymphadenectomy, received postoperative irradiation to the prostate bed. This radiotherapy was given between 42-90 days after surgery and consisted of a median dose of 48 Gy. Patient survival, disease free survival, time to clinical and chemical relapse and the incidence of local and systemic relapse were analyzed. The influence of multiple parameters on the treatment outcome including patient age, treatment period, clinical stage, pathological stage, Gleason's score, prostate specific antigen (PSA), radiotherapy techniques and radiation dose were examined using univariate and multivariate analysis. Follow-up ranged from 3 to 15 years, with a median of 5 years. RESULTS: The overall 5- and 10-year actuarial survival was 92% and 83% (median > 10 years), respectively and the 5- and 10-year disease-free survival (clinical and PSA) was 67% and 53% (median > 10 years), respectively. A total of 61 (30%) patients had a recurrence, including 23 (11%) patients who had clinical and 38 (19%) who had PSA recurrence. Of the 23 patients with clinical recurrence, 10 (5%) had local recurrence, including two patients who had local and systemic recurrence. Pathological stage and Gleason's score were independently predictive of recurrence (each with p < 0.001 after controlling for the other). Patients in the worst prognostic category with pathological stage C3 and Gleason's score 8-10 were predicted to be at 7.2 times the risk of recurrence, compared to stage C1 or C2 and Gleason's score 2-7 patients. Preoperative PSA level (> 25 ng/ml) was also an important independent factor predicting tumor recurrence, p = 0.05. All other investigated parameters were not significant in predicting tumor recurrence. This treatment program was very well tolerated by the study patients, with seven (3.5%) recorded with major and 18 (9%) with minor surgical complications, while 65% of patients had minor and clinically insignificant radiation complications. CONCLUSION: Surgery followed by moderate dose radiotherapy in patients with PS C (T3) prostatic carcinoma was well tolerated and resulted in excellent overall and disease free survival, with a low incidence of local recurrence. New treatment strategies need to be developed for patients with C3 tumors and those with high (8-10) Gleason's score and those with high (> 25 ng/ml) PSA level at diagnosis.
Aged↗
Prognostic markers in bladder cancer: a contemporary review of the literature.
PURPOSE: We provide a contemporary review of bladder tumor markers and summarize their role as prognostic indicators. MATERIALS AND METHODS: A comprehensive review of the literature on prognostic markers for transitional cell carcinoma of the bladder was performed. RESULTS: Intense research efforts are being made to identify and characterize better various bladder cancers and their true biological potential. The need to predict which superficial tumors will recur or progress and which invasive tumors will metastasize has led to the identification of a variety of potential prognostic markers. Blood group antigens, tumor associated antigens, proliferating antigens, oncogenes, peptide growth factors and their receptors, cell adhesion molecules, tumor angiogenesis and angiogenesis inhibitors, and cell cycle regulatory proteins have recently been identified. The potential clinical applications of these tumor markers are under active investigation. Recent attention has focused on which tumor markers may predict the responsiveness of a particular bladder cancer to systemic chemotherapy. CONCLUSIONS: At present conventional histopathological evaluation of bladder cancer (tumor grade and stage) cannot predict accurately the behavior of most bladder tumors. With a better understanding of the cell cycle, and cell to cell and cell to extracellular matrix interactions as well as improved diagnostic techniques (immunohistochemistry), progress is being made to identify and characterize other potential prognostic markers for transitional cell carcinoma of the bladder. The ultimate goal is to develop reliable prognostic markers that will accurately predict not only the course but also the response of a tumor to therapy. This information may then be used to dictate more aggressive treatment for tumors that are likely to progress and less aggressive treatment for those that are unlikely to progress. In the future these biological markers may also be used in gene therapy for the treatment of bladder cancer.
Antigens, Neoplasm↗
A serous lined antireflux valve: in vivo fluorourodynamic evaluation of antireflux continence mechanism.
PURPOSE: We evaluate the fluoroscopic and urodynamic performance of a new serosal lined antireflux continence valve (T pouch valve) using an in vivo animal model. MATERIALS AND METHODS: Intestinal reservoirs were constructed using an in vivo pig model. Multiple serosal lined valves of varying diameters and tunnel lengths were evaluated in the acute (immediately after construction) and chronic (4 weeks postoperatively) settings. Video fluorourodynamic evaluations were performed to identify valve leak point pressures and optimal tunnel length-to-luminal diameter ratios. RESULTS: Four serosal lined valves tapered to a diameter of 18 and 30F in 1 and 2 cm. tunnels were evaluated. Immediately following construction of the valves no leakage was observed during reservoir filling (maximal pressure 50 cm. water) or external compression maneuvers to simulate a Valsalva maneuver (maximal intra-reservoir pressure 100 cm. water). Identical fluorourodynamic studies performed after a 4-week recuperation demonstrated leakage through the 30F, 1 cm. tunnel valve during reservoir filling (intra-reservoir pressure 19 cm. water). Increasing the tunnel length of the 30F system to 2 cm. (tunnel length-to-luminal diameter ratio 2:1) eliminated all evidence of valve leakage up to a maximal intra-reservoir pressure of 100 cm. water. CONCLUSIONS: These studies demonstrate the urodynamic characteristics of a new serosal lined valve. This easily constructed mechanism serves as a reliable antireflux (afferent) or continence (efferent) system.
Animals↗
The T pouch: an orthotopic ileal neobladder incorporating a serosal lined ileal antireflux technique.
PURPOSE: At our institution the Kock ileal neobladder has been the primary form of urinary diversion after cystectomy. The few associated complications are primarily related to the intussuscepted antireflux afferent limb, including stones, stenosis and extussusception of the afferent nipple. We present a novel orthotopic ileal neobladder, the T pouch, with an innovative antireflux technique designed to prevent complications of the intussuscepted afferent nipple. MATERIAL AND METHODS: From November 1996 through August 1997, 40 patients an average of 67 years old underwent construction of an orthotopic ileal neobladder (T pouch). Mean followup is 10.5 months (range 8 to 14). The T pouch incorporates an antireflux mechanism using a serosal lined ileal tunnel technique. Urinary reflux is prevented without ileal intussusception and with complete preservation of the blood supply to the afferent ileal segment. Followup in all cases includes clinical and functional results, and radiographic evaluation of the urinary reservoir and upper urinary tracts. RESULTS: One perioperative death (2.5%) and 5 early complications (12.5%) were unrelated to urinary diversion. There have been no late complications. All T pouch reservoirs had excellent capacity without evidence of urinary reflux. The upper urinary tracts remain unchanged or improved in all patients. CONCLUSIONS: The T pouch is an orthotopic ileal neobladder that incorporates an effective, innovative antireflux mechanism created by a serosal lined ileal tunnel. Early clinical and functional results of this type of urinary diversion have been excellent. Furthermore, we suspect that this antireflux technique may eliminate the complications associated with an intussuscepted afferent nipple and maintain an effective antireflux mechanism.
Adult↗
Prospective pathologic analysis of female cystectomy specimens: risk factors for orthotopic diversion in women.
OBJECTIVES: To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion. METHODS: Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra). RESULTS: Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. CONCLUSIONS: We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.
Adult↗
Adrenal cortical carcinoma associated with a splenic vein tumor thrombus.
A unique case is reported of a left adrenal cortical carcinoma with a splenic vein tumor thrombus. En bloc radical nephroadrenalectomy, distal pancreatectomy, splenectomy and splenic vein tumor thrombectomy were performed. Reconstruction of the proximal portal vein was required, incorporating a segment of the left renal vein (harvested from the surgical specimen) as a free interposition graft, bridging the defect between the superior mesenteric vein and portal vein. To our knowledge, this is the first reported case of an adrenal cortical carcinoma associated with a splenic vein tumor thrombus. In addition, the described technique used to reconstruct the proximal portion of the portal vein has not been previously reported.
Adrenal Cortex Neoplasms↗
Treatment of a ureteral stricture following failed management with ureteral wall stent.
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Constriction, Pathologic↗
An alternative ureteroileal reimplantation used in augmentation cystoplasty for neurogenic bladder with bilateral vesicoureteral reflux.
PURPOSE: We describe the use of a serous lined extramural tunnel for ureteral reimplantation during augmentation of a neurogenic bladder to prevent reflux. MATERIALS AND METHODS: A 46-year-old male C6 spinal cord injury patient presented with a high pressure bladder, detrusor-sphincter dyssynergia and bilateral grade II/III vesicoureteral reflux. Despite maximal anticholinergic therapy and intermittent catheterization, detrussor pressures were between 80 and 100 cm. water at volumes of 100 to 150 cc with consistent leakage between catheterizations. Preoperative ultrasound and voiding cystourethrogram demonstrated moderate bilateral hydronephrosis and a heavily trabeculated bladder. Augmentation cystoplasty with the formation of 3 cm. extramural ureteral tunnels as described by Ghoneim was performed. The serosa of the adjacent limbs of the ileal segment were opposed to form the back wall of a serosal lined tunnel. RESULTS: At 3 weeks postoperatively a cystogram demonstrated no extravasation or reflux. At 8 weeks an excretory urogram showed prompt function and excretion bilaterally with marked improvement of preoperative hydronephrosis. CONCLUSIONS: Subserosal ureteral tunnels can be used as an alternative antireflux technique during augmentation cystoplasty when ureteral reimplantation is required. Two advantages of this technique include the elimination of staples and avoidance of ischemic problems associated with an afferent intussuscepted nipple valve.
Humans↗
Hydronephrosis as a prognostic indicator in bladder cancer patients.
PURPOSE: Pathological stage is the standard measure of prognosis in patients who have undergone radical cystectomy for bladder cancer. Despite the development of new imaging techniques, clinical staging for bladder cancer continues to be inaccurate. We investigated whether the presence of unilateral or bilateral upper tract obstruction could accurately predict advanced cancer stage (extravesical extension, stage greater than p3b or N+). MATERIALS AND METHODS: A retrospective study of 415 patients diagnosed with transitional cell carcinoma of the bladder who were treated with radical cystectomy between 1983 and 1993 was conducted. All patients were followed for survival. The criteria for analysis included hydronephrosis status (no obstruction, unilateral, bilateral) as well as pathological stage of the tumor. RESULTS: Of 415 patients 72% presented with no, 22.7% unilateral and 5.3% bilateral obstruction. Our results showed a significant correlation between hydronephrosis and advanced cancer stage (p <0.0001), and decreased patient survival (p <0.0001). More than 90% of patients with bilateral obstruction had disease with extravesical extension. Of the patients with unilateral obstruction a third had disease confined to the bladder with a significant proportion confined to the bladder mucosa. CONCLUSIONS: The presence of unilateral or bilateral hydronephrosis is a clinical datum that is already available to help accurately stage bladder tumors. The presence of bilateral obstruction is an ominous sign, while a significant proportion of patients presenting with unilateral obstruction have disease confined to the bladder.
Carcinoma, Transitional Cell↗
25-year experience in the management of invasive bladder cancer by radical cystectomy.
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Aged↗
An acute scrotum following a laparoscopic appendectomy.
We report a case of a 13-year-old boy who developed an acute left hemiscrotum following a laparoscopic appendectomy for a perforated appendicitis. Laparoscopic techniques have provided surgeons and their patients with effective and less invasive methods to treat illness that previously required open surgery. However, complications can occur with these new surgical modalities. It is incumbent upon the surgeon to carefully document and evaluate these complications, facilitating preventive measures, and allow for a proper and timely diagnosis and treatment plan in the future. Herein, we present a previously unreported urologic complication of an acute scrotum following a laparoscopic appendectomy for a perforated appendicitis.
Adolescent↗
Salvage radical cystoprostatectomy and orthotopic urinary diversion following radiation failure.
PURPOSE: Salvage surgery followed by lower urinary tract reconstruction is a viable therapeutic option for patients in whom definitive radiation therapy for localized bladder or prostate cancer has failed. Improvements in surgical technique and postoperative care have significantly improved overall outcome. An enhanced understanding of the rhabdoid sphincteric mechanism responsible for maintaining urinary continence following cystoprostatectomy has helped make the orthotopic neobladder the procedure of choice for patients requiring lower urinary tract reconstruction. We describe our experience with salvage surgery and orthotopic bladder substitution following failed radical radiation therapy. MATERIALS AND METHODS: We evaluated the complications of 18 patients in whom definitive radiation therapy (total minimum dose 60 Gy. or greater) for bladder or prostate cancer had failed. All patients underwent a salvage procedure with creation of an orthotopic neobladder. RESULTS: Operative characteristics, postoperative outcomes and postoperative complications related or unrelated to urinary reconstruction were similar between irradiated and nonirradiated patients. Good day and night continence following surgery was reported by 67 and 56% of irradiated patients, respectively. Patients with poor postoperative continence were successfully treated with the placement of an artificial urinary sphincter. CONCLUSIONS: Salvage surgery with orthotopic urinary reconstruction is a safe, effective procedure that provides a functional lower urinary tract in patients in whom definitive pelvic radiation therapy has failed.
Aged↗