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PubMed1996

Ureteral frozen section analysis during cystectomy: a reassessment.

PURPOSE: Frozen section analysis of the distal ureteral margins is commonly performed at cystectomy to exclude involvement of tumor in retained ureter. We reviewed our experience with 101 consecutive cystectomies to determine the contemporary incidence and clinical significance of the urothelial abnormalities detected by frozen section analysis performed at operation. METHODS AND MATERIALS: The pathology reports for 101 patients treated with nerve sparing cystectomy between 1982 and 1989 were reviewed. Frozen section and final ureteral analyses were compared. RESULTS: Of the patients 8% had evidence of a urothelial abnormality ranging from mild atypia to frank carcinoma in situ involving the distal ureters on frozen section. Only 4 patients had documented carcinoma in situ at the final margin and all 4 ultimately died of disease. The frozen section false-positive and false-negative rates were 2 and 6%, respectively. In 6 patients with ureteral urothelial abnormalities documented on frozen section ureterointestinal anastomosis was performed despite persistent abnormalities at the ureteral margins, frequently after multiple frozen analyses failed to clear the margins definitively. None of the 6 patients in this group experienced upper tract recurrence during a mean followup of 41 months. CONCLUSIONS: These data suggest that routine frozen section analysis of the ureteral margins at cystectomy may not be necessary for most patinets undergoing cystectomy.

Adult↗
PubMed1996

[Infiltrating cancer of the bladder: can radiochemotherapy be an alternative to cystectomy?].

In order to improve the results obtained by cystectomy alone and to determine the possibilities of conservative treatment in invasive bladder cancer, we designed a prospective study using a combination of 5-FU--Cisplatin and concomitant radiation therapy, followed either by cystectomy or additional chemoradiotherapy. Sixty six patients (pts) with T2-T4 operable untreated invasive bladder cancer were entered into the study. Treatment was begun in all patients by trans-urethral resection (complete in 30 pts) and followed by 5-FU-Cisplatin combination with concomitant bifractionated split course radiation therapy. The neo-adjuvant irradiation dose was 24 Gy delivered in 8 fractions over 17 days, according to a modified bifractionated split course schedule. Each fraction delivered 3 Gy, twice on day (D1, D3, D15 and D17. The patients received concomitant Cisplatin (15mg/m2/d) and 5-FU (400mg/m2/d) on day D1, D2, D3 and D15, D16, D17. A control cystoscopy was performed six weeks after completion of the neoadjuvant program. Patients with persistent tumor underwent cystectomy. Complete responders were treated either by additional chemoradiotherapy (group A) or cystectomy (group B). At control cystoscopy, 51 of the 66 patients (77%) had histologically documented complete response. Among the 51 patients with complete tumor regression 31 were treated by conservative chemoradiotherapy and 20 underwent cystectomy. With a mean follow-up of 35 months, five responders developed recurrent pelvic disease (4/31 in group A and 1/20 in group B). Metastatic disease, which developed in 22 patients, occurred more frequently in the non responders (93%) than in responders (16%). Disease free survival at 5 years was 51%; it was significantly better in responders than in non responders. There was no difference in survival between groups A and B. This neoadjuvant chemoradiotherapy combination, easy to implement and well-tolerated even in elderly patients, provides a high CR rate. It may prove to be effective in inoperable patients and may be proposed as conservative treatment in patients with a complete response to the initial course of chemoradiation.

Adult↗
PubMed1997

[Infiltrating bladder tumor in a renal transplant patient: cystectomy with prostatic conservation and enterocystoplasty].

OBJECTIVE: The principles of treatment of de novo bladder tumours in renal transplant patients are comparable to those applied in non-transplant patients. In the case of an invasive tumour, techniques can be used to restore urinary tract continuity after cystectomy. A case of cystectomy with enterocystoplasty for invasive bladder tumour in a renal transplant patient is reported. MATERIAL AND METHODS: An invasive urothelial bladder tumour was discovered in a 62-year-old man, 3 months after a 2nd renal transplantation. Treatment consisted of cystectomy with prostatic preservation and nontubulized enterocystoplasty. RESULT: With a follow-up of 21 months after cystectomy, the patient is alive without recurrence. He is perfectly continent during the day, with normal sexual intercourse and no reflux or residual urine. Renal function is normal. CONCLUSION: Cystectomy with enterocystoplasty can be an effective treatment for invasive bladder tumour in renal transplant patients. This treatment ensures oncological control and acceptable comfort while preserving the transplant.

Carcinoma, Transitional Cell↗
PubMed1998

Presentation, methods of diagnosis and therapy for pelvic recurrence following radical cystectomy for transitional cell carcinoma of the bladder.

PURPOSE: We evaluated the presentation, methods of diagnosis and treatment of pelvic recurrence following radical cystectomy for transitional cell carcinoma of the bladder. MATERIALS AND METHODS: We reviewed the records of 33 patients who underwent radical cystectomy for transitional cell carcinoma between May 1960 and August 1995 at our cancer center and who later had pelvic recurrence. RESULTS: The majority of patients underwent cystectomy for clinically advanced transitional cell carcinoma. Median time from cystectomy to recurrence was 10 months. Of the patients 25 were symptomatic (76%) at the time recurrence was diagnosed. Recurrence was discovered by digital rectal examination in 4 asymptomatic patients (12%) and by routine pelvic imaging in 2. Treatment included chemotherapy, surgery or radiation (alone or in combination). Of the 33 patients 29 died of progressive disease with a median survival of 7 months from the time of recurrence, and 4 remained free of disease at 7, 14, 26 and 95 months after local recurrence. Despite the poor survival rate following treatment 11 of 14 patients had complete resolution of symptoms following chemotherapy. CONCLUSIONS: The prognosis of patients with local recurrence is poor regardless of therapy. These recurrences are often symptomatic but careful post-cystectomy tumor surveillance, including digital rectal examination and pelvic imaging, provides an opportunity to diagnose local recurrences when they may be amenable to therapy. Systemic chemotherapy offers excellent palliation for symptomatic patients.

Aged↗
PubMed1981

Bladder cancer in men and women treated by radiation therapy and/or radical cystectomy.

Four-hundred fifty-one patients with bladder cancer, 348 men and 103 women, were treated by radiation therapy and/or radical cystectomy during the last two decades at Memorial Sloan-Kettering Cancer Center. Radical cystectomy alone was the treatment in 98 men and 39 women. Radical radiation therapy to an average tumor dose of 6,000 rad in six weeks was given to 79 men and 30 women +/- one year before salvage cystectomy was done for recurrent or persistent tumors. Planned preoperative irradiation was delivered to the true pelvis either 4,000 rad in four weeks in 95 men and 24 women or 2,000 rad in one week in 76 men and 10 women +/- six weeks and two days, respectively, before radical cystectomy. Over-all survival and recurrence results in both sexes were similar, 40 per cent of men and 36 per cent of women were alive at five years without recurrence, 45 per cent of men and 48 per cent of women died in five or more years with local and/or distant recurrences, and 21 per cent of men and 15 per cent of women died before five years from causes other than cancer recurrence. Higher five-year survival for high clinical stage B2 to D1 tumors was noted similarly in the irradiated men (30 per cent) and women (37 per cent) than in the cystectomy alone patients (19 per cent in men and 4 per cent in women). Similar survival rates (52 to 57 per cent) were observed in men and women with low clinical stage O to B1 tumors treated with or without irradiation.

Adult↗
PubMed1985

Salvage cystectomy following failed definitive radiation therapy for transitional cell carcinoma of bladder.

Between 1971 and 1983 we performed 18 salvage cystectomies on patients with recurrent transitional cell bladder cancer initially treated with definitive radiation therapy (5,500-6,820 R). The interval between tumor diagnosis and radiation ranged from zero to twenty-one years (mean 3.5 years), and the interval between radiation therapy and cystectomy ranged between six months and twelve years (mean 2.5 years). Early major complications occurred in 5 patients, and there was one early and one late postoperative death. The overall patient survival from the time of diagnosis to death or the present (1985) ranged from two to thirty-one years (mean 9.8 years), and from the time of radiation to the present or death ranged from one to nineteen years (mean 6.2 years). The overall crude five-year survival from the time of cystectomy excluding 2 patients operated on in 1982 and 1983 was 50 per cent, however 3 of these patients died of cancer after five years. Breakdown of survival of these patients by stage demonstrated the best survival in patients with carcinoma in situ and Stage A or no neoplasm at the time of cystectomy. This report confirms the value of salvage cystectomy after radiation failure in invasive transitional cell bladder cancer.

Aged↗
PubMed1984

Upper urinary tract transitional cell cancer after radical cystectomy for bladder cancer.

We studied 425 patients who had undergone radical cystectomy for transitional cell cancer of the bladder and were followed for 5 years or more, or until death. Upper urinary tract urothelial cancer developed in 14 patients (3.3 per cent), 3 of whom had bilateral disease: 2 synchronous and 1 asynchronous. The interval between cystectomy and emergence of the upper tract tumor ranged from 8 to 100 months (mean 40 months). There was a declining incidence of upper tract cancer relative to cystectomy P stage for carcinoma in situ (9.1 per cent), papillary stages O and A (3.6 per cent), stages B1, C and D1 (2.6 per cent) and no residual cancer (0 per cent). Of the 14 patients 8 (57 per cent) had features of multifocal carcinoma in situ in the cystectomy specimens. In 4 of the 14 patients (29 per cent) ipsilateral disease developed when the distal ureteral margins were involved with cancer at cystectomy. Only 3 of the 14 patients (21.4 per cent), all with stage I disease, were alive at the time of this report.

Adult↗
PubMed1984

Indications for urethrectomy in men undergoing single stage radical cystectomy for bladder cancer.

During a 10-year period 174 consecutive male patients underwent radical cystectomy with pelvic lymph node dissection for transitional cell cancer of the bladder. Urethrectomy, either performed en bloc with the cystectomy or secondarily, was required in 23 patients. Of these 23 patients 9 died of metastatic disease and 4 deaths were believed to be directly related to development of tumor in the urethra. A careful review of our data suggests that patient selection is possible so that urethrectomy in all patients undergoing cystectomy may be avoided, while maintaining the ability to treat those at risk for carcinoma in the retained urethra before invasion occurs. We recommend the following indications for urethrectomy: 1) en bloc cystourethrectomy for clinically overt involvement of the anterior urethra with carcinoma or tumor extending into the prostatic urethra, 2) immediate or delayed total urethrectomy either during the initial hospitalization or within 2 months of cystectomy for all patients with pathological evidence of invasion of the prostate (P4) or carcinoma in situ of the prostatic urethra, 3) indefinite close followup of all patients whose bladder specimens demonstrate carcinoma in situ (urethral cytology within 4 months of cystectomy and every year thereafter, and immediate total urethrectomy for any urethral cytology positive for malignant cells), and 4) immediate total urethrectomy for any patient experiencing bloody urethral discharge.

Carcinoma in Situ↗
PubMed1978

Radical cystectomy for carcinoma of the bladder.

A personal series of 50 radical cystectomies has been reviewed to decide whether it is a justifiable operation and, if so, when it should be performed. In spite of the fact that radical cystectomy had a higher operative mortality than simple cystectomy and was sometimes followed by lymphoedema, in patients with invaded iliac lymph nodes it was followed by a 25% 5-year survival. It appears, therefore, to be a justifiable procedure. It is recommended that simple cystectomy should be performed for patients with papillomatosis, carcinoma in situ, and as a salvage procedure after radiotherapy has failed, and that radical cystectomy should be reserved for elective cases in of invasive vesical tumours, and for those patients who are found at exploration to have obvious metastic deposits in the iliac lymph nodes.

Adult↗
PubMed1982

Factors influencing salvage cystectomy results.

Analysis of 86 patients who underwent salvage cystectomy following a radical course of radiotherapy for bladder cancer and 37 patients who underwent primary cystectomy has shown a greater survival for women than men. The following factors were associated with a significant deterioration in survival: 1. Age at time of cystectomy: post-operative mortality and tumour recurrence are greater over the age of 70. 2. Non-function of one kidney on IVU. 3. Grade 3 tumour on cystectomy specimen. 4. pT3 or pT4 tumour on cystectomy specimen.

Age Factors↗
PubMed1982

The effects of radiotherapy on the integrity of the ureteroileal segment following cystectomy.

Thirty-nine patients treated by cystectomy and ileal loop diversion for carcinoma of bladder were divided into 3 groups: A. cystectomy alone, B. cystectomy combined with pre-operative irradiation, C. Salvage cystectomy following radical radiotherapy. The post-operative complications and subsequent function of the ureteroileal segment of the urinary diversion were compared in the 3 groups. Those having primary cystectomy had the fewest complications and best long-term function, whilst those having surgery within 12 months of radical radiotherapy had the highest incidence of ureteroileal obstruction. The possible aetiology is discussed.

Female↗
PubMed1987

Invasive bladder cancer. Should patients who respond to radiotherapy be treated by cystectomy?

A retrospective study was carried out on the long-term survival (5-12 years) of 160 patients with invasive transitional cell cancer of the bladder treated with irradiation between 1972 and 1980. Following 40 Gy irradiation of the lower abdomen, treatment consisted of cystectomy or continued irradiation of the bladder region only. A full urological examination of the bladder established whether a patient was a responder or non-responder. The patients were divided into four groups: 27 responders treated with cystectomy and diversion; 48 responders treated with continued radiotherapy up to 65 Gy; 24 non-responders treated with cystectomy and diversion; 42 non-responders treated with continued radiotherapy up to 65 Gy. Survival and complications of treatment were compared with regard to category and grade of the tumours and sex and age of the patients. It was concluded that the responders who underwent cystectomy after 40 Gy irradiation survived longer than those who received a full course of radiotherapy. The responders had a better survival rate than non-responders, regardless of further treatment. Salvage cystectomy was rarely carried out and proved to be an unsatisfactory alternative, with a high operative risk and short survival.

Aged↗
PubMed1988

Transitional cell carcinoma of the urethra in men after radical cystectomy for bladder cancer. Is prophylactic urethrectomy indicated?

A retrospective study of the incidence and clinical course of transitional cell carcinoma of the urethra is reported. Of 110 consecutive male patients who underwent cystectomy during a 9-year period, 9 had or developed a urethral tumour. Five patients undergoing radical cystectomy had known or suspected urethral involvement which was confirmed at urethrectomy. All 5 had deeply invasive (T3 or T4) transitional cell carcinomas of the bladder and subsequently died of metastatic disease. Four patients underwent urethrectomy because of signs or symptoms of urethral recurrence at an average interval of 2.5 years after cystectomy. There were two deaths in this group, neither of which appeared to be due to urethral recurrence. Six additional patients had undergone prophylactic urethrectomy because of prostatic urethral involvement or diffuse carcinoma in situ in the cystectomy specimen, and none had identifiable tumour in the anterior urethra. The residual urethra is a potential focus for recurrent tumour and this necessitates careful follow-up with serial cytology, but the low incidence of urethral recurrence (3.5% in this series) does not appear to warrant routine urethrectomy at the time of cystectomy.

Aged↗
PubMed1987

Radical cystectomy--often too late?

From 1967 to 1985, 246 cystectomies for treatment of transitional cell carcinoma of the urinary bladder were performed. Perioperative mortality decreased from 15% in the early years to 0% in 1985. Preoperative radiotherapy was not given. Patients who underwent cystectomy immediately following the diagnosis of invasive bladder carcinoma had a significantly better prognosis than those having cystectomy after recurrence of a transurethrally resected invasive carcinoma in spite of identical G and T criteria. A total of 26 patients who were cystectomized because of tumor recurrence after definitive radiotherapy (salvage cystectomy) represented the group with the worst prognosis: they had a 5-year survival rate of less than 10%. It is concluded from these results that recurrence of an infiltrating bladder tumor is an indication of poor prognosis. Early cystectomy after diagnosis of tumor infiltration can improve survival rates. Transurethral resection without adjuvant therapy cannot be regarded as reliable curative treatment of bladder cancer infiltrating the lamina propria (pT1). Modern surgical techniques of continent urinary diversion or total bladder replacement combined with sparing of the pelvic nerves (and thus preservation of potency) reinforce our view that radical cystoprostatectomy need no longer be regarded as mutilating surgery.

Carcinoma, Transitional Cell↗
PubMed2001

Molecular determination of perivesical and lymph node metastasis after radical cystectomy for urothelial carcinoma of the bladder.

PURPOSE: Current methods used to determine the pathological stage of the primary tumor and associated lymphatics after radical cystectomy are tedious, costly, and may lack the sensitivity afforded by molecular approaches such as reverse transcription-PCR (RT-PCR) for markers specific for urothelial tissue such as the uroplakin II (UPII) gene. Thus, we sought to evaluate an objective and sensitive molecular approach for the assessment of perivesical extension and lymph node status after radical cystectomy, based on the detection of UPII expression using RT-PCR and compare this assay to standard clinical and pathological examination. EXPERIMENTAL DESIGN: From November 1999 to September 2000, 27 patients with clinical T(a)-T(3)N(0)M(0) urothelial bladder cancer underwent radical cystectomy, 19 (70%) of which also had pelvic lymphadenectomy. At the completion of cystectomy, systematic biopsies of the external surface of the bladder specimen as well as from the largest palpable lymph node found at lymphadenectomy were obtained for molecular analysis. RT-PCR analysis for UPII mRNA was carried out on these biopsy specimens, and results were compared with data obtained from conventional pathological examination. RESULTS: Pathologically organ-confined tumors had a 42% (5 of 12) incidence of positive signals in the perivesical tissues and 17% (1 of 7) in the lymph nodes. Corresponding percentages for pT(3a)N(0) and pT(3b)-T(4)N(0) lesions were 67% (4 of 6)/25% (1 of 4) and 67% (4 of 6)/33% (2 of 6), respectively. Overall, pathologically node-negative cancers had a perivesical positivity rate of 54% (13 of 24) and a lymph node positivity rate of 25% (4 of 16). All patients with pathologically positive nodes had positive UPII signals in the lymph node sample. CONCLUSIONS: This molecular assay aimed at assessing perivesical extension and lymph node status after radical cystectomy appears to identify patients that may harbor residual disease not appreciated by conventional histology. Larger studies with 5-7-year follow-up will be required to determine the prognostic significance of such molecular information.

Aged↗
PubMed1988

Radical prostato-cystectomy for infiltrating bladder carcinoma using a combined abdomino-perineal approach.

Radical abdomino-perineal cystectomy was used in 23 Pts with Tis to T4 bladder tumors, 12 of whom had previously been submitted to radical Radiotherapy (salvage cystectomy). The perineal approach greatly facilitated the prostatic dissection in 10 cases, in which it was considered extremely hazardous from the abdomen. There were two post-operative deaths from acute myocardial infection in patients over 70. Prolonged drainage of the perineal wound occurred in four Pts. Abdomino-perineal cystectomy is not a routine procedure and should be considered in two settings: in the case of salvage cystectomy when Radiotherapy - induced desmoplastic reactions make the dissection of the prostate from the rectum hazardous, and when urethrectomy is mandatory and the patients status requires an expeditious procedure. Although the early cystectomies for bladder carcinoma were performed using a combined perineo-abdominal or abdomino-perineal approach (Couvelaire 1948, Hinman 1939, Wilhem 1947), this procedure has fallen into disuse since the early 1950's in favor of the suprapubic approach. Nevertheless, the combined abdomino-perineal procedure offers three advantages: 1) better exposure of the urethra, prostatoseminal pedicles, and puboprostatic ligaments, 2) total urethrectomy can be done at the same time, 3) drainage through the perineal incision is excellent. These advantages are maximized when two surgeons operate simultaneously through the perineal and suprapubic incisions (Ameline 1948, Boccon-Gibod 1979, Boccon-Gibod 1984, Crawford 1980, Pascal 1974).

Adult↗
PubMed1997

[A clinical study of arthroscopic cystectomy on popliteal cysts associated with rheumatoid arthritis].

PURPOSE: We performed a prospective study of arthroscopic cystectomy on popliteal cysts associated with rheumatoid arthritis. MATERIALS: We performed arthroscopic cystectomy on three patients, four knees, and an open excision of a cyst on one patient, one knee, who had pain and swelling in the popliteal region. Of these five rheumatoid knees, three were grade I on the Larsen radiographic scale, one was II, and one was III. OPERATIVE METHOD: First, we performed synovectomy on the posterior compartment using a multi-portal approach. Second, we confirmed a small communication hole between the posterior compartment and the Popliteal cyst after the synovectomy with an angled arthroscope through the anterior compartment. Third, we enlarged the communication hole and performed a cystectomy (the excision of the membranous septum and the contents of the cyst) from the inside by using a motorized shaver. Finally, we performed a synovectomy on the anterior compartment. The follow-up period ranged from 1 year 6 months to 3 years, 4 months (the mean was 2 years, 4 months). EVALUATION: We assessed the results using objective oriteria based on the evaluation of swelling, pain and subjective criteria based on the evaluation of the range of motion of the knee and confirmation of the disappearance of the cyst using MRI. RESULT: We had good results in this study. All the four knees on which the arthroscopic cystectomy was performed had a reduction of pain and swelling right after the operation. The absence of the cyst was verified using MRI. We had no patient whose ROM was aggravated. However, synovitis and popliteal cysts reoccurred in one knee after the open excision (this case had the vasculitis, larsen grade III radiographically, and severe rheumatism). DISCUSSION: The recurrence rate of the popliteal cyst was very high (over 50%) when a cyst was performed open exision using a posterior approach. Open synovectomy of an anterior compartment needed the manipulation in several cases because of limited knee movement. We had a reduction in pain and a disappearance of the cyst right after operation. Further more, there was no restriction in ROM resulting from this operative method. CONCLUSION: Arthroscopic cystectomy is a superior procedure for treating the popliteal cysts associated with rheumatoid arthritis.

Arthritis, Rheumatoid↗
PubMed1994

Results of radical cystectomy for transitional cell carcinoma of the bladder and the effect of chemotherapy.

BACKGROUND: Radical cystectomy continues to be one of the primary modalities of treatment for locally advanced bladder cancer. However, long-term survival after cystectomy has improved only marginally in the last decade, and still, nearly half of the patients die from the disease within 5 years. Adjuvant treatments such as radiation therapy and chemotherapy have been used, but a clear advantage has not been demonstrated. METHODS: The authors reviewed 130 patients who underwent radical cystectomy by the same surgeon as treatment for transitional cell carcinoma of the bladder. Morbidity, postoperative mortality, overall survival time, and accuracy of clinical staging as well as the effect of perioperative chemotherapy were evaluated. RESULTS: The overall actuarial survival rate at 2, 5, and 10 years was 80%, 53%, and 45%, respectively. The survival rate based on T-classification at 5 years was 82%, 65%, and 28% for less than pT2, pT2, and greater than pT2, respectively. Regional lymph node status had a significant effect on survival. The 5-year survival rate for all patients with negative nodes was 65%, whereas patients with positive nodes had a 18% 5-year survival rate. The overall clinical staging error was 61.5%, with 41.5% of the cancers understaged. Of the patients with cTis, 60% were found to be of greater extent than pT1 tumors. No apparent survival advantage was noted for those patients who received perioperative chemotherapy when compared with patients who were followed conservatively or received chemotherapy upon relapse. These results, however, are not conclusive because this was an observation study and the number of patients was limited. CONCLUSIONS: Only a modest improvement in survival time after radical cystectomy has been observed in the last decade, despite the use of adjuvant treatments such as radiation and chemotherapy. The pathologic (pT) classification is the most accurate prognostic indicator. Clinical errors in classification are common and impair the evaluation of neoadjuvant treatments. A high incidence of invasive tumors of greater extent than pT1 was found among patients with clinical cTis; this supports an aggressive approach when these patients do not respond promptly to intravesical chemotherapy. Prospective randomized studies are needed to evaluate objectively the benefit of perioperative adjuvant treatment in locally advanced transitional cell carcinoma of the bladder.

Aged↗