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PubMed2003

An interval longer than 12 weeks between the diagnosis of muscle invasion and cystectomy is associated with worse outcome in bladder carcinoma.

PURPOSE: The standard of care for muscle invasive transitional cell carcinoma of the bladder is radical cystectomy. Definitive therapy may often be delayed for various reasons. We assessed whether pathological stage and survival correlated with the length of time between diagnosis of muscle invasion and cystectomy. MATERIALS AND METHODS: The records of 290 consecutive patients who underwent radical cystectomy between February 1987 and July 2000 were reviewed. Of 265 (91.4%) cystectomies performed for transitional cell carcinoma data were available for 247 (85.2%) and 189 (65.2%) patients were identified who underwent surgery for muscle invasive disease (T2 or greater). The interval between diagnosis of muscle invasion and cystectomy was calculated for each patient. Patients were divided into groups based on time to surgery as group 1-less than 4 weeks, 2-4 to 6 weeks, 3-7 to 9 weeks, 4-10 to 12 weeks, 5-13 to 16 weeks, and 6-greater than 16 weeks. Exploratory univariate and multivariate analyses were performed to test the association of time lag with clinical features and postoperative survival. RESULTS: Mean patient age was 66 years (range 37 to 84) and overall 3-year Kaplan-Meier estimated survival was 59.1% +/- 4% (median followup 36 months). For all patients mean interval from diagnosis to cystectomy was 7.9 weeks (range 1 to 40). Extravesical disease (P3a or greater) or positive nodes were identified in 84% (16 of 19) of patients when the delay was longer than 12 weeks, compared with 48.2% (82 of 170) in those with a time lag of 12 weeks or less (p < 0.01). Similarly 3-year estimated survival was lower (34.9% +/- 13.5%) for patients with a surgery delay longer than 12 weeks compared to those with a shorter interval 62.1% +/- 4.5% (hazards ratio 2.51, 95% CI 1.30-4.83, p = 0.006). When adjusted for nodal status, and clinical and pathological stages the interval was still statistically significant (adjusted hazards ratio 1.93, 95% CI 0.99-3.76, p = 0.05). CONCLUSIONS: In patients undergoing radical cystectomy a delay in surgery of greater than 12 weeks was associated with advanced pathological stage and decreased survival. Although this relationship persisted after adjusting for nodal status, and clinical and pathological stages, the presence of lymph node metastasis remained the strongest predictor of patient outcome.

Adult↗
PubMed2002

Incidental appendectomy during radical cystectomy--is it necessary?

OBJECTIVES: To evaluate the rationale behind incidental appendectomy during radical cystectomy. Incidental appendectomy during radical cystectomy is done to avoid the morbidity due to the future development of appendicitis and an additional operation. METHODS: We performed a retrospective review of 105 patients who underwent radical cystectomy during an 8-year period (1986 to 1993). Appendectomy was incorporated in the initial 40 radical cystectomies and was avoided in the next 65 radical cystectomies. RESULTS: We had a median follow-up of greater than 10 years in patients who underwent appendectomy along with radical cystectomy and of more than 7 years in patients in whom appendectomy was avoided. None of the patients from either group had any complication related to the appendicular pathologic findings. CONCLUSIONS: The data from this study suggest that no advantage exists in persisting with incidental appendectomy during radical cystectomy.

Adult↗
PubMed2003

Radical cystectomy for bladder cancer after definitive prostate cancer treatment.

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

Aged↗
PubMed2004

Hand assisted laparoscopic radical cystectomy for cancer bladder.

AIM: To evaluate the efficacy, safety and feasibility of hand assistance in performing laparoscopic radical cystectomy and to describe our point of technique of hand assisted laparoscopic radical cystectomy (HALRC) with extra-corporeal ileal conduit reconstruction for muscle invasive bladder cancer. This is the second case report of HALRC in the world literature. METHODS: A five-port transperitoneal laparoscopic approach with an indigenous hand port was used to perform the radical cystectomy in a patient with muscle invasive TCC of bladder. After specimen retrieval, ileal conduit reconstruction was performed extra-corporeally through the site of hand port incision. RESULTS: HALRC was successfully completed in 4.3 hrs and the patient was discharged on the 7th day. The blood loss was 500 ml, and patient was transfused 2 units of blood, as the pre operative hemoglobin was 9 gms%. The analgesic requirement was 350 mgs of Pethidine (equivalent to 35 mgs of Morphine) and 450 mgs of oral Diclofenac Sodium. It took about 23 days for patient to resume normal activity. The histopathology was reported as T3b, left perivesical margin was positive and 2/5 of left pelvic lymph nodes were also involved. However, 7 lymph nodes removed from the right side did not show any disease. In view of histopathology report patient was given 4 cycles of postoperative chemotherapy, At the current follow up of 25 months the patient is free of any recurrence of disease. CONCLUSION: This case demonstrates the applicability of hand port assistance in to the laparoscopic field inside the abdomen, which helps in retraction and performing blunt dissection coupled with tactile sensation. It is feasible to use hand during laparoscopic radical cystectomy. Its usefulness has to be weighed against the standard laparoscopic radical cystectomy and additional time required for set up and the added cost. The technical success rate currently for standard laparoscopic radical cystectomy clearly demonstrates that hand assistance is not necessary. But, just as its applicability is being investigated, its role should be assessed in larger series of laparoscopic radical cystectomy.

Aged↗
PubMed2005

Costs of radical cystectomy.

OBJECTIVE: The total costs of radical cystectomy comprise a significant part of the total costs of bladder cancer treatment. The aims of this study were to determine the costs of cystectomy, with and without complications, and to investigate related prognostic factors. MATERIAL AND METHODS: The clinical records and relevant economic files of 70 consecutive patients operated on between 1994 and 1998 were studied. Uni- and multivariate analyses were performed on 22 variables of possible prognostic significance to high total costs. RESULTS: The total (median) costs for 53 uncomplicated and 17 complicated cystectomies were 181,096 and 290,625 SEK, respectively. The preoperative variables (patient characteristics) had no or minimal prognostic significance for high total costs. High peri-operative blood loss was the most important factor associated with high total hospital costs for radical cystectomy. CONCLUSIONS: Total costs may be very high for a cystectomy with complications. Peri-operative blood loss was the most important factor associated with high total hospital costs for radical cystectomy due to bladder cancer. If the amount of bleeding can be influenced then substantial reductions in the total costs of cystectomy would seem possible.

Aged↗
PubMed2000

Preoperative concurrent chemoradiotherapy against muscle-invasive bladder cancer: results of partial cystectomy in elderly or high-risk patients.

BACKGROUND: Good local control has been reported in cases of muscle-invasive bladder cancer treated by chemoradiotherapy and transurethral resection (TUR). However, definitive irradiation or extensive chemotherapy is often intolerable for elderly or poor-risk patients. We report here benefits of partial cystectomy after concurrent low-dose chemoradiotherapy for high-risk patients. METHODS: Thirty-seven patients with localized muscle-invasive bladder cancer (T2-T4) were treated with concurrent cisplatin (50-100 mg/body x 2 courses) and pelvic irradiation (40 Gy) preoperatively. Among 17 patients (46%) who achieved complete response (CR), 10 were not suitable for radical cystectomy and underwent partial cystectomy. Radical cystectomy was performed in 24 cases [CR = 6, partial response (PR) = 18]. Two patients (one CR and one PR) rejected open surgery and were treated by TUR of the primary site. One no change (NC) patient received no further treatment because of mental disorder. RESULTS: Median follow-up was 12 months (range 2-37 months). Fifteen of 36 evaluable cases (42%) achieved a pathological T0 response (no residual tumor). Estimated 3-year disease-free survival was 56% for all patients and 100% for T0 responders. Seven of 21 patients with pathological persistent tumor developed local recurrence (three patients) or distant metastasis (four patients). All of the 10 patients (eight with T0 response and two with a small residual tumor nest) who underwent partial cystectomy were recurrence-free for an observation period of up to 3 years. CONCLUSIONS: Bladder preservation by partial cystectomy may be a choice for patients who show a good response to preoperative chemoradiotherapy and are not suitable for radical cystectomy.

Aged↗
PubMed2004

The management of urethral transitional cell carcinoma after radical cystectomy for invasive bladder cancer.

PURPOSE: Previous reports have identified risk factors for urethral recurrence following radical cystectomy for transitional cell carcinoma (TCC). However, reports of the clinical presentation, treatment and outcome in these patients are lacking. We report our experience with the diagnosis, management and outcome of urethral TCC after radical cystectomy for bladder cancer. MATERIALS AND METHODS: A database of 1,054 patients who underwent radical cystectomy and urinary diversion for TCC from 1971 to 1997 was retrospectively reviewed. All patients with urethral TCC after surgery were identified. RESULTS: Urethral TCC was diagnosed in 47 men a median of 18.5 months (range 2 to 116) after cystectomy with 20 (42%) diagnosed within 1 year. Symptomatic recurrence developed in 24 of 42 evaluable patients (57%), 21 had bloody urethral discharge and 7 had pain or a palpable mass. A total of 13 patients (31%) were asymptomatic with abnormal cytology. The remaining 5 patients underwent prophylactic urethrectomy based on cystectomy pathology. Overall 41 patients underwent urethrectomy, which was total in 36 and distal with perineal urethrostomy in 5, including later conversion to total urethrectomy in 2. Overall at a median followup of 26 months (range 3 to 275) since diagnosis 36 of 47 patients (76%) were dead, including 25 of metastatic disease. Only 10 patients (21%) remained disease-free. Median overall survival in patients with urethral TCC after radical cystectomy was only 28 months after the diagnosis of urethral TCC. Urethral stage (superficial vs invasive disease) at diagnosis was the most import predictor of overall survival in this cohort of patients. CONCLUSIONS: Most patients with urethral recurrence present with symptoms. However, screening cytology alone still detects a significant proportion. The median survival of patients with urethral TCC after radical cystectomy is only 28 months after diagnosis. Urethral stage (superficial vs invasive disease) at diagnosis is the most import predictor of overall survival in this cohort of patients.

Adult↗
PubMed2004

Complications of laparoscopic radical cystectomy during the initial experience.

AIM: Radical cystectomy is the standard of care for patients with muscle invasive bladder cancer. While open radical cystectomy is now a standard procedure, laparoscopic radical cystectomy is still in its infancy. We performed this surgery laparoscopically in 11 patients and review the procedure specific complications. METHODS: Beginning in February 1999, 11 patients underwent laparoscopic radical cystectomy at the Department of Urology, All India Institute of Medical Sciences, New Dehli. Urinary diversion was performed by an open-hand sewn ileal conduit. RESULTS: There were three intraoperative complications specifically related to the laparoscopic radical cystectomy. These included injury to the external iliac vein in one patient and a small rectal tear in two. All were repaired with laparoscopic free hand suturing with normal postoperative recovery. Other laparoscopy-related complications were subcutaneous emphysema in one patient and hypercarbia necessitating conversion to open surgery in a patient who, four weeks after surgery, died of multiple organ failure. One patient had margins positive and received cisplatinum-based chemotherapy. All patients had normal renal function and preserved upper tracts with no evidence of metastasis at a mean of 18.4 months follow up (range 1-48 months). CONCLUSIONS: Though there were three complications specific to the laparoscopic radical cystectomy, none necessitated a conversion to open surgery or hampered the overall outcome. Absence of local recurrence or metastatic disease at four years of follow up suggests that the procedure is oncologically valid. Laparoscopic radical cystectomy is a new procedure and it is important to critically analyze the complications in order to reduce their occurrence and allow the development of a better technique.

Adult↗
PubMed2004

Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer.

OBJECTIVE: To evaluate the long-term results of salvage cystectomy after interstitial radiotherapy (IRT) and external beam radiotherapy (EBRT) for transitional cell carcinoma, and to assess the morbidity and functional results of the different urinary diversions used. PATIENTS AND METHODS: The records of 27 patients treated with salvage cystectomy in one institution between 1988 and 2003 were retrospectively analysed. RESULTS: Salvage cystectomy was used after failure of IRT in 14 or EBRT in 13 patients, with a 3- and 5-year survival probability of 46% (95% confidence interval 26-65) and 33 (11-54)%. The 5-year overall survival after cystectomy was 54% after IRT and 14% after EBRT (P = 0.12). Tumour category, response to radiation, American Society of Anesthesiology score, and complete tumour resection had a significant influence on survival. Five of seven patients with incomplete resection died because of local disease, with a median survival of 5 months. There was clinical understaging after radiotherapy in 41% of patients. Nine patients had an orthotopic neobladder, with complete day- and night-time continence in eight and four, respectively. All patients but one had good voiding function. There were early complications in two and late complications in six patients (for Bricker, seven of 14 and none; for Indiana, none of four and two of four). The duration of hospitalization was not influenced by the type of diversion. Erectile function was maintained in four of six patients after a sexuality-preserving cystectomy and neobladder. CONCLUSIONS: Salvage cystectomy can be performed with acceptable morbidity using any type of urinary diversion. Understaging after radiotherapy is common, but preoperative selection needs improving. A very significant factor for an adverse outcome and death from local tumour recurrence was incomplete resection, suggesting that salvage cystectomy should only be attempted if complete resection is probable.

Adult↗
PubMed2004

Survival rates after radical cystectomy according to tumor stage of bladder carcinoma at first presentation.

INTRODUCTION: The aim of this study was to establish to what extent the survival rates of muscle-invasive bladder carcinoma are influenced by the tumor stage at initial presentation. PATIENTS AND METHODS: This study examined the clinical course of 230 patients who underwent radical cystectomy for bladder carcinoma from 1992 to 2002. The patients were divided into three groups according to the histological results of the initial and final transurethral tumor resection (TURB). In group 1 (n = 41) radical cystectomy was carried out for a superficial bladder carcinoma which had a high likelihood of progressing. Group 2 (n = 57) consisted of patients who displayed a superficial tumor stage when they first presented and developed progressive muscle-invasive bladder carcinoma under conservative treatment. Group 3 (n = 132) was made up of patients who were already at the muscle-invasive tumor stage in the course of primary TURB. The histopathological characteristics of all transurethral tumor resections and radical cystectomy were recorded. Progression-free survival and overall survival in the three groups were then compared. RESULTS: The average patient age when cystectomy was carried out was 63.9 (35-80) years and the average follow-up period was 38 months. An average of 2.3 (1-16) transurethral tumor resections were carried out before radical cystectomy (median = 1). Progression-free survival and overall survival of all 230 patients was 54 and 50%, respectively, after 5 years. The best result was a 74% progression-free 5-year survival rate with organ-confined lymph node-negative tumors (n = 106) which was statistically significant (p = 0.0004) compared to the progression-free 5-year survival rate of 50% for non-organ-confined, lymph node-negative tumors (n = 64). Lymph node-positive patients achieved a progression-free survival rate of 21% after 5 years regardless of the tumor infiltration. Patients in group 1 achieved a progression-free 5-year survival rate of 77% and an overall survival rate of 63% after 5 years. In group 2 patients achieved a progression-free survival rate of 51% after 5 years and an overall survival rate of 50%. In the case of primary muscle invasion (group 3), progression-free survival and overall survival were 49 and 46%, respectively, after 5 years. There was no significant difference between groups 2 and 3 with regard to their progression-free or overall survival rates (p > 0.35). However, both groups displayed a significantly poorer progression-free and overall survival rate compared with group 1 (p < 0.01). CONCLUSION: Our results show that superficial bladder carcinoma with tumor progress to muscle invasion does not have a better prognosis after radical cystectomy than initial muscle-invasive bladder carcinoma. Survival rates in this group can only be improved by singling out patients on the basis of risk factors at an earlier stage and carrying out a cystectomy.

Adult↗
PubMed2006

Optimal nutrition should improve the outcome and costs of radical cystectomy.

INTRODUCTION: Nutritional support has been demonstrated to improve recovery from radical cystectomy, but is expensive and when used inappropriately may actually increase the costs and morbidity of surgery. We sought to establish national patterns of practice with regard to feeding following cystectomy in the UK. AIMS AND METHODS: Following consultation with the specialist nutrition team, a questionnaire was designed to investigate the feeding strategy after cystectomy and dispatched by post to all UK urologists. RESULTS: The majority (60%) of respondents employed a traditional strategy of resting the bowel and feeding orally after bowel recovery. A minority used either early total parenteral nutrition (TPN; 18.5%) or enteral nutrition (6.5%), but a larger proportion (29%) felt enteral nutrition was the 'optimal' feeding regime. Only 30% used guidelines and 52% felt trials would help to establish a nutrition strategy following cystectomy. CONCLUSION: There is little evidence that TPN improves the outcome of cystectomy and it may actually increase morbidity and costs, whereas enteral nutrition may improve recovery. Despite this evidence TPN is widely used by urologists whereas enteral nutrition is used infrequently. Implementation of an evidence-based feeding regime after cystectomy is likely to reduce the morbidity and financial costs of cystectomy.

Costs and Cost Analysis↗
PubMed2001

Sexuality preserving cystectomy and neobladder: initial results.

PURPOSE: Standard cystectomy for bladder cancer in males and females includes removal of organs that are vital to normal sexual function. We report the initial results of modified cystectomy in males and females meant to preserve all sexual function, called sexuality preserving cystectomy and neobladder. MATERIALS AND METHODS: Sexuality preserving cystectomy and neobladder consists of pelvic lymph node dissection followed by cystectomy alone with preservation of the vasa deferentia, prostate and seminal vesicles in males, and all internal genitalia in females. An ileal neobladder is anastomosed to the margins of the prostate in males and urethra in females. Indications for this type of surgery are bladder cancer stages T1-T3 with absent tumor growth in the bladder neck in males and females, absent tumor in the prostatic urethra in males and absent invasive tumor in the trigone in females. Further requirements are patient motivation for the preservation of sexual function, no prostate cancer and no cervical/uterine abnormalities. Preoperative evaluation in males involves prostate specific antigen measurement and transrectal ultrasound with sextant prostate biopsies, while females undergo gynecological examination with a cervical smear and transvaginal ultrasound. Voiding and sexual function are assessed by a structured interview with preoperative urodynamics. Erectile function is evaluated by RigiScan (UroHealth Systems, Inc., Laguna Niguel, California) nocturnal penile erection measurement. A short course of 20 Gy. external radiation therapy to the bladder is given shortly before surgery. No patient has been lost to followup, which involves repeat RigiScan examination and regular endoscopy. All patients were entered in a prospective clinical trial approved by the medical ethics committee. RESULTS: From 1995 to 1998, 10 males and 3 females 38 to 71 years old (mean age 55) were enrolled in this protocol. Bladder cancer was stage T carcinoma in situ N0M0 in 1 case, Ta multiple grade 3 N0M0 in 1, T1 multiple grade 3 N0M0 in 4, T2 grade 3 N0M0 in 5, T2 grade 3 N1M0 in 1 and T3 grade 3 N1M0 in 1. Mean followup was 3.5 years (range 3 to 6). Two patients died of widespread metastasis without local recurrence. In 1 case prostate cancer developed 5 years after sexuality preserving cystectomy and neobladder, which was treated with external radiation therapy. Erection was normal in 7 men with antegrade ejaculation in 5 and vaginal lubrication was reported to be normal in all women. Daytime continence was achieved in 9 of the 10 males and 2 of the 3 females, while nighttime continence was achieved in 7 and 2, respectively. One woman and 3 men perform intermittent catheterization because of post-void residual urine after voiding. Postoperatively a vaginal fistula and ureteral stenosis developed in 1 case each. CONCLUSIONS: Sexuality preserving cystectomy and neobladder achieves maximal tissue conservation, resulting in preserved normal sexual function and satisfactory urinary tract reconstruction. Using strict criteria oncological results have not been jeopardized to date.

Adult↗
PubMedDate not supplied

[Radical cystectomy for superficial tumors in the BCG era].

OBJECTIVE: To analyze the indications and outcome of cystectomy for superficial bladder cancer since the introduction of BCG therapy. METHODS: From June 1990 to December 1996, 384 patients underwent cystectomy for transitional cell bladder tumor. A retrospective study was carried out on 43 cases (11.1%) that underwent cystectomy for Tis, Ta, T1 tumors. The characteristics of patients with superficial bladder cancer, correlation between the clinical stage (determined after TUR) and pathological findings (cystectomy specimen) and outcome were analyzed. RESULTS: 36 patients were male and 7 were female; mean age 63 years (range 39-79). Mean follow-up was 48 months (8-120). Twenty-nine patients received BCG therapy prior to surgery. No response to BCG was the main indication for cystectomy. By clinical stage, 79% were high grade, 65% T1 and 65% CIS. A correlation between the clinical stage and the pathological findings was found in 32.5%, overstaging in 28% and understaging in 39.5%. The increase in stage after analysis of the surgical specimen in 13 patients (30%) was due to progression of the superficial bladder tumor to infiltrating or metastatic tumor. Urinary tract tumor was found during follow-up in 8 patients (18.6%). Eleven patients died of bladder cancer, 3 of other causes and 29 (67%) are free of disease. Seven of the 13 patients (53%) that were clinically understaged and had infiltrating tumor or metastasis died. CONCLUSIONS: No response to BCG therapy was the main indication for cystectomy. Before starting conservative treatment for high risk superficial bladder cancer, the possibility of endoscopic understaging should be taken into account. Patients undergoing cystectomy for superficial bladder cancer have a high risk of developing urinary tract tumor.

Adult↗
PubMed1996

[Analysis of 34 cases of infiltrating carcinoma of the bladder treated exclusively with partial cystectomy (part 1)].

OBJECTIVES: The widely accepted and, until recently, the only alternative in muscle-infiltrating transitional cell carcinoma of the bladder, whatever the extent of muscle infiltration, has been radical cystectomy, although the advantages of partial cystectomy has not been questioned. METHODS: We reviewed the records of 34 patients with infiltrating carcinoma of the bladder stage T2 or higher and a follow-up ranging from 3 to 194 months, who underwent partial cystectomy. The patient received no radiotherapy and only one patient was treated with preoperative chemotherapy. RESULTS: The surgical specimen was tumor free (pTO) in 7 patients, pT1 in 7 pts, pT2 in 4 pts, pT3 in 4, pT3b in 8 and Px in 4. Six patients showed lymph node involvement. Eleven patients had bladder recurrence; 3 had bladder recurrence and metastasis; 1 had bladder recurrence, a pelvic mass and metastasis and 2 had metastasis alone. We performed radical cystectomy in 2 cases; one for a prostatic cancer and the other for an upper urothelial tumor in a solitary kidney. Both bladders were tumor free. The extravesical disease free interval and survival were better that those of patients submitted to radical cystectomy, although this was a highly selected group. CONCLUSIONS: With the same possibilities relative to the extravesical disease free interval and survival, this approach requires a shorter operating time, carries less risk, low postoperative morbidity and mortality, requires less hospitalizations, and has less late sequelae. It affords a better quality of life, with no cutaneous stoma, incontinence or impotence. The risk of bladder recurrence persists, although the procedures required to resolve the complications of bladder diversion or substitution are more aggressive than TUR, which is sufficient for most of the recurrences, and if the recurrence is an infiltrating tumor, one can always recur to radical cystectomy. This is the current situation, even in the era of the so-called "minimally invasive techniques". We believe that in this group of patients combination preoperative radio- and chemotherapy would have contributed little to the partial cystectomy. In our series, it is evident that the pT0 is the result of complete resection by TUR. The differences in tumor definition make it very difficult to evaluate the benefits of the neoadjuvant measures. Patients with no bladder tumor (pT0) or pT1-pT2, and even pT3a tumors, should not be included in protocols for evaluating the efficacy of combination cystostatic therapy; many of them can be overtreated. Preoperative radiotherapy adds nothing with respect to local recurrence of this tumor type and it evidently has no effect on metastasis. We should not forget that the cytostatic agents currently utilized in combination therapy have severe side effects and are therefore only indicated in patients at higher risk of distant dissemination at diagnosis. Some studies, however, have indicated that the cytostatics may have some negative tumoral effect.

Adult↗
PubMed2004

Cystectomy for immature teratoma of the ovary.

OBJECTIVES: Most patients with malignant ovarian germ cell tumors (MOGCT) of the ovary are in their reproductive years and wish to preserve fertility. Because of the excellent response to chemotherapy, the standard of care is unilateral salpingo-oophorectomy (USO), but some patients undergo cystectomy only before final pathology. In view of the lack of information concerning the outcome following cystectomy in germ cell tumors, we retrospectively evaluated the clinical outcome of patients who underwent cystectomy only as part of their surgical treatment. METHODS: The clinical and pathological records of 38 patients diagnosed with MOGCT, treated and followed in the department of gynecologic oncology were reviewed. Eight patients underwent cystectomy only at their initial surgery and are the subjects of this study. RESULTS: All the eight patients who underwent cystectomy were diagnosed with immature teratoma (three grade 1, four grade 2, and one grade 3) on final pathology following surgery. All except three patients (two with grade 1 and one with grade 2 disease) received adjuvant chemotherapy. Follow-up was available for all the patients, with a median duration of 4.7 years. No recurrences were observed during this period. Three patients delivered a total of seven babies. CONCLUSIONS: Cystectomy followed by adjuvant chemotherapy appeared satisfactory for apparent early-stage immature teratoma when close follow-up was carried out. It is still unclear whether cystectomy alone will also be safe. Further studies will need to address this issue.

Adolescent↗
PubMed1980

Complications of radical cystectomy for carcinoma of the bladder.

A total of 165 consecutive patients underwent radical cystectomy for bladder cancer, 19 patients without preoperative radiation therapy, 109 patients after planned preoperative radiation therapy and 37 patients after failure of definitive radiation therapy (salvage cystectomy). The operative mortality was 2.4 per cent of the entire group: less than 1 per cent of the 128 patients undergoing cystectomy as primary treatment and 8.1 per cent of the 37 patients undergoing salvage cystectomy. Early complications occurred in 28 per cent of the 165 patients and included wound infeciton, urine leak, ureterointestinal obstruction, small bowel obstruction, intestinal leak, rectal fistual and/or medical complications. Postoperative hospitalization for those patients suffering any complication averaged 27 days compared to the average hospitalization of 12.7 days when no complications occurred. Selective use of the initial perineal approach in male patients who had received more than 6,000 rad and of staged cystectomy after urinary diversion in some high risk patiens, associated with salvage cystectomy, can reduce the postoperative mortality and morbidity significantly. The addition of a meticulous pelvic iliac lymph node dissection did not increase the operative mortality or morbidity compared to simpler procedures. Results of this study support the early aggressive use of single stage radical cystectomy with pelvic iliac lymph node dissection and urinary diversion in the management of patients with bladder cancer.

Adult↗
PubMed1980

Carcinoma of the bladder treated by partial or total cystectomy.

The results obtained in 37 patients treated by partial cystectomy and 51 patients treated by total cystectomy are presented. Partial cystectomy was usually performed for deeply invasive tumours. THere were no operative deaths, but 85% of the patients died in the first two years of follow-up and the five-year survival was 11%. Of the 51 patients having total cystectomy, 22 were operated upon after other treatments had failed. There were six (11.8%) operative deaths, only one following simple cystectomy, and the remainder following radical cystectomy with or without urethrectomy. Almost half the survivors died in the first two years, and the five-year survival was 31%. The better prognosis in total cystectomy is attributable to the presence of a number of patients with multicentric but relatively non-invasive tumours. Thirteen patients, all with invasive bladder tumours, had 4,000 R irradiation to the pelvis before operation. There was no benefit demonstrated in this combined treatment. The loss survival rate despite treatment in deeply invasive bladder tumours indicates the value of early diagnosis and the need for more effective forms of treatment.

Adult↗
PubMed1988

Reappraisal of the role of radical radiotherapy and salvage cystectomy in the treatment of invasive (T2/T3) bladder cancer.

One hundred and eighty-two patients with invasive (T2/T3) bladder cancer were treated by radical radiotherapy at the London Hospital between 1974 and December 1985. Cystectomy was reserved for patients whose tumours either did not respond completely to radiation or recurred later, provided they were fit for surgery and had not developed distant metastases. The overall corrected 5-year survival rate was 40%; 75 patients responded to radiation and did not relapse during the period of follow-up; 20 patients had an initial response to radiation but subsequently relapsed, with a 5-year survival rate following relapse of 20%. Of these, 11 patients had a cystectomy with a 5-year survival following relapse of 36%, whereas all 9 patients who did not have a cystectomy died within 3 years; 87 patients who did not respond to radiation had a 5-year survival rate of 18%. Of these, 22 patients underwent salvage cystectomy with a 5-year survival of 47%, whereas the 65 patients who did not have a cystectomy had a 5-year survival of 3%. These results justify a policy of radical radiotherapy and salvage cystectomy rather than elective cystectomy in the treatment of invasive bladder cancer.

Adult↗