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PubMed2005

Contemporary management of the urethra in patients after radical cystectomy for bladder cancer.

The incidence of urethral TCC after radical cystectomy is approximately 8% overall. The most important risk factor for urethral TCC after radical cystectomy and urinary diversion is prostatic involvement by TCC, particularly stromal invasion. The safety of using the urethra for orthotopic urinary diversion seems to be best when intra-operative frozen section analysis of the urethral margin is performed at the time of radical cystectomy. There is provocative but unconfirmed evidence that orthotopic urinary diversion may be protective against the development of urethral TCC. Although most urethral "recurrences" occur within 5 years, delayed recurrences have been documented, mandating life-long follow-up of the retained urethra. Follow-up should include urinary cytology, either voided or urethral wash cytology as appropriate, with evaluation by endoscopy of any urethral related symptoms or change in voiding symptoms. The management of urethral TCC after cystectomy remains a total urethrectomy including excision of the meatus; however, in carefully selected patients with superficial disease and an orthotopic urinary diversion, urethra sparing may be attempted after a careful discussion with the patient. Survival after urethral TCC has generally been disappointing. The relative value of urethral versus original cystectomy pathologic stage and symptomatic versus nonsymptomatic recurrence in predicting survival remains controversial and awaits further studies that will most likely require the pooling of data from several large series.

Carcinoma, Transitional Cell↗
PubMed2004

Impact of transurethral resection of bladder tumor: analysis of cystectomy specimens to evaluate for residual tumor.

OBJECTIVES: To analyze the impact of transurethral resection of bladder tumor (TURBT) on the outcome of patients with bladder cancer who undergo subsequent cystectomy. METHODS: We reviewed the records of 90 patients with pathologic Stage T2 or less transitional cell carcinoma of the bladder at our institute. Before radical cystectomy, TURBT was performed for diagnostic and therapeutic purposes in all patients. We used the term "complete TURBT" in the following situations: no residual tumor endoscopically after TURBT, the presence of a muscle layer in the TURBT specimen, and no gross residual tumor in the cystectomy specimen as evaluated by a pathologist. RESULTS: No statistically significant differences in the completeness of TURBT were observed by age, sex, tumor multiplicity, shape, history of previous TURBT, tumor grade, or stage. Of 21 patients with superficial bladder tumors who had undergone incomplete resection, 14 (66.7%) had a higher stage on the cystectomy specimen; 3 (17.7%) of 17 patients had a higher stage in the complete TURBT group. Of 34 patients with an invasive tumor who underwent complete TURBT, 10 (29.4%) had an identical pathologic stage after cystectomy; the remaining patients had a lower stage. However, only 3 (16.7%) of 18 patients had a lower stage in the incomplete resection group. Of patients with Stage T2, those with pT0 stage had a better chance of survival than those with residual tumor (P = 0.04). CONCLUSIONS: Our findings indicate that the completeness of TURBT is an important aspect of patient outcome in cases of superficial or invasive bladder cancer.

Aged↗
PubMed2004

Local recurrence after radical cystectomy for invasive bladder cancer: an analysis of predictive factors.

OBJECTIVES: To examine which clinicopathologic parameters predict clinically detectable local recurrence after radical cystectomy. Local recurrence after radical cystectomy for invasive bladder cancer was infrequently observed until 20 years ago because of the lack of adequate diagnostic tools. The recent development and use of pelvic computed tomography has allowed us to detect local recurrence more precisely. However, only a few studies have investigated the rate and pattern of local recurrence in the computed tomography era. METHODS: This retrospective review included 145 patients with muscle-invasive bladder cancer treated with radical cystectomy, regional pelvic lymph node dissection, and urinary diversion between January 1990 and December 2001. The development of local recurrence and/or distant metastasis was analyzed as the endpoint using univariate and multivariate analyses. RESULTS: Local recurrence developed in 27 (18.6%) of the 145 patients at a median of 8 months after cystectomy. Of the 27 patients, 8 had local recurrence alone and 19 had concurrent distant metastasis. Distant metastasis without local recurrence developed in 34 patients (23.4%). Univariate and multivariate analyses revealed that Stage pT3-T4 and pathologic pelvic lymph node involvement were statistically significant factors predicting clinical failure, local recurrence, and/or distant metastasis. However, a concomitant squamous cell carcinoma component in the specimen was the only independent predictor of local recurrence alone in both univariate and multivariate analyses. CONCLUSIONS: Only the finding of a concomitant squamous cell carcinoma component in the specimen was an independent predictor of local recurrence in patients treated with radical cystectomy.

Adult↗
PubMed2006

Neurovascular preservation in orthotopic cystectomy: impact on female sexual function.

OBJECTIVES: The published data regarding female orthotopic cystectomy have focused primarily on urethral recurrence and urinary continence. In a new era of sexuality, evaluating postoperative sexual outcome has become a new surgical endpoint. In this study, we focused on the impact of neurovascular preservation after radical cystectomy and neobladder construction. METHODS: We assessed female sexuality in 13 patients after orthotopic cystectomy using a standardized questionnaire, Female Sexual Function Index (FSFI). Six patients had undergone nerve-sparing cystectomy and seven had undergone contemporary non-nerve-sparing cystectomy. Intraoperatively, the tumor was deemed oncologically safe for neurovascular preservation. All 13 patients were sexually active preoperatively, were younger than 65 years old, had recurrence-free follow-up findings after 1 year, and had undergone no pelvic irradiation. The 19-item FSFI questionnaire analyzed six domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) of sexual function. RESULTS: In the nerve-sparing group (mean age 55.9 years), the baseline and 12-month postoperative scores showed a minimal decline in results, with a total mean FSFI score of 24.5 versus 22.3, respectively. In analyzing each of the six domains, no significant decline or difference was observed. Conversely, in the non-nerve-sparing group (mean age 56.7 years), a significant decline or difference was found in the 12-month total mean FSFI scores between the baseline and postoperative FSFI scores (25.0 versus 11.0, respectively). In the non-nerve-sparing group, 6 of 7 patients ultimately discontinued sexual intercourse. CONCLUSIONS: Female sexual function was preserved in patients who received neurovascular preservation. In contrast, all domains of sexual function declined in patients who had undergone non-neurovascular preservation.

Cystectomy↗
PubMed2006

Laparoscopic en bloc partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma.

INTRODUCTION: Surgical options for treating urachal adenocarcinoma include radical cystectomy and en bloc partial cystectomy with excision of the urachus and umbilectomy. Recently, laparoscopy has been increasingly used to treat bladder and urachal pathologic findings efficaciously. We describe two techniques for performing laparoscopic en bloc partial cystectomy with bilateral extended pelvic lymphadenectomy. TECHNICAL CONSIDERATIONS: We performed the procedure in 3 patients with established urachal adenocarcinoma. The anatomic boundaries of resection were similar to those described for open surgery. We used an inverted V-shaped, five-port configuration, with the camera port placed 3 cm supraumbilically. An antegrade approach was performed for tumors less than 5 cm in 2 cases. The steps of the procedure included an inverted V-shaped incision along the peritoneum lateral to the medial umbilical ligament on either side; urachal disconnection, dissection of the urachus using the "twist and roll technique"; anterior cystotomy, circumferential resection of the tumor-bearing bladder dome, under vision; tumor placement in a "lap-bag"; bladder reconstruction using intracorporeal suturing; bilateral extended pelvic lymphadenectomy; placement of catheter and drain; and specimen retrieval. We evolved a retrograde technique for larger size tumors (larger than 5 cm). The procedure was successfully completed in all patients, with a mean operative time of 180 minutes (range 150 to 210). No significant intraoperative or postoperative complications occurred, except for a left inferior epigastric artery injury in 1 case. The resected nodes (range 8 to 11) were free of tumor. No local or distant recurrences were observed at a mean follow-up of 6.5 months (range 4.5 to 9). CONCLUSIONS: Laparoscopic en bloc partial cystectomy and bilateral extended pelvic lymphadenectomy is a safe, feasible, minimally invasive alternative to open partial cystectomy for urachal tumors.

Adenocarcinoma↗
PubMedDate not supplied

Benefit of radical cystectomy in the elderly patient with significant co-morbidities.

Although recent series have demonstrated that radical cystectomy can be safely performed in elderly patients, few if any, have examined the long-term success of this procedure. We sought to determine the long-term benefit and survival outcomes after radical cystectomy in the elderly, high operative risk patient. We reviewed the records of all patients undergoing radical cystectomy between July 1994 and January 2000. Of these 382 patients, we identified 38 patients with transitional cell carcinoma who met our predetermined selection criteria of elderly, high peri-operative risk patients [age > or = 75 years and American Society of Anesthesiologists (ASA) classification > or = 3]. We analyzed patient characteristics, presenting symptoms, pathology, outcomes, and survival. Median age was 79 years (75-87 years). All but a single patient underwent surgery for symptomatic disease. No patient died in the early perioperative period. At a mean follow-up of 22 months (3-90 months), 11/38 (29%) patients are alive. Of the patients with < or = pT2B pathology, 9/27 (33%) are alive and are disease-free. There are 2/11 patients (18%) with > or = pT3 pathology still alive with 1 of those patients (pT4a) alive with disease 34 months after his radical cystectomy. Kaplan-Meier survival curves demonstrate that patients with organ confined disease (< or = pT2B) had a significantly longer mean overall survival than patients with nonorgan confined disease (> or = pT3): 31 months vs. 18 months, P = 0.046. Cause of death was known in 17 patients, with the majority (14/17) because of bladder cancer. However, there were no local recurrences, and palliative goals were achieved in all patients. Our results validate radical cystectomy as a safe and effective treatment choice in the elderly patient with significant co-morbidities. These patients, most of whom are symptomatic, can achieve palliation of their symptoms, local control, and long term survival, especially if their bladder cancer is organ confined. Reluctance to offer timely, aggressive local therapy may compromise ultimate survival, even amongst high operative risk, elderly patients.

Age Factors↗
PubMedDate not supplied

The effects of stage divergence on survival after radical cystectomy for urothelial cancer.

INTRODUCTION: Discrepancies between clinical and pathologic staging, herein referred to as stage divergence, are common after radical cystectomy. The implications of stage divergence on survival are ill defined in the context of those treated by surgery alone and would facilitate patient counseling and enhance prognostication. METHODS: There were 78 consecutive radical cystectomy patients with clinical stage T2 or less urothelial carcinoma who comprised our study population. Kaplan-Meier plots were constructed to determine the effects of stage divergence on survival and the log-rank test employed to assess the significance. Regression models were developed to determine predictors of overall and cancer-specific survival. RESULTS: Stage divergence was common after radical cystectomy with downstaging and upstaging occurring in 27% and 49% of patients, respectively. Downstaged patients had better overall (P = 0.003) and bladder cancer-specific (P = 0.0004) survivals. None of the downstaged patient died from bladder cancer (median follow-up 35.9 months). Upstaged patients were five times as likely to succumb from bladder cancer or other illness compared to downstaged patients. This effect was not isolated to patients with lower clinical stages but also demonstrated in patients with clinical stage T2 bladder cancer. CONCLUSIONS: Stage divergence is common after radical cystectomy occurring in 76% of patients in this study. The implications of stage divergence are equally relevant for those who are upstaged or downstaged in terms of survival, and such data is useful when counseling patients postoperatively. Downstaging at the time of radical cystectomy is associated with better overall and cancer-specific survival.

Aged↗
PubMed1997

Radical cystectomy in the octogenarian.

PURPOSE: We evaluated the morbidity and outcome of cystectomy and urinary diversion in patients 80 years old or older with invasive bladder cancer. MATERIALS AND METHODS: We reviewed the records of all patients older than 80 years who underwent cystectomy during the last 15 years. Of 1,186 cystectomies 44 patients (4%) were identified. Patients were evaluated for complications, mortality and functional status after surgery. RESULTS: The 44 patients had a median age of 81 years (range 80 to 87). Of the patients 78% had significant co-morbidity, including 41% with 2 or more medical problems. Median hospital stay was 14 days, with 20% of the patients requiring intensive care for 24 hours. There was a 51% complication rate including 25% due to surgical complications and 26% from underlying medical illness. Operative mortality was 4.5%. Within 6 months of surgery 66% were rehospitalized for medical or surgical reasons. Median survival time was 25 months. Median performance status before and after surgery decreased slightly from 70 to 65. CONCLUSIONS: The results of this study support the use of cystectomy in octogenarians with invasive bladder cancer. Surgery can be accomplished with acceptable morbidity and mortality. Radical cystectomy in this population offers the best opportunity for sustained disease-free quality survival.

Age Factors↗
PubMed2006

Cancer specific outcomes in patients with pT0 disease following radical cystectomy.

PURPOSE: We assessed clinical outcomes in patients found to have no evidence of disease, ie pT0, in the cystectomy specimen following radical cystectomy for transitional cell carcinoma. MATERIALS AND METHODS: Between 1984 and 2003, 955 consecutive patients underwent bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer at 3 institutions, namely The Johns Hopkins Hospital, University of Texas Southwestern Medical Center and Baylor College of Medicine. Excluding nonTCC histology and patients with missing data resulted in 888 evaluable cases. Primary end points were recurrence-free survival and bladder cancer specific survival. RESULTS: Final pathological evaluation revealed absent transitional cell carcinoma in the cystectomy specimen, ie pT0, in 59 patients (7%), of whom 2 (3%) had pathologically positive lymph nodes. Transurethral resection stage or clinical stage data were available on 56 patients (95%), including Tis in 5 (9%), Ta in 2 (4%), T1 in 18 (32%), T2 in 29 (52%) and T3 in 2 (4%). Overall 6 recurrences (10%) were noted, including cTis in 1 case, cT1 in 1, cT2 in 3 and cT3 in 1. Median followup in patients with pT0 disease was 56 months (range 3 to 183). Three patients (5%) died of bladder cancer and another 4 (7%) died of other causes. Five and 10-year bladder cancer progression-free and cancer specific survival estimates in patients with pT0 disease were 90% and 81%, and 95% and 85%, respectively. CONCLUSIONS: Despite excellent clinical outcomes in the majority of patients with no evidence of tumor on final pathological evaluation not all patients with pT0 disease in the cystectomy specimen are cured of bladder cancer. These events may even occur in patients with nonmuscle invasive or muscle invasive organ confined pathology at staging transurethral resection. Further study is needed to identify prognostic factors in this population.

Adult↗
PubMed2002

Laparoscopic hand assisted radical cystectomy with ileal conduit urinary diversion.

PURPOSE: Hand assisted laparoscopy was originally described in the early 1990s. Since then many studies have shown that hand assisted techniques have the same advantages of laparoscopy including decreased need for postoperative narcotics and rapid return to routine activities. Laparoscopic techniques are advancing rapidly and intracorporeal laparoscopic cystectomy is reported. To our knowledge we report the first case of hand assisted, laparoscopic radical cystectomy with ileal conduit urinary diversion. MATERIALS AND METHODS: A 68-year-old male with rapidly recurring grade III transitional cell carcinoma elected to undergo hand assisted radical cystectomy. We performed a radical cystectomy with bilateral pelvic lymph node dissection removing the specimen through the hand port site. The ileal loop urinary diversion was constructed by pulling the small bowel through the hand port incision. We made another separate hole for the stoma and a drain was placed through a port site. The incisions were closed in the standard fashion. RESULTS: Operative time was 7 hours with 750 cc of blood loss and no complications. All surgical margins were negative. The patient did well and was discharged from the hospital on postoperative day 7 with return to normal activity without limitations at 4 weeks. CONCLUSIONS: To our knowledge this is the first reported case of hand assisted laparoscopic radical cystectomy with ileal loop diversion. Hand assistance facilitated this technically demanding surgery resulting in a good outcome without significant added operative time.

Aged↗
PubMed2006

Partial cystectomy for muscle invasive urothelial carcinoma of the bladder: a contemporary review of the M. D. Anderson Cancer Center experience.

PURPOSE: Partial cystectomy is a surgical option for select patients diagnosed with urothelial carcinoma. We review our experience with partial cystectomy for muscle invasive urothelial carcinoma to assess local control and survival rates. MATERIAL AND METHODS: From 1982 to 2003 a total of 37 patients with muscle invasive urothelial carcinoma underwent partial cystectomy with curative intent. Reviewed data included history of superficial tumors, presence of variant histology, tumor location, clinical stage, pathological stage, presence of carcinoma in situ, adjuvant therapy and disease status. RESULTS: The 5-year overall, disease specific and recurrence-free survival rates were 67%, 87% and 39%, respectively. Mean followup was 72.6 months (range 6 to 217). Of the 37 patients 19 (51%) did not have tumor recurrence, 9 (24%) had superficial recurrence in the bladder that was treated successfully and 9 (24%) had recurrence with advanced disease. A total of 24 patients (65%) had an intact bladder with no evidence of disease after a median of 53 months. There were 6 patients (16%) who died of bladder cancer, 3 of whom died of late recurrence of muscle invasive cancer (41, 44 and 138 months after partial cystectomy). On multivariate analysis higher pathological stage (HR 3.4, p = 0.04) was associated with shorter recurrence-free survival. A history of superficial tumors (p <0.01) and clinical stage (p = 0.01) was associated with advanced recurrence-free survival. The use of adjuvant chemotherapy (HR 0.18, p = 0.03) was associated with prolonged advanced recurrence-free survival, however adjuvant chemotherapy did not impact overall survival. CONCLUSIONS: Partial cystectomy provides adequate local control of muscle invasive bladder cancer in select patients. Because late recurrence is not uncommon and is potentially life threatening, lifelong followup with cystoscopy is recommended.

Adult↗
PubMed2006

Patterns of initial transitional cell recurrence in patients after cystectomy.

PURPOSE: We characterized initial relapse patterns in patients who underwent cystectomy for transitional cell carcinoma of the bladder at our institution. MATERIALS AND METHODS: Between June 1995 and December 2001 a total of 417 patients underwent radical cystectomy for transitional cell carcinoma. Of the 399 patients treated with orthotopic diversion or incontinent cutaneous diversion, recurrent TCC developed in 86 (21.6%). We retrospectively examined this population to determine if any perioperative variables influenced the first site of disease recurrence. RESULTS: Of the 86 patients in whom metastatic disease developed after cystectomy, the mean followup was 22.1 months. Mean time to disease recurrence was 15.1 months. Recurrence was most commonly initially in the pelvis (30.2%). Other common sites of first recurrence included the viscera (26.7%), the retroperitoneum (16.3%) and the skeletal system (16.3%). The site of first recurrence did not correlate significantly with gender, age, diversion type, pathological stage, nodal status, prostatic involvement or the presence of a positive surgical margin. Lymphovascular invasion was more prevalent in the pelvic recurrence group (62%) than in the retroperitoneal (36%), visceral (22%) or skeletal metastases (29%) groups (p = 0.03). CONCLUSIONS: While the pelvis is the most common site of disease recurrence following radical cystectomy, TCC of the bladder recurs in an unpredictable pattern and aggressive surveillance is indicated. Patients with local pelvic recurrence had a higher percentage of lymphovascular invasion on cystectomy than the other recurrence site groups.

Adult↗
PubMed1993

The effect of intermittent pneumatic compression devices on intraoperative blood loss during radical prostatectomy and radical cystectomy.

Intermittent pneumatic compression devices are a widely used, effective and presumed risk-free method of deep venous thrombosis prophylaxis, presumably by increasing peak venous blood velocity, and stimulating local and systemic fibrinolysis. We investigated whether intermittent pneumatic compression devices had any effect on intraoperative blood loss or transfusion during radical pelvic urological surgery. To our knowledge no previous study has addressed these issues. Records were reviewed for patients undergoing radical retropubic prostatectomy or radical cystectomy with diversion from 1985 to 1990. A total of 91 cases was reviewed: 38 radical retropubic prostatectomies and 53 radical cystectomies with diversion (34 male and 19 female patients). There were 59 patients with intermittent pneumatic compression devices (29 radical retropubic prostatectomies and 30 radical cystectomies with diversion) and 32 without intermittent pneumatic compression devices (9 radical retropubic prostatectomies and 23 radical cystectomies with diversion). Intraoperative blood loss and transfusions were calculated for each group with and without intermittent pneumatic compression devices. No clinically apparent lower extremity deep venous thrombosis or pulmonary embolus was diagnosed in any patient. For the group with intermittent pneumatic compression devices mean intraoperative blood loss was 2,541 ml. (range 700 to 8,850) versus 1,807 ml. (range 450 to 5,100) without a device, for a statistically significant difference of 734 ml. (p = 0.005). When 5 patients with excessive intraoperative blood loss (more than 5,000 ml.) were excluded the statistically significant difference was maintained. When comparing radical retropubic prostatectomy and radical cystectomy with diversion, with and without intermittent pneumatic compression devices, blood loss was greater for the group with a device for each procedure. Differences in intraoperative blood loss were independent of sex or tumor stage. Intraoperative transfusions were increased by approximately 0.6 units per patient with the device. Our study suggests that intermittent pneumatic compression devices may increase blood loss during a radical pelvic operation.

Blood Loss, Surgical↗
PubMed2000

Incidental appendectomy during radical cystectomy: an interdepartmental survey and review of the literature.

OBJECTIVES: To survey and review the incidence of appendectomy performed during radical cystectomy and urinary diversion. We were interested in the reasons behind the decision and if continent diversions have changed the policy. METHODS: We performed a selective survey among urologists in academic centers throughout the United States regarding their practice of incidental appendectomy during radical cystectomy. We also reviewed the literature regarding the rationale for incidental appendectomy in general and during radical cystectomy in particular. RESULTS: Among the 13 departments and 26 urologists replying to the survey, 9 (69%) departments and 20 (77%) individual clinicians are not performing routine incidental appendectomy. In 2 departments, it is considered a matter of choice, and, in 4 (31%) departments, appendectomy is performed routinely. Many believe that the low risk of subsequent appendicitis does not justify the procedure and that the appendix may be useful for future reconstruction. A review of the literature suggests that incidental appendectomy during radical cystectomy is not necessary. CONCLUSIONS: Incidental appendectomy during radical cystectomy is not necessary and is no longer being performed in many academic centers. The risk of subsequent appendicitis is extremely low. The decision may depend on the form of urinary diversion planned.

Academic Medical Centers↗
PubMed2001

Complications of cystectomy in patients with a history of pelvic radiation.

OBJECTIVES: To compare the complications occurring during the first year of follow-up after radical cystectomy in two groups, one with and one without a history of pelvic radiation. Radical cystectomy and urinary diversion is the treatment of choice for invasive bladder cancer. METHODS: One hundred ninety-four cystectomies were performed between January 1995 and June 2000 by a single surgeon. Twenty-three patients were identified with a history of external beam radiotherapy to the pelvis (EBRT group), and 23 additional patients without a history of pelvic radiation were randomly selected to serve as the control group. RESULTS: Although the overall risk of having a complication was not statistically different in the EBRT group (48%) than in the control group (30%; P = 0.183), complications directly related to surgery were higher in the EBRT group than in the control group (48% versus 26%; P = 0.045). The patients in the EBRT group were more likely to require an invasive procedure (39% versus 9%; P = 0.018). In addition, 5 (22%) of 23 patients in the EBRT group had a symptomatic fluid collection, which was diagnosed as a urine leak (n = 2) or an abdominal abscess (n = 3). In contrast, no patient in the control group developed a symptomatic fluid collection. CONCLUSIONS: Cystectomy after pelvic radiation is associated with acceptable morbidity; however, compared with cystectomy performed in a nonirradiated pelvis, the risk of complications that will require invasive intervention is increased. A history of prior pelvic radiation significantly increases the risk of a symptomatic fluid collection.

Aged↗
PubMed2003

Laparoscopic nerve- and seminal-sparing cystectomy with orthotopic ileal neobladder: the first three cases.

INTRODUCTION AND OBJECTIVES: Seminal and prostate sparing cystectomy represents an alternative in young patients where preservation of urinary continence and sexual potency are fundamental. We present our preliminary experience with this procedure performed laparoscopically. METHODS: Three men-53, 58 and 49 years old-suffering from recurrent superficial transitional cell carcinoma of the bladder, resistant to intravesical therapy, underwent laparoscopic nerve, prostate and seminal vesical sparing cystectomy. One week before surgery, TURP was performed to create an adequate prostate capsule. After pneumoperitoneum induction and the positioning of five/six trocars, the ureters were clipped and transected, the vas deferens and seminal vescicles were identified and prepared for the conservative procedure. Cystectomy was performed with vascular pedicles transection by EndoGia. The reconstruction of the bladder was obtained through a 7 cm longitudinal periumbilical incision using 60 cm of ileus and an orthotopic neobladder realized outside the abdomen. The ileocapsular anastomosis was performed laparoscopically after the re-induction of pneumoperitoneum. RESULTS: No major complications were recorded. The surgical time was respectively 480, 450 and 410 min. Blood loss was 150, 220 and 300 ml respectively. Drains were removed after 4 days (two patients) and 6 days (one patient) and the patients were discharged after 8 days (two patients) and 9 days. The patients were fully continent after catheter removal with normal uroflowmetry. At the three month follow-up they had a normal sexual function, equivalent to the preoperative assessment. The patients reported adequate erections for intercourse. CONCLUSIONS: Laparoscopic prostate and seminal cystectomy with orthotopic ileal neobladder is a safe, feasible, reproducible surgical technique. In patients who desire to preserve sexual functioning and obtain complete continence it represents a valid alternative to classic radical cystectomy.

Carcinoma, Transitional Cell↗
PubMed2001

Staging error in the bladder tumor: the correlation between stage of TUR and cystectomy.

OBJECTIVES: Because tumor stage is very important in determining therapy, accurate staging of bladder cancer must be estimated. For this aim, we examined the stage of TUR and compared it with the stage of cystectomy. MATERIALS AND METHODS: From 1992 to 1999, operations were performed on 127 patients with local invasive bladder cancer. Eight cases (74 male, 6 female) underwent complete TUR of the tumor and then radical cystectomy. There was no residual macroscopic tumor after TUR in the bladder. The pathological staging of TUR and cystectomy were estimated and compared in these 80 cases. All pathologies were evaluated by the same pathology center. RESULTS: There was correlation in only 20 patients (25%; 15 were T1, 5 were T2) while there was global error and discordance in 60 patients (75%). All of these 60 cases were overstaging in cystectomy specimens and downstaging was not found in any case. Fifty per cent of 10 T1 tumors were T1, while 50% were T3a; 21.4% of T2 tumors were T2, 35.7% were T3a and 42.8% were T3b. CONCLUSIONS: The staging error of TUR in the bladder tumor may cause severe mistakes on deciding about radical surgery. However, although there was no understaging, which is more risky for false cystectomy indication, urologists must be careful about overstage/understage in the staging of TUR.

Adult↗
PubMed2002

Radical radiotherapy and salvage cystectomy as the primary management of transitional cell carcinoma of the bladder. Results following the introduction of a CT planning technique.

The objective of this study was to review the results of our policy of primary radiotherapy (RT) and salvage cystectomy for transitional carcinoma (TCC) of the bladder in the light of changes in our radiotherapy planning procedure, in particular the introduction of CT planning. The case notes of 163 patients treated with radical radiotherapy using a CT planning technique were examined. The main endpoint for assessment was response at the time of the check cystoscopy 6 months after the completion of treatment. In addition survival was estimated by stage of disease and by response at the time of first cystoscopy. Patterns of relapse and time to relapse were analysed. All percentages quoted in the text use the initial 163 patients as the denominator. One hundred patients (61%) achieved a complete response. The complete response rate was significantly related to T stage at presentation being 90% for T1, 75% for T2, and 53% for T3 disease respectively. Of these patients 78 remain disease free in the bladder (47%). Twenty-two have relapsed in the bladder, of whom 5 have also relapsed at metastatic sites. Fifteen patients have relapsed outside the bladder whilst remaining disease free within the bladder. At the time of last follow up or death from other causes 63 of the 100 patients who had a complete response remained disease free with an intact bladder. There were 18 (11%) partial responders. Seven of these patients went on to have a cystectomy. Ten remain alive, 7 disease free, 4 with intact bladders. In 24 patients (15%) there was no response and these patients have all died, the median survival being 10 months. In 21 patients (13%) a postradiotherapy cystoscopy was not performed. In all but one patient, who was lost to follow up, this was because of progressive disease. The median survival of these 20 patients was 6 months. Of the 163 patients 35% are alive and well with an intact bladder. If patients dying from other causes are included then 42% were rendered disease free. Cause specific survival was significantly related to stage of disease at presentation with 5 year actuarial survival being 87%, 48% and 26%, for T1, T2 and T3 disease respectively. Survival was also related to response to treatment at 6 months with 5 year survival being 64%, and 52% for complete and partial responders respectively. Survival was extremely poor for non-responders with only 37.5% surviving 1 year and none 5 years. There was a highly significant relationship between response and the development of, and the time to developing metastatic disease. Of those who exhibited a response 21% developed metastatic disease compared to 78% of non-responders. Salvage cystectomy offers the possibility of cure in those who achieve a complete or partial response with 42% of such patients being rendered disease free. Results however are poor in those who did not respond with all patients dying of their disease. Response rates for all stages, and survival for stages T1 and T2 are much improved from those previously reported from this centre and compare favourably with other published series. These results confirm the place of radiotherapy and salvage cystectomy in the management of TCC of the bladder in selected patients. In about one-third of patients the desired outcome of curing the patient of their cancer with organ preservation is achieved. The prognostic significance of cystoscopic response at 6 months and stage at presentation is confirmed. The outcome for patients with early stage disease is excellent. The relationship between response and the development of metastatic disease would suggest that even if these patients had had a primary cystectomy they may have fared badly, a conclusion supported by the fact that these results are comparable with surgical series. This series supports the role of radiotherapy in the management of this disease and suggests that modern RT techniques including CT planning have had a beneficial effect on the results of radical radiotherapy.

Aged↗