Pelvic recurrence following radical cystectomy and orthotopic neobladder substitution for invasive bladder cancer

To determine the incidence, characteristics and factors influencing local pelvic recurrence following radical cystectomy and orthotopic neobladder substitution for invasive bladder cancer. Seventy two radical cystectomies and orthotopic neobladder substitution were performed on 70 men and 2 women. Sixty nine patients had transitional cell carcinoma [TCC], 2 patients had squamous cell carcinoma [SCC] and one had rhabdomyosacrcoma. Seven patients with TCC received adjuvant chemotherapy; 6 for micro-nodal disease and one patient had open cystotomy. Median follow up was 36 months. Eight of the 72 patients [11%] developed pelvic recurrence, 6 patients with TCC, one patient with SCC and another with rhabdomyosarcoma. All recurrences developed within 12 months of cystectomy. None of the recurrences involved the uretero-ileal anastomosis. Of the 6 patients with TCC, 4 patients had P3bN+ GIII TCC with vascular invasion while 2 patients had P3aN+ GIII TCC tumors. In one patient with P3b NO GIII TCC the recurrence invaded the neobladder. Three of the 6 patients with TCC had received adjuvant chemotherapy, 2 for positive nodes and one for open cystotomy. Five patients with TCC received a combination of external beam radiation and chetherapy. Partial response was achieved and 3 died of their disease. The patient with SCC was treated with radiation and the patient with recurrent rhabdomyosarcoma, that also invaded the neobladder, had total pelvic extenteration. Both died of their disease. Neobladder tolerated adjuvant chemotherapy and radiation well. Pelvic recurrence following orthotopic neobladder substitution is comparable to other forms of urinary diversion. Factors influencing recurrence are high stage, high grade disease, positive nodes, bladder violation and vascular invasion. Local recurrence can invade the neobladder. Radiation and chemotherapy result in partial response with poor prognosis

effect of antibiotics on elevated serum prostate specific antigen in patients with urinary symptoms and negative digital rectal examination: a pilot study

Introduction and objectives 65-70% of patients with abnormal prostate specific antigen [PSA] do not have cancer on prostate needle biopsy. Prostate biopsy is a potentially morbid procedure. Prostatitis is commonly reported on needle biopsies. To cut down on the number of unnecessary prostate biopsies we evaluated the effect of antibiotic on PSA level in patients with lower urinary tract symptoms [LUTS], normal digital rectal examination [DRE], normal urinalysis and elevated PSA. Material and methods 48 selected patients with LUTS, normal DRE, normal urinalysis and elevated PSA [range 5.0-28.5 ng/ml], that usually will undergo prostate biopsy, received 2 weeks of Ciprofloxacin. An alpha-blocker was added if the patient was bothered. PSA was repeated and prostate biopsy was performed if PSA did not drop. Results 25/48 patients [52%] dropped their PSA [median of 42% drop], with 80% improvement in LUTS, were not biopsied. 23/48 patients [48%] did not drop their PSA, with 65% improvement in LUTS, were biopsied. 9/23 patients [39%] had prostate cancer. Conclusion Almost 50% of patients with LUTS, normal DRE and elevated PSA will drop their PSA following 2 weeks of Ciprofloxacin thus by avoiding prostate biopsy. This needs to be done in a very strict manner with careful follow-up of those patients dropping their PSA especially not to normal levels

Tuberculous epididymo-orchitis following intravesical BCG for superficial bladder cancer

A seventy-two-year-old man with transitional cell carcinoma of the bladder received intra-vesical Bacillus Calmette-Guerin [BCG] following which he developed left testicular pain and swelling that partially resolved with conservative treatment. Six months later a second course of BCG was given for recurrent disease. Ten months later, he developed left testicular swelling and severe induration along with a draining scrotal sinus. Tuberculous orchitis was suspected and a left orchiectomy was performed. Pathology showed caseating granulomatous orchitis and epididymitis with numerous acid fast bacilli on Ziehl-Neelson stain. The patient received a six-month course of antituberculous therapy. This case highlights a rare but serious complication of intravesical BCG

value of free and total prostate specific antigen in indentifying patients for prostatic biopsy and its relationship to gleason score and number of positive cores

Introduction and The percentage of free over total prostate specific antigen [%F/T PSA] seems to enhance the predictive value of PSA in diagnosing prostate cancer. We evaluated the value of F/T PSA in 50 consecutive patients who underwent prostate needle biopsy, its relationship to the Gleason score and number of positive cores. Material and methods: 50 patients underwent prostate needle biopsy for abnormal PSA and/or abnormal digital rectal examination [ORE]. There were 8 patients with PSA equal or less than 4 ng/ml, 6 with F/T PSA < 20%, group I [GI]. 27 patients with PSA between 4.1 ng/ml and 10.0 ng/ml, 20 with F/T PSA < 20%, group II [Gil] and 15 patients with PSA > 10.1 ng/ml [13 with F/T PSA < 20%], group III [GUI]. At least six needle biopsies were obtained guided by transrectal ultrasound selectively or randomly. Pathological evaluation included Gleason grade and number of cores involved. 21/50 patients [42%] had positive biopsies, 3/8 in GI, 8/27 in GIl [6 had negative DRE] and 10/15 in GUI [9 had positive DRE]. 19/21 patients with positive biopsies had F/T PSA < 20%. The sensitivity, specificity and positive predictive value of PSA between 4-10 ng/ml and F/f PSA < 20% was 87.5%, 31% and 35% respectively. Stratifying patients with positive biopsies to F/T PSA < 10%, F/T PSA > 10% and the three PSA groups, there was no relationship to either Gleason score or number of positive cores. With a cutoff of 20%, F/T PSA seems to be an important parameter in selecting patients with abnormal PSA for biopsy. It will be helpful mostly with PSA 4-10 ng/ml. No relationship was observed between the level of F/T PSA, grade or number of positive cores

Advantages of the ileal over the ileocecal orthotopic neobladder in patients with invasive bladder cancer

Introduction and different segments of small and large bowel have been used in the construction of the orthotopic neobladder in patients undergoing cystectomy for invasive bladder cancer. Ileocecal and ileal neobladders performed in a single institution are compared. Materials and in 29 patients, ileocecal neobladder was constructed while 23 patients had ileal neobladder. In the ileocecal group, the cecum and the ascending colon are mobilized, appendectomy is performed, the ileocecal valve is opened, the ureters are implanted in the taenia, and a cecostomy tube is placed. In the ileal group, the ureters are subserosally implanted and no suprapubic tube is exteriorized. there was no operative mortality in either group. Three patients needed intermittent catheterization. Both groups tolerated adjuvant chemotherapy and radiation therapy. Three patients from the ileocecal group developed uretero-intestinal strictures versus one from the ileal group. Mucus production was significantly higher in the ileocecal group. Operating time was longer for the ileocecal group. Conclusions: both ileal and ileocecal neobladder are excellent urinary substitutes, and they are functionally comparable. The ileal neobladder offers the following advantages: [1] Mobilization of the cecum and ascending colon and appendectomy are not required which leads to a shorter operating time. [2] Intact ileocecal valve. [3] Fewer uretero-intestinal strictures. [4] Less mucus production meaning that there is no need for a suprapubic tube

Late recurrence with malignant degeneration of testicular teratoma. Case Report

Radical orchiectomy was performed on a 25-year-old man for benign mature teratoma. A synchronous without change 3 cm retroperitoneaal mass was followed for years. The mass enlarged and became symptomatic twelve years after orchiectomy. Excision of the mass revealed a non-seminomatous germ cell tumor. Possible explanation is malignant degenertion of the teratomatous elements. Testicular teratomas should be treated as potentially malignant non-seminomatous tumor