Analysis of the perioperative and five-year oncological outcome of two hundred cases of open radical cystectomy: a single center experience.

OBJECTIVES: We prospectively evaluated our perioperative and five-year oncological results of 200 cases of open radical cystectomy with urinary diversion, for formulating contemporary benchmarks, for future comparison of minimally invasive techniques. This is one of the largest prospective series reported from India of open radical cystectomy. MATERIALS AND METHODS: Between 2004 and 2009, patients undergoing open radical cystectomy with urinary diversion, at our institution, were prospectively enrolled in the study. Data were recorded and analyzed statistically. RESULTS: Two hundred patients were enrolled in the study. The mean age was 65.1 years. The patients undergoing ileal conduit and orthotopic neobladder were 159 (79.5%) and 41 (20.5%), respectively. The mean operating time was 275 minutes. The mean operating time for ileal conduit and orthotopic neobladder were 262 minutes and 288 minutes, respectively. The mean estimated blood loss was 690 ml. Blood transfusion was required in 37 (18.5%) patients. The mean hospital stay was 6.1 days. Major and minor complications were recorded in 16 (8%) and 31 (15.5%) patients, respectively. Perioperative mortality was recorded in only two (1.5%) patients. The pathologically organ-confined and non-organ-confined cases were 135 (67.5%) and 65 (32.5%), respectively. Thirty-three (16.5%) patients had pathologically confirmed lymph nodes. Median follow-up was 60.1 months. Local recurrence and distant metastases were recorded in 16 (8%) and nine (4.5%) patients, respectively. A five-year disease-free survival, cancer-specific survival, and overall survival were 75.5, 71.5, and 63.5%, respectively. CONCLUSIONS: Open radical cystectomy has an acceptable perioperative morbidity and mortality, along with a favorable five-year oncological efficacy. Minimally invasive techniques need a long-term prospective comparison with this approach, before being accepted as a standard treatment for urinary bladder malignancy.

Management of BCG non-responders with fixed dose intravesical gemcitabine in superficial transitional cell carcinoma of urinary bladder.

AIMS AND OBJECTIVES: The incidence of bladder malignancy is increasing worldwide and the projected rise is 28% by 2010 for both sexes (WHO). Though intravesical adjuvant therapy with BCG is superior to any other immunotherapeutic/chemotherapeutic agent in reducing tumor recurrences and disease progression, its real efficacy remains controversial as one-third of the patients will soon become BCG failure. Hence there is a need for an alternative intravesical agent for treatment of BCG failure. Our aim was to study the efficacy, tolerability and safety of intravesical Gemcitabine in managing BCG-refractory superficial bladder malignancy. MATERIALS AND METHODS: Thirty-five BCG failure patients, 26 males and nine females between 20-72 years of age were instilled with 2000 mg of Gemcitabine in 50 ml of normal saline intravesically two weeks post tumor resection, for six consecutive weeks. Mean follow-up was for 18 months with cystoscopies. RESULTS: Twenty-one patients (60%) showed no recurrences, 11 patients (31.4%) had superficial recurrences while three patients (8.6%) progressed to muscle invasiveness. Average time to first recurrence was 12 months and to disease progression was 16 months. Adverse event was low and mild. Therapy was well tolerated. CONCLUSION: Gemcitabine fulfils all requirements as an alternative agent, in treating BCG failure patients with low adverse events, is well tolerated and highly effective in reducing tumor recurrences.

Role of botulinum toxin-A in management of refractory idiopathic detrusor overactive bladder: Single center experience.

BACKGROUND: Overactive bladder (OAB) is a bothersome condition affecting the quality of life, financial constraint on the individual, and community. Anticholinergic drugs cannot be used for long term due to adverse side effects. Botulinum toxin has recently shown promising and encouraging result in management of OAB. AIM: Aim was to study the safety, efficacy, tolerability, and duration of effect of 200 units of botulinum toxin in refractory idiopathic detrusor overactivity. MATERIALS AND METHODS: Thirty-nine female patients (average age of 52 years) clinically and urodynamically diagnosed as idiopathic OAB were injected 200 units of botulinum toxin-A mixed with 20 ml of normal saline, intradetrusally at the rate of 1 mL at each site for 20 such sites sparing the trigone and ureteric orifices. Follow up at 3rd, 6th, 9th, and 12th month with clinical and urodynamical questionnaire was done. RESULTS: There were 4 dropouts and 35 patients were evaluated, of which 30 patients (85.7%) showed improvement in clinical features like frequency, urgency, nocturia, and incontinence within 1 week of injection, which lasted for mean period of 7 months (varying from 6 to 9 months). Volume at first desire to void improved from median baseline of 104-204 ml and maximum cystometric capacity of bladder increased from mean baseline value of 205-330 ml. The detrusor pressure decreased by 49% from the baseline and postresidual urine volume increased by 30% of maximum cystometric capacity of bladder. There was no adverse effect on our patient. CONCLUSION: Intradetrusor injection of Botox-A in management of refractory overactive idiopathic bladder is not only safe and well tolerated, but also very effective with practically no side effects.

Combined low-dose intravesical immunotherapy (BCG + interferon alpha-2b) in the management of superficial transitional cell carcinoma of the urinary bladder: a five-year follow-up.

Between July 1994 and July 2001, all patients with superficial transitional cell carcinoma (TCC) of urinary bladder (pT1 and pTa), 7 days after undergoing transurethral resection of tumor were subjected to intravesical instillation of 60 mg BCG (Danish 1331) combined with 5 million IU interferon alpha-2b (Intron-A) mixed with 50 ml of physiological saline weekly for 8 weeks, then fortnightly for 8 weeks, then monthly for 8 weeks, followed by maintenance dose at the end of the 9th, 12th, 18th, 24th months. Each instillation was for 2 h duration with an average follow-up period of 60 months. At the end of the 1st year of follow-up 84% of patients had no tumor recurrence which dropped to 36% at the end of 5-year follow-up, while no incidence of disease progression at the end of the first year was recorded but was 20% at the end of 5 years, thereby resulting in a disease progression-free 5-year interval in 80% of our patients. Drug tolerance was excellent with a very low incidence of toxicity.

ROLE OF HYSTEROSCOPY IN DIAGNOSIS OF MENSTRUAL DISORDERS.

Hysteroscopic evaluation was carried out in 120 cases of menstrual disorders with no clinical positive findings. The ages of patients ranged from 20 years to 48 years. Abnormal findings on hysteroscopy were noted in 48.3 percent (58 cases) and histologically abnormal lesions were observed in 35.8 percent (43 cases). Histological correlation with hysteroscopy was 74.1 percent Lesions like submucous fibroid, polyps, and uterine synechiae were diagnosed with 100 percent accuracy. This study suggests that hysteroscopic evaluation increases the diagnostic precision in patients with intra-uterine lesions and should be done in cases of menstrual disorders alongwith other traditional methods of evaluation.

CAESAREAN SECTION - CHANGING TRENDS DURING LAST TWO DECADES.

Changing trends of caesarean section during last twenty years have been studied. There seems to be a gradual increase in the incidence of caesarean section over the years with a simultaneous decline in the perinatal mortality rate. The incidence of caesarean section has slowly been increasing for post-caesarean pregnancy, breech presentation and foetal distress. This opens up a debate as to what extent this increase is justifiable. The trend needs a close observation.