Comparison of modified Taguchi and Bricker ureteral reimplantation techniques after radical cystectomy.

OBJECTIVES: To present our experience with the modified Taguchi "single-stitch" ureteral reimplantation technique in patients undergoing radical cystectomy with urinary diversion compared with a traditional Bricker reimplantation technique. Improved techniques are continually sought for ureteroenteric anastomoses during urinary diversion. The modified Taguchi "single-stitch" ureteral reimplantation is reportedly a time-efficient technique that preserves anastomotic integrity. METHODS: We retrospectively examined 75 consecutive patients with bladder cancer who underwent cystectomy and urinary diversion between October 1, 1999 and March 31, 2001. The ureteroenteric anastomosis was performed using a reinforced single-stitch modified Taguchi technique in the first 36 patients and an interrupted two-layer Bricker technique in the subsequent 39 patients during the creation of 47 orthotopic neobladders and 28 ileal conduit diversions. Ureteral stents were not routinely used. The demographic and perioperative clinical parameters were evaluated in each cohort, with particular attention to ureteral complications. RESULTS: Modified Taguchi and Bricker ureteral anastomoses were performed in 48% and 52% of patients, respectively. Patient age, sex, and body mass indexes were similar between groups. Apart from pathologic stage, univariate analysis did not demonstrate statistically significant differences between the groups in the demographic, intraoperative (estimated blood loss, diversion type, operative time) or postoperative (length of stay, rate of complications) parameters. Ureteral complications occurred in 8% of the Bricker group and 15% of the modified Taguchi group (P = 0.23). CONCLUSIONS: Either technique can be performed safely and in a timely fashion. However, the increased number of ureteral leaks in the modified Taguchi cohort combined with no advantage in procedure time, prompted our return to the Bricker technique exclusively.

Impact of body mass index on radical cystectomy.

PURPOSE: Radical cystectomy has a significant rate of morbidity and it is important to elucidate the factors that contribute to this risk. Obesity is a major problem in the United States and is associated with increased health hazard. Morbid obesity may even preclude definitive surgical treatment. This study examines the impact of body mass index (BMI) on radical cystectomy. MATERIALS AND METHODS: Retrospective analysis was performed on 498 patients who underwent radical cystectomy primarily for bladder cancer from July 1, 1990 to May 10, 2002. Patient BMI was defined as normal (less than 25 in 151), overweight (25 to 29.9 in 198), obese (30 to 34.9 in 98) and morbidly obese (35 or greater in 51). The bivariate relationships among BMI categories and clinical parameters were assessed using the chi-square test, the analysis of variance and the log rank test. Multivariate analyses were performed using Cox regression models. RESULTS: Median followup for the cohort was 3.3 years. Mean BMI was 28 and 70 of the study group was above normal weight. Compared to normal BMI, upper weight BMI groups were younger (p <0.0001), and had increased estimated blood loss (p = 0.01) and operative time (p = 0.001). Complication number (p = 0.0004) was increased in these groups but complication severity was similar (p = 0.54). Morbidly obese patients underwent incontinent diversion more often (p = 0.03). In multivariate models increased BMI was independently associated with increased estimated blood loss (p = 0.004), prolonged operative time (p = 0.006) and increased complication rate (p = 0.01). CONCLUSIONS: Increased BMI independently poses a greater perioperative risk to the patient and contributes to the technical challenge of the cystectomy. This is most appreciated in the morbidly obese population and likely contributes to a greater use of incontinent diversion in this group. The increased perioperative risk associated with elevated BMI is significant but not prohibitive and should not preclude cystectomy as definitive treatment.

Salvage prostatectomy in patients who have failed radiation therapy or cryotherapy as primary treatment for prostate cancer.

Asymptomatic prostate-specific antigen (PSA) recurrence after radiation therapy for prostate carcinoma poses a diagnostic and therapeutic dilemma for clinicians. Patients with locally recurrent disease can consider treatment options of salvage surgery, cryotherapy, watchful waiting, or androgen deprivation. Of these options, only salvage surgery has been shown to result in long-term disease-free survival for selected patients. However, salvage surgery is associated with significant morbidity, including urinary incontinence and rectal injuries. Ideally, salvage surgery outcomes can be optimized with careful patient selection according to clinical stage, serum PSA levels before radiation and surgery, the medical condition of the patient, and clear expectations of the physician and patient. Among patients with locally recurrent disease, those with localized prostate carcinoma amenable to radical prostatectomy before radiation or cryotherapy would be the most suitable candidates for salvage surgery.