Radical cystoprostatectomy: an extraperitoneal retrograde approach.

PURPOSE: We describe a new technical approach for the surgical management of bladder cancer. MATERIALS AND METHODS: Patients with invasive bladder cancer underwent radical cystoprostatectomy using a technically different approach than the conventional method. The important features of this modification include a small infraumbilical incision, completely extraperitoneal dissection to maintain the bowel loops away from the operating field, urethral dissection performed earlier in the operation rather than at the end to preserve the striated urethral sphincter with the neurovascular bundles, completely retrograde dissection of the rectovesical plane for increased safety and reperitonealization done at completion to isolate the urinary anastomoses from the bowel anastomosis. RESULTS: More than 50 consecutive patients with early bladder cancer underwent this operation during a 2-year period. The technique was safe and satisfactory. CONCLUSIONS: Radical retrograde extraperitoneal cystoprostatectomy is based on a finer knowledge of anatomy. It requires accurate dissection, making it inherently superior to the conventional method.

What is optimum neck dissection for T3/4 buccal-gingival cancers?

Buccal-gingival (BG) cancers are an integral part of oral cancers but are biologically distinct, particularly with regard to the propensity and pattern of neck metastases. This study was undertaken to examine the adequacy of limited neck dissection in the management of these tumors. Between 1980 and 1989, 527 T3/4 BG cancers were treated surgically at Tata Memorial Hospital, Bombay. These cases were reviewed retrospectively. Among these, 178 underwent radical neck dissection (RND), 166 supradigastric dissection (SD) and 183 supraomohyoid dissection (SOHD) after confirming the negativity of levels II and III for nodal disease on frozen section. The overall incidence of histological node positivity was 42.5% (224/527). Level I was the most frequent site of metastases, with a skip rate of only 9%. The incidence of pure regional failure (primary controlled) was 3% with RND (67/178), 12% with SD (11/95) and 5% with SOHD (7/141) in patients with N0 necks. In the N+ category the regional failure was 18% with RND (20/111), 34% with SD (24/71) and 19% with SOHD (8/42). These findings show that a limited (SD) dissection is grossly inadequate in the management of T3/4 BG cancers, whereas an SOHD when neck levels II and III are confirmed negative on frozen section yields results comparable to RND for both N0 and N+ necks.

Dilation of esophageal strictures induced by radiation therapy for cancer of the esophagus.

During a 2-year period, 103 consecutive patients undergoing dilation of esophageal strictures induced by radiation therapy for cancer of the esophagus were prospectively studied. The length of the strictures ranged from 0.5 to 13.5 cm (median, 5 cm) and the luminal diameter from 1 to 11 mm (median, 6 mm). Patients were referred for dilation from 2 weeks to 5 years (median, 2 months) after completion of radiation therapy. The guide wire was placed using fluoroscopy in 21 patients, endoscopy in 61, and a combination of endoscopy and fluoroscopy in 21. At least one dilator larger than the stricture could be passed in 101 (98%) patients. Five strictures were dilated to 16 mm, 29 to 15 mm, 28 to 14 mm, 16 to 12.8 mm, and 23 to 12 mm or less during the initial procedure. Development of complications and severe resistance were the limiting factors for optimal dilation. Relief of dysphagia was adequate in 66% of patients. The duration of dysphagia relief was 3 to 84 weeks (median, 16 weeks). Complications included persistent pain in 7 patients, unexplained fever in 2, perforation in 2, and delayed tracheo-esophageal fistula in 1. Two patients died of treatment-related complications. Repeated dilation was required in 32 of the 75 patients on long-term follow-up. We conclude that adequate palliation of dysphagia can be achieved by dilation in two-thirds of patients with radiation therapy-induced strictures of the esophagus. Dilation of these strictures is relatively simple and safe if performed with care.