Radical cystectomy and orthotopic urinary reconstruction in patients with bladder cancer after renal transplantation: clinical outcomes and description of technique.

OBJECTIVES: Radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion is the standard treatment for muscle-invasive bladder cancer. In the setting of prior renal transplantation, surgical treatment remains the mainstay but is technically challenging. We report our patient outcomes in this unique population with a description of the technique. METHODS: We identified five patients with a history of renal transplantation who underwent RC and orthotopic urinary diversion. Preoperative clinical and demographic features were compiled and disease-specific and functional outcomes were assessed. Intraoperative technical challenges and maneuvers for avoiding complications are highlighted. RESULTS: Four patients were male and one was female, with a median age of 64 years. Gross hematuria was the most common sign at presentation. Clinical staging was T2, T2 with carcinoma in situ (CIS), high-grade (HG) Ta with CIS, T2 with squamous differentiation, and HG T1, and pathologic tumor stage was pTisN1, pT3N0, pTisN0, pT3N0, and pT0N0, respectively. One patient received a Studer-type diversion and four underwent Hautmann diversion. Median follow-up after cystectomy was 12.9 months. Graft ureteral identification was aided by the use of intravenous dye in all patients. Ipsilateral pelvic lymph node dissection was not possible in any patient. All patients are alive at follow-up, with two experiencing recurrence at 7.2 months and 66.8 months. No patient experienced a significant decrease in estimated creatinine clearance postoperatively. Postoperative daytime control was reported by all patients whereas two noted complete nighttime control. CONCLUSIONS: RC with orthotopic diversion is a technically demanding procedure in patients with a history renal transplantation. Meticulous technique and careful attention to the altered anatomy are required for successful outcomes.

A comparison of hospital-based charges following partial and radical nephrectomy.

OBJECTIVE: Recent studies demonstrate similar survival rates in patients treated with either partial or radical nephrectomy for renal tumors less than 4 cm. We retrospectively compared the hospital based charges for these two procedures in a similar cohort of patients treated at Memorial Sloan-Kettering Cancer Center. PATIENTS AND METHODS: A retrospective review of 103 consecutive cases of renal tumors less than 4 cm treated by either radical or partial nephrectomy from 1996 to 1999 was conducted. Overall hospital charges were calculated by analyzing 18 separate departmental charge categories including room and board, pharmacy, radiologic tests, operating room charges, and laboratory services. RESULTS: A total of 66 partial and 37 radical nephrectomies were analyzed. No difference was found in the mean charge per procedure ($16,660, partial and $16,545, radical); (p > .05). The major cost drivers for partial and radical nephrectomy respectively were: 1) room and board, 42% and 44%; 2) operating room charges, 28% and 25%; 3) pathology, 6% and 6%; 4) recovery room, 6% and 7%; and 5) biochemistry, 5% and 5%. Significant increases in charges for partial nephrectomy were noted from the blood bank services and intraoperative surgical supplies. The median length of stay (5 days) was identical for partial and radical nephrectomy. No difference was found in the complication rate for these procedures (p > .05). CONCLUSION: Hospital-based charges for radical and partial nephrectomy are similar at when performed at a tertiary care referral center.

Impact of separate versus en bloc pelvic lymph node dissection on the number of lymph nodes retrieved in cystectomy specimens.

PURPOSE: Pelvic lymphadenectomy during radical cystectomy yields a various number of lymph nodes depending on the extent of lymph node dissection and pathologist aggressiveness when searching the specimen. How the surgeon submits lymph nodes for pathological evaluation may also affect how many are retrieved. MATERIALS AND METHODS: Bilateral pelvic lymph node dissection and radical cystectomy for transitional cell carcinoma of the bladder was performed in 32 patients. The extent of lymph node dissection involved standard and extended lymphadenectomy in 20 and 12 cases, respectively. In patients who underwent standard dissection unilateral en bloc submission of the lymph nodes was done with the contralateral lymph node dissection sent as an individual discrete packet. In those who underwent extended dissection all lymph nodes from each side were submitted en bloc or as 6 packets. RESULTS: Standard lymphadenectomy en bloc specimens yielded a mean of 2.4 lymph nodes compared with 8.5 retrieved from individual lymph node specimens (p = 0.003). Extended lymphadenectomy en bloc specimens yielded a mean of 22.6 lymph nodes compared with 36.5 retrieved from the individually submitted packets (p = 0.02). CONCLUSIONS: Submitting pelvic lymph nodes as separate specimens optimizes pathological evaluation of the number of lymph nodes that may be involved with metastatic cancer. Such information is important for identifying patients who may benefit from adjuvant chemotherapy.

Results of high dose rate brachytherapy, anterior pelvic exenteration and external beam radiotherapy for carcinoma of the female urethra.

PURPOSE: We evaluated a multimodality approach to locally advanced urethral carcinoma in women. MATERIALS AND METHODS: Between August 1996 and July 1999, 6 women were treated for locally advanced carcinoma of the urethra with anterior pelvic exenteration followed by high dose 192iridium intraoperative radiation therapy. Four of the 6 patients were also treated with neoadjuvant or concomitant platinum based chemotherapy. RESULTS: Two patients had no evidence of disease, 3 had distant metastasis and 2 had local recurrence at a mean followup of 21 months (range 12 to 47). Radiation was relatively well tolerated with no major adverse events. CONCLUSIONS: High dose intraoperative brachytherapy followed by external beam radiation is relatively well tolerated. Local control seems to have improved. We must evaluate a larger cohort of patients to determine this impact of the combined modality on local control and patient survival.

Does early cystectomy improve the survival of patients with high risk superficial bladder tumors?

PURPOSE: We compared survival after early versus delayed cystectomy in patients with high risk superficial bladder tumors. MATERIALS AND METHODS: Of 307 patients with high risk superficial bladder tumors who were treated initially with transurethral resection and bacillus Calmette-Guerin (BCG) therapy 90 (29%) underwent cystectomy for recurrent tumor during a followup of 15 to 20 years. Disease specific survival distribution of these 90 patients was determined relative to the indications for and time of cystectomy. RESULTS: Of the 90 patients who underwent cystectomy 44 (49%) survived a median of 96 months. Of 35 patients with recurrent superficial bladder tumors 92% and 56% survived who underwent cystectomy less than 2 years after initial BCG therapy and after 2 years of followup, respectively. Of 55 patients with recurrent muscle invasive bladder disease 41% and 18% survived when cystectomy was performed within and after 2 years, respectively. Multivariate analysis showed that survival was improved in patients who underwent earlier rather than delayed cystectomy for nonmuscle invasive tumor relapse. CONCLUSIONS: Earlier cystectomy improves the long-term survival of patients with high risk superficial bladder tumors in whom BCG therapy fails.

Radiographic versus pathologic size of renal tumors: implications for partial nephrectomy.

OBJECTIVES: To compare the radiographic size with the pathologic size of renal tumors to determine whether these two measurements vary significantly and to evaluate whether any differences in tumor size could have an impact on the decisions regarding partial nephrectomy. METHODS: In 87 renal tumors excised by partial nephrectomy, the maximum transaxial tumor size on computed tomography (CT) was compared with its corresponding pathologic transverse size. Tumors were locally excised after vascular occlusion and hypothermia. The average size of the tumors selected for partial nephrectomy by preoperative CT scan was 3.4 cm (range 1.9 to 9.3). The difference between the CT size and pathologic size was correlated with the histologic type of the renal tumors. RESULTS: Of the 87 tumors, 52 (60%) were classified as clear cell carcinoma and 35 (40%) as other histologic types (papillary, chromophobe, oncocytoma, and angiomyolipoma). Clear cell carcinomas decreased an average of 0.97 cm versus 0.39 cm for the other tumor types. Of 62 tumors greater than 3 cm on CT, 43 averaged 0.87 cm smaller at pathologic evaluation (36 clear cell and 7 other types) and 19 showed no significant (less than 0.5 cm) decrease in size (2 clear cell and 17 other histologic types). Of 30 tumors greater than 4 cm on CT, 22 clear cell carcinomas shrank more than 1 cm and 8 tumors displaying other histologic features showed no decrease in size. CONCLUSIONS: For renal tumors measuring greater than 4 cm, a decrease in tumor size may help facilitate partial nephrectomy, especially for clear cell carcinomas that do not extensively involve major vascular structures or the collecting system.

The efficacy of transurethral biopsy for predicting the long-term clinical impact of prostatic invasive bladder cancer.

PURPOSE: Involvement of the prostate by bladder cancer directly impacts survival, the risk of urethral recurrence, and treatment decisions concerning the timing of cystectomy and type of urinary diversion. Transurethral lateromontanal loop biopsies are proposed as the most accurate method for evaluating the prostatic urethra. Due to the potential clinical impact on individuals we assessed its accuracy in a large cohort. MATERIALS AND METHODS: Transurethral lateromontanal loop biopsies were performed in 246 of 416 male patients at our institution between 1989 and 1997. The predictive value and sensitivity of transurethral biopsy, patterns of recurrence, survival and clinical impact were assessed in a cohort with 10 years of followup. RESULTS: The sensitivity of transurethral biopsy for prostatic stromal invasion was 53%, specificity was 77%, positive predictive value was 45% and negative predictive value was 82%. At the 10-year followup 129 patients (52.4%) were dead, 85 (32%) had no evidence of disease, 16 (6.5%) had disease and 16 (6.5%) were lost to followup. Mean followup in patients at risk for urethral recurrence was 61.7 months (range 0.56 to 134.1, median 56.8). Delayed urethrectomy was performed in 15 of 235 cases (6.4%) at a mean of 15.2 months. Of the 246 patients 99 had prostatic disease at transurethral biopsy and/or cystectomy, including 11 (11%) with urethral recurrence. No patient required continent diversion takedown or died of urethral recurrence. CONCLUSIONS: Transurethral biopsy did not accurately determine prostatic involvement. Prostatic involvement at biopsy or cystectomy translated into a higher risk of urethral recurrence. However, it did not have significant clinical impact or affect survival and should not be an absolute contraindication to urethral diversion.

Outpatient flexible cystoscopy in men: a randomized study of patient tolerance.

PURPOSE: We evaluate the pain of immediate versus delayed outpatient flexible cystoscopy in men after topical local anesthesia application. MATERIALS AND METHODS: A total of 100 consecutive men with superficial bladder tumors were randomized to immediate or delayed surveillance flexible cystoscopy after intraurethral instillation of lidocaine gel. Patients recorded the level of pain experienced during cystoscopy on a 4-point pain scale and on a 10-point visual linear analog self-assessment scale. RESULTS: Of the 100 patients 50 underwent immediate and 50 underwent delayed cystoscopy. The mean pain score on a scale of 1-no to 4-severe pain was 1.7 after immediate cystoscopy compared with 1.6 after delayed cystoscopy (p = 0.9). The mean linear analog self-assessment score on a scale of 1-no to 10-most pain was 2.1 after immediate cystoscopy versus 1.8 after delayed cystoscopy (p = 0.7). CONCLUSIONS: There was no difference in pain perception in men undergoing immediate or delayed outpatient flexible cystoscopy using the same local anesthetic.

Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse.

PURPOSE: To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting. PATIENTS AND METHODS: Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months). RESULTS: Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P =.001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers. CONCLUSION: Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.

Mechanisms of prostatic stromal invasion in patients with bladder cancer: clinical significance.

PURPOSE: We assess the pathological mechanisms of silent prostatic stromal invasion in patients with bladder cancer for early detection and treatment. MATERIALS AND METHODS: Between August 1998 and January 1999, 10 patients with clinically organ confined transitional cell carcinoma of the bladder and known prostatic stromal invasion on transurethral biopsy or who were high risk for prostatic involvement due to tumor location near the bladder neck were studied for histological patterns of prostatic invasion. There were 5 cystectomy specimens distended for 24 hours with formalin via a Foley catheter, then step sectioned longitudinally at 3 mm. intervals through the bladder neck and prostate. Standard hematoxylin and eosin staining methods were used and sections were analyzed by 2 pathologists. RESULTS: There were 3 separate patterns of prostatic stromal invasion elucidated, including 2 previously described methods of extravesical or intraurethral invasion into the prostatic stroma and a third one through the bladder neck directly into the prostatic stroma. The third pattern was not grossly evident on endoscopy or urethral biopsy before cystectomy. CONCLUSIONS: Longitudinal sectioning of the bladder neck and prostate of cystectomy specimens suggests tumors at the bladder neck may directly invade the prostatic stroma without histological evidence of extravesical or intraurethral spread. Such direct silent tumor invasion of the prostate by superficial or endoscopically inapparent tumor is difficult to detect clinically by current biopsy methods. New methods of detection are necessary.

Post-chemotherapy surgery in patients with unresectable or regionally metastatic bladder cancer.

PURPOSE: We update our experience with post-chemotherapy surgery in patients with unresectable or lymph node positive bladder cancer. METHODS: Of 207 patients with unresectable or regionally metastatic bladder cancer 80 (39%) underwent post-chemotherapy surgery after treatment with a cisplatin based chemotherapy regimen. We assessed the impact of surgery on achieving a complete response to chemotherapy and on relapse-free survival. RESULTS: No viable cancer was present at post-chemotherapy surgery in 24 of the 80 cases (30%), pathologically confirming a complete response to chemotherapy. Of the 24 patients 14 (58%) survived 9 months to 5 years. Residual viable cancer was completely resected in 49 patients (61%), resulting in a complete response to chemotherapy plus surgery, and 20 (41%) survived. Post-chemotherapy surgery did not benefit those who failed to achieve a major complete or partial response to chemotherapy. Only 1 of the 12 patients (8%) who refused surgery remains alive. CONCLUSIONS: Post-chemotherapy surgical resection of residual cancer may result in disease-free survival in some patients who would otherwise die of disease. Optimal candidates include those in whom the pre-chemotherapy sites of disease are restricted to the bladder and pelvis or regional lymph nodes, and who have a major response to chemotherapy.

Transurethral resection of muscle-invasive bladder cancer: 10-year outcome.

PURPOSE: To determine the 10-year outcome of patients with muscle-invasive bladder cancer treated by transurethral resection (TUR) alone. PATIENTS AND METHODS: Of 432 newly evaluated patients with muscle-invasive bladder cancer, 151 were treated by standard radical cystectomy or by definitive TUR, if restaging TUR of the primary tumor site showed no (T0) or only non-muscle-invasive (T1) residual tumor. Patients were followed-up every 3 to 6 months thereafter for a minimum of 10 years and up to 20 years. Primary end points of the study were disease-specific survival, survival with a bladder, frequency of recurrent invasive tumors in the bladder, and survival after salvage cystectomy. RESULTS: The 10-year disease-specific survival was 76% of 99 patients who received TUR as definitive therapy (57% with bladder preserved) compared with 71% of 52 patients who had immediate cystectomy (P: = .3). Of the 99 patients treated with TUR, 82% of 73 who had T0 on restaging TUR survived versus 57% of the 26 patients who had residual T1 tumor on restaging TUR (P: = .003). Thirty-four patients (34%) relapsed in the bladder with a new muscle-invasive tumor, 18 (53%) were successfully treated with salvage therapy via cystectomy, and 16 patients (16%) died of disease. CONCLUSION: Radical TUR for muscle-invasive bladder cancer is a successful bladder-sparing therapeutic strategy in selected patients who have no residual tumor on a repeat vigorous resection of the primary tumor site.

Upper-tract tumors after an initial diagnosis of bladder cancer: argument for long-term surveillance.

PURPOSE: To determine the relative risk (RR) of upper-tract tumors (UTT) after bladder cancer, stratified by bladder tumor characteristics, demographic factors, and follow-up duration, in order to develop an improved risk-based surveillance strategy. PATIENTS AND METHODS: The 1973 to 1996 Surveillance, Epidemiology, and End Results (SEER) database was used to determine the observed and expected number of UTT after bladder cancer. The RR with 95% confidence intervals (CI) were calculated, stratifying by race, sex, stage, grade, histology, and follow-up duration. The tumor characteristics and clinical outcome were compared in patients with UTT after bladder cancer and those with de novo UTT. RESULTS: A total of 94,591 patients had a first diagnosis of bladder cancer, of whom 91,245 had follow-up (median, 4.1 years), with no antecedent or synchronous UTT. UTT developed subsequently in 657 of 91,245 (0.7%), with 12.80 expected cases (RR = 51.3; 95% CI, 47.5 to 55.4). The respective RRs for UTT for white men and women were 64.2 (95% CI, 55.1 to 74.3) and 75.4 (95% CI, 57.7 to 96.9) at less than 2 years, 44.3 (95% CI, 36.7 to 53.0) and 40.5 (95% CI, 27.9 to 56.8) at 2 to 5 years, 50.8 (95% CI, 42.2 to 60.7) and 42.1 (95% CI, 28.8 to 59.4) at 5 to 10 years, and 43.2 (95% CI, 32.6 to 56.1) and 22.2 (95% CI, 10.1 to 42.2) at >or= 10 years. Similar RRs were seen among different strata of race, stage, grade, and histology. Patients with UTT after bladder cancer had lower stage and improved disease-specific survival compared with those with de novo UTT. CONCLUSION: The incidence of UTT is stable on long-term follow-up, with no significant risk factors identified. These findings suggest that upper-tract surveillance remain rigorous on extended follow-up of bladder cancer patients.

Outcome of patients with grossly node positive bladder cancer after pelvic lymph node dissection and radical cystectomy.

PURPOSE: Should the surgeon proceed with surgery when grossly positive nodes are found at cystectomy? To answer this question, we determine the outcome of patients after radical surgery alone for grossly node positive bladder cancer. MATERIALS AND METHODS: A total of 84 patients with grossly node positive (N2-3) bladder cancer found at cystectomy underwent extended pelvic lymph node dissection and have been followed for up to 10 years. The end point of study was disease specific survival. RESULTS: Of the 84 patients 20 (24%) survived and 64 (76%) died of disease. Median survival time was 19 months for all patients and 10 years for surviving patients. Of 53 patients with clinical stage T2 (organ confined) tumors 17 (32%) survived versus 3 of 31 (9.7%) with stage T3 (extravesical) tumors. CONCLUSIONS: A proportion of patients with grossly node positive bladder cancer can be cured with radical cystectomy and thorough pelvic lymph node dissection.

Does cystoscopy correlate with the histology of recurrent papillary tumours of the bladder?

OBJECTIVE: To correlate the cystoscopic appearance of recurrent papillary bladder tumours with the histology after transurethral resection, and thus ascertain whether cystoscopy can reliably identify low-grade, noninvasive papillary tumours suitable for outpatient fulguration. PATIENTS AND METHODS: In all, 150 recurrent papillary tumours of the bladder identified at outpatient flexible cystoscopy were classified as either low-grade and noninvasive (TaG1), high-grade and noninvasive (TaG3), or invasive (TIG3) tumours, and correlated with urine cytology and histology of tumour stage and tumour grade after transurethral resection. RESULTS: Cystoscopy classified 84 of the 150 papillary tumours as TaG1 and 66 as either TaG3 or T1G3. Cystoscopy correctly predicted the histology of 78 of 84 (93%) TaG1 tumours, 71 of 72 (98%) TaG1 tumours associated with a negative urine cytology, and 92% of TaG3 or T1G3 tumours. CONCLUSIONS: A skilled urologist can identify noninvasive, low-grade recurrent papillary bladder tumours on follow-up cystoscopy that do not require biopsy and that may be treated by outpatient fulguration alone.

Immediate versus delayed outpatient flexible cystoscopy: final report of a randomized study.

PURPOSE: To evaluate discomfort experienced by men undergoing an immediate versus delayed outpatient flexible cystoscopy after topical local anesthesia. PATIENTS AND METHODS: Two hundred eighty eight consecutive men with superficial bladder tumors were randomized to undergo immediate or delayed surveillance flexible cystoscopy after intraurethral instillation of lidocaine jelly. The patients recorded their level of pain experienced during cystoscopy on a 4-point pain scale and on a 10-point visual analogue (VAS) scale. RESULTS: Of the 288 patients, 145 underwent immediate cystoscopy and 143 had a delayed cystoscopy. The mean pain score on a scale of 1 (no pain) to 4 (severe pain) was 1.6 after immediate cystoscopy compared with 1.5 after delayed cystoscopy (p=7). The mean VAS score on a scale of 1 (no pain) to 10 (most painful) was 1.8 after immediate cystoscopy versus 1.7 after delayed cystoscopy (p=5). CONCLUSION: There was no difference in pain perception among men undergoing an immediate or a delayed outpatient flexible cystoscopy using the same local anesthetic.

Quality of life of asymptomatic men with nonmetastatic prostate cancer on androgen deprivation therapy.

PURPOSE: We evaluate the quality of life of asymptomatic men with nonmetastatic prostate cancer who receive androgen deprivation therapy. MATERIALS AND METHODS: Quality of life was longitudinally evaluated in a cohort of 144 men with locally advanced prostate cancer or prostate specific antigen relapse after local therapy who chose to receive (79 patients) or not to receive (65 patients) androgen deprivation therapy. Androgen deprivation therapy consisted of orchiectomy, leuprolide alone or leuprolide plus flutamide. Multivariate analysis of variance was used to test the effect of different treatment regimens on patient quality of life. RESULTS: Men who received androgen suppression had more fatigue, loss of energy, emotional distress and a lower overall quality of life than men who deferred hormone therapy. Combined androgen blockade had a greater adverse effect on quality of life than monotherapy. CONCLUSIONS: Androgen deprivation therapy may significantly impair the physical and emotional health of asymptomatic patients with nonmetastatic prostate cancer.

Current use and questions concerning intravesical bladder cancer group for superficial bladder cancer.

Bacille Calmette-Guerin (BCG) is the most effective therapy for CIS of the bladder. Although several series have shown a decrease in recurrence and progression of T1 tumor, this effect is temporary. More than one half of patients with T1 tumors treated with BCG will progress over the longterm. A second course of BCG is indicated after an initial complete response. There is no definitive answer regarding the efficacy of maintenance therapy or the optimum dose of BCG. Randomized trials are needed to address these issues in a more conclusive manner. Phase III trials have shown that mitomycin C can be as effective as BCG in the management of papillary tumors; however, BCG is more effective in patients with CIS and high-risk superficial tumors.