Screening cystoscopy and survival of spinal cord injured patients with squamous cell cancer of the bladder.

PURPOSE: Yearly cystoscopy has been advocated in spinal cord injured patients with chronic or recurrent urinary tract infections secondary to the increased risk of squamous cell cancer of the bladder. We examined the effectiveness of this protocol in our patients. MATERIALS AND METHODS: The medical records of all spinal cord injured patients with squamous cell cancer of the bladder between 1980 and 1996 were reviewed for the method of detection of the lesion. Screened patients (those presenting with chronic or recurrent urinary infections) were considered asymptomatic and were compared to symptomatic patients (those presenting with overt signs or symptoms of the bladder lesion) with respect to age, latency since spinal cord injury, treatment of neurogenic bladder, therapy, pathological stage and survival. RESULTS: Of 14 patients (9 symptomatic at presentation) 13 underwent cystoprostatectomy, while 1 presented with metastatic disease and was treated with supportive care only. Three symptomatic patients received adjuvant radiation therapy for positive lymph nodes or margins. Pathological stage was more advanced in the symptomatic group, including 7 patients (78%) with stage pT3a or pT3b (4 had positive lymph nodes), 1 with stage pT1N0M0 and 1 with stage pT2N0M0 cancer. In the asymptomatic group 3 patients had stage pT2N0M0, 1 had stage pT3aN0M0 and 1 had pT3bN0M0 disease. Overall and cancer specific survival rates for symptomatic patients were 44 and 50%, respectively, with a median of 40 months to death. In the asymptomatic group there was 1 noncancer related death, while the remaining patients were alive at a mean followup of 8.2 years. CONCLUSIONS: Cystoscopy to screen for squamous cell cancer of the bladder in spinal cord injured patients with chronic or recurrent urinary tract infection results in an earlier stage at diagnosis and appears to convey a survival advantage. Such a protocol should be strictly followed and careful prospective studies must be performed to ascertain if this will become significant.

A comparative study of postoperative complications associated with the modified Indiana pouch in elderly versus younger patients.

PURPOSE: We defined the nature and risk of complications associated with the modified Indiana pouch in patients older than 75 years. MATERIALS AND METHODS: We analyzed the clinical course of 25 elderly patients and a control group of 25 selected randomly from the cohort of those younger than 75 years. All patients underwent the modified Indiana pouch procedure. Charts were reviewed for type of operation, mean patient age, length of hospital stay, medical conditions, and early and late morbidity and mortality. Comparisons were made between the 2 groups. RESULTS: Simultaneous cystectomy or anterior exenteration was performed in 84% and 95% of patients in the elderly and younger groups, respectively. Mean age was 78.5 years in the elderly and 59.3 years in the younger group. Medical illnesses and early postoperative complication rates did not differ significantly between the 2 groups. Mean hospital stay was increased but not significantly in the elderly group (12.4 versus 11.1 days). There were 2 perioperative deaths in the elderly group (8%) and 1 in the control group (4%). Mean followup was 24.5 months (range 4 to 64) in the elderly versus 29.5 months (range 6 to 69) in the younger group. Late complications with the pouch were also similar (16% in the elderly and 12% in the control group). Of the elderly patients 9 died (intercurrent medical disease in 1 and cancer progression in 8) compared to 4 in the younger group (intercurrent medical disease in 1 and cancer progression in 3). Of the elderly patients 13 are alive (mean age 81 years) with a well functioning continent diversion. CONCLUSIONS: The modified Indiana pouch can be created with acceptable postoperative morbidity and mortality in elderly patients, and it provides an excellent functional result.

Continent urinary diversion using a Modified Indiana Pouch in elderly patients.

A total of 25 patients at least 75 years old underwent continent urinary diversion via a modified Indiana Pouch during a 68-month period, 21 of these with simultaneous radical cystectomy or anterior exenteration. The preoperative medical conditions as well as the early and late operative morbidity and mortality are reviewed with a mean follow up of 27 months. Average age of patients was 78.5 years, and the mean age of survivors is 81 years. There were two early mortalities attributed to ileal gangrene with secondary sepsis and aspiration pneumonia. Postoperative complications (superficial wound infection, middle colic vein bleed, right ureteral leak, ileus) occurred in five patients, two of whom required re-operation. Mean hospital stay was 12.4 days and ranged from 9-20. There were only six late complications [ureteral stricture (3), small bowel obstruction (1), incontinence (1)] necessitating re-hospitalization and surgical intervention. Late infectious complications included recurrent urinary tract infections (3), pyelonephritis (2), and C. Difficile enterocolitis (2) all managed medically. In addition, 10 other patients have died, 9 from metastatic disease and 1 from intercurrent medical problems. Of the 13 remaining patients, 11 are disease free and all are continent with a mean follow-up time of 33 months. We conclude that continent urinary diversion via a modified Indiana pouch with radical cystectomy or anterior exenteration can be performed with minimal morbidity or mortality, even in an elderly population.