The need for repeated urological evaluation in low-risk patients with microscopic hematuria after negative diagnostic work-up.

AIM: To evaluate the role of repeated urological evaluation after negative initial diagnostic work-up of asymptomatic microhematuria (AMH) in low-risk patients. PATIENTS AND METHODS: Criteria for patient inclusion were a complete negative initial diagnostic assessment including ultrasound (US), cystoscopy, upper urinary tract (UUT) imaging using intravenous urography (IVU) or multiphasic computed tomography (CT), absence of risk factors and a follow-up period of at least three years. Based on our institutional practice, urinalysis was repeated yearly; cystoscopy with US was repeated three years after initial work-up. The oncological outcome was evaluated across a mean follow-up of 8 (range: 3.7-10.2) years. RESULTS: A case series of 87 (32.2% of 270) low-risk patients, 56 women and 31 men, with a mean age of 52.4 (range: 19-87) years was studied. Three years after initial work-up, cystoscopy confirmed no bladder carcinoma in any of these 87 patients. Prostate cancer was diagnosed in one (1.1%) patient. In five (5.6%) patients, nephrological evaluation due to concomitant proteinuria on follow-up demonstrated chronic renal insufficiency (n=3), IgA nephropathy (n=1) and papillary necrosis of the kidney (n=1). CONCLUSION: Low-risk patients with persistent AMH after negative urological evaluation have a neglectable risk of developing bladder cancer on follow-up. Newly-discovered proteinuria on follow-up should be clarified by a nephrologist, as proteinuria could be a sign of significant glomerular disease.

Orthotopic bladder replacement in women: focus on functional results of a retrospective, single-centre study.

OBJECTIVE: The aim of this study was to investigate the functional and oncological outcomes of orthotopic neobladders in women with urothelial cancer. MATERIAL AND METHODS: From 1993 to 2007, 61 women underwent radical cystectomy and orthotopic ileal neobladder using the hemi-Kock pouch or Skinner T pouch. Sixteen of them were excluded owing to a lack of available follow-up data. Finally, 39 women with diagnosed TCC were included in this retrospective study. Demographic data, functional outcome including micturition characteristics such as voided volume, continence situation, use of clean intermittent catheterization (CIC), residual urine volume and recurrence rate were collected 3, 6 and >12 months after surgery. RESULTS: Tumours were non-muscle-invasive in 13 patients (pT1; 32.8%) with isolated carcinoma in situ (after failure of bacillus Calmette-Guérin) in five patients (13.0%) and muscle-invasive in 19 patients (pT2-3; 49.0%), extensive superficial bladder cancer was shown in one patient (2.6%), and remaining dysplasia after transurethral resection of the bladder for T1 G2 in one patient (2.6%). Median follow-up was 37 (range 3-165) months. Day-time (71.4%) and night-time (67.8%) continence (0-1 pad/24 h) 3 months postoperatively increased to 83.8% on long-term follow-up. Clean intermittent self-catheterization was required by 20%. At a mean follow-up of 39.5 (8-86) months, two women experienced local recurrence (septum rectovaginale, pelvic floor), urethral recurrence was seen in 5.2% and distant metastasis (pulmonary, peritoneal carcinosis) also in 5.2%. CONCLUSIONS: Orthotopic bladder replacement is an efficient option in appropriately selected women undergoing radical cystectomy, with encouraging functional outcome and low urethral recurrence rates, similar to published literature in men.

Two cycles of cisplatin-based chemotherapy for low-volume stage II seminoma: results of a retrospective, single-center case series.

BACKGROUND: To report on the oncological outcome and toxicity of patients treated with 2 cycles of cisplatin-based chemotherapy for low-volume metastatic stage II seminoma. METHODS: We retrospectively identified a case series of 15 patients with seminoma stage IIA (26.7%) and IIB (73.3%) who underwent chemotherapy consisting of 2 cycles of cisplatin, etoposide and bleomycin (PEB) (cisplatin 20 mg/m(2) on days 1-5, etoposide 100 mg/m(2) on days 1-5, bleomycin 30 mg on days 1, 8 and 15) according to patient preference (refusing a 3rd cycle of PEB) or institutional practice in the last decades. Complete staging before chemotherapy was available in all patients. Patient age, the side and diameter of the primary tumor, the size of the lymph nodes before and after chemotherapy, acute and late toxicity of chemotherapy, the incidence of second malignancies, the relapse-free rate and cancer-specific mortality were recorded. RESULTS: Chemotherapy was well tolerated and no episode of febrile neutropenia occurred. Thrombocytopenia grade 4 was not seen in any patient, while leukopenia grade 4 was observed in 4 (26.6%) patients. The mean (range) lymph node size decreased significantly from 2.54 cm (1.1-4.0) before chemotherapy to 0.75 cm (0.4-2.2) after chemotherapy (p < 0.001). After a median (range) follow-up of 60 (13-185) months, no patient had relapsed, no patient had died as a result of seminoma and second malignancy was seen in only 1 (6.6%) patient. CONCLUSIONS: These excellent long-term results from a retrospective case series of 2 cycles of PEB in stage IIA/IIB seminoma patients represent a hint for further research with a view to reducing treatment burden. However, these incidental findings should be studied in prospective trials prior to drawing any conclusions.

Considerations on implementing diagnostic markers into clinical decision making in bladder cancer.

Bladder cancer is a common disease that is often detected late and has a high rate of recurrence and progression. Cystoscopy is the main tool in detection and surveillance of bladder cancer but is invasive and can miss some cancers. Cytology is frequently utilized but suffers from a poor sensitivity. There are several commercially available urine-based tumor markers currently available but their use is not recommended by guideline panels. Markers such as the Urovysion FISH assay and the NMP22 BladderChek test are approved for surveillance and detection in patients with hematuria. The added benefit of these markers and other commercially available markers (e.g. Ucyt+, BTA stat) has not been well investigated though it appears these markers are insufficiently sensitive to replace cystoscopy. Additional studies are needed to determine the clinical scenarios where bladder markers are best utilized (screening, surveillance, early detection, evaluating cytologic atypia) and what impact they should have on clinical decision making. Furthermore, a variety of issues and barriers can affect the movement of clinical tests from research to clinical practice. This article addresses some of the challenges facing research and medical communities in the delivery and integration of markers for bladder cancer diagnosis. Moreover, we attempt to outline criteria for the clinical utility of new bladder cancer diagnostic markers.

Results of bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer.

PURPOSE: We evaluated the feasibility and early oncological outcome of a laparoscopic nerve sparing bilateral retroperitoneal lymph node dissection. The surgical technique is described. MATERIALS AND METHODS: From July 2004 to December 2007 a total of 42 patients with nonseminomatous germ cell tumor (21 with stage I, 2 with stage IIA marker negative and 19 with post-chemotherapy stage IIB disease) underwent transperitoneal bilateral laparoscopic retroperitoneal lymph node dissection. The sympathetic trunk and postganglionic nerves were identified, and lymphatic tissue was dissected between the nerves. Patients with clinical stage I and IIA disease that was lymph node positive at laparoscopic retroperitoneal lymph node dissection did not receive additional chemotherapy. RESULTS: Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Mean operative time was 323 minutes. No intraoperative complications occurred. Of patients with stage I and marker negative stage IIA disease active tumor was found in 5 retroperitoneal lymph node dissection specimens, and no patients had recurrence. Of 19 patients with post-chemotherapy stage IIB disease teratoma was found in the lymphatic tissue in 4 (21.0%). No retroperitoneal recurrence was observed. Pulmonary metastases developed 9 months after surgery in 1 patient with stage I disease and negative retroperitoneal histology, and were treated successfully. All patients are currently free of disease at a mean followup of 17.2 months. Antegrade ejaculation was preserved in 36 patients (85.7%). CONCLUSIONS: Bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection is feasible and associated with low morbidity if performed by experienced hands. The oncological efficacy of this approach is promising and currently under evaluation.