Risk factors for intravesical recurrence after surgical management of transitional cell carcinoma of the upper urinary tract.

OBJECTIVES: To identify risk factors for developing subsequent bladder cancer in patients undergoing surgical management of transitional cell carcinoma (TCC) of the upper urinary tract. METHODS: This study included 177 patients who were diagnosed as having clinically localized upper urinary tract TCC and thereafter underwent nephroureterectomy after exclusion of those with a previous and/or concurrent history of bladder cancer. Univariate and multivariate analyses using both the logistic regression model and the Cox proportional hazards model were carried out in these 177 patients to determine the risk factors for intravesical recurrence after nephroureterectomy. RESULTS: Of the 177 patients, 63 (35.6%) developed recurrent bladder cancer after a median interval of 7.5 months. Intravesical recurrence-free survival rates for these 177 patients at 1, 3, and 5 years were 75.7%, 63.7%, and 54.1%, respectively. Univariate analyses showed that patients with low-stage tumors and those with multifocal tumors were likely to undergo subsequent intravesical recurrence; however, there was no significant impact of other factors on subsequent intravesical recurrence, including age, tumor side, tumor location, surgical modality, operation time, management of the distal ureter, tumor grade, lymph node metastasis, microvascular invasion, lymphatic invasion, and margin status. Furthermore, pathologic stage and tumor multifocality were identified as independent predictors for the development of recurrent bladder cancer by multivariate analyses. CONCLUSIONS: The incidence of intravesical recurrence after nephroureterectomy for upper urinary tract TCC is comparatively high. It could be important to perform careful follow-up targeting intravesical recurrence for such patients after nephroureterectomy, particularly those with low-stage tumors and/or multifocal tumors.

[Modifications in the technique for apical dissection of radical retropubic prostatectomy to improve urinary incontinence].

PURPOSE: To evaluate urinary continence after modified radical retropubic prostatectomy. MATERIAL AND METHODS: From March 1999 to May 2004, 110 patients with prostate cancer underwent radical retropubic prostatectomy. In all patients, the fascia of the levator ani was preserved, and the plane between the prostate and rectum was dissected prior to cutting the urethra. A modification to the technique of apical dissection was introduced in May 2002. The modified method included cutting the urethra along a precise line between the prostate and urethra following the shape of the prostatic apex. The grade of early urinary incontinence was analyzed by using the incontinence rate (urinary incontinence volume (ml)/total urinary volume x 100 (%)). The incontinence rate was compared between the conventional and modified surgical techniques. Several other risk factors were also examined in these patients. Continence rates were analyzed among the patients over a one-year postoperative course. RESULTS: The incontinence rate on the day, the next day and 5-7 days after the removal of the urethral catheter were 18.1%, 11.2%, 6.0% in the modified group, and 36.6%, 22.5%, 12.6% in the conventional group, respectively. With the introduction of this modified method, the incontinence rate was significantly decreased (P<0.005). Complete continence rates 3 and 12 months after the operation were 81.3% and 98.3% in the modified and 60.0% and 97.8% in the conventional group. The time to regain complete continence in the modified was earlier than that in the conventional. After one-year, the rate of complete continence was similar and a satisfactory average in each group. Except for surgical techniques, no other factors were associated with a risk of incontinence statistically. CONCLUSIONS: We recommend modified apical dissection to preserve the urethral striated sphincter, which can be useful in improving the early incontinence rate and the recovery of continence.