Long-term functional and urodynamic results of 50 patients receiving a modified sigmoid neobladder created with a short distal segment.

PURPOSE: We assessed the long-term functional and urodynamic outcomes of a modified sigmoid neobladder. MATERIALS AND METHODS: A total of 50 patients received a sigmoid neobladder with a short distal segment after radical cystoprostatectomy. Patients were followed at 3-month intervals the first year and every 6 months thereafter. Continence and voiding patterns were assessed using questionnaires and interview. The International Continence Society classification was used after 1996. Urodynamic assessment was performed 3 times during followup. RESULTS: Mean sigmoid segment length +/- SD was 18 cm (+/- 2.8). Mean followup was 38 months (+/- 24.8). Ureter stricture and reflux were present in 8% and 17% of the reimplanted units, respectively. Mean creatinine serum levels did not change after surgery and remained stable during followup. At 2 years 89% of the patients were continent in the daytime and 90% had good or satisfactory daytime continence according to the International Continence Society classification. At 3 years 77% of the patients voided every 3 or 4 hours during the day. Nighttime continence was poor. Only 10% of the patients complied with an alarm program. Mean maximal capacity of the reservoir was 300 ml and remained stable during followup. Mean intrareservoir pressure at maximal capacity decreased from 61 to 51 cm H2O from the first to the third urodynamic evaluation. No patient required clean intermittent catheterization. CONCLUSIONS: This modified sigmoid neobladder offers good daytime continence with low post-void residual and adequate daytime micturition frequency. Nighttime continence is poor. The presence of high intrareservoir pressures did not impair renal function.

Comparison of orthotopic sigmoid and ileal neobladders: continence and urodynamic parameters.

OBJECTIVES: The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments. METHODS: Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups. RESULTS: The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7-32) ml/s, IN group 25.5 (range 5-35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night. CONCLUSION: A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.

Long-term follow-up of a randomized prospective trial comparing a standard 81 mg dose of intravesical bacille Calmette-Guérin with a reduced dose of 27 mg in superficial bladder cancer.

OBJECTIVES: To determine the efficacy of a three-fold reduced dose (RD, 27 mg) of intravesical bacille Calmette-Guérin (BCG) against the standard dose (81 mg) in patients with superficial bladder cancer, assessing recurrence, progression and differences in toxicity. PATIENTS AND METHODS: Five hundred patients with superficial bladder cancer (Ta, T1, Tis) were enrolled and randomly assigned to be treated after transurethral resection of all visible lesions with intravesical BCG Connaught strain (weekly x six and thereafter fortnightly x six) either with the standard or RD instillation. RESULTS: All but one of the 500 patients were evaluable for efficacy and toxicity (252 in the standard arm and 247 in the RD arm). The median follow-up was 69 months (maximum 104); 71 (28%) patients in the standard arm and 76 (31%) in the RD arm developed recurrences; the median time to recurrence has not yet been attained, but at 5 years the mean (sd) percentage of recurrence-free patients was 70.5 (3.12) and 70.4 (3.1) for the standard and RD arms, respectively. In patients presenting with multifocal tumours, the standard dose was more effective against recurrences than the RD (P=0.0151). In those with G3 and high-risk tumours overall, the superiority of the standard dose was marginal (P=0.060 and P=0.082). Twenty-nine (11.5%) tumours in the standard arm and 33 (13.3%) in the RD arm progressed to invasive disease; the median time to progression has not yet been attained, but the percentage of progression-free patients at 5 years was 88.8 (2.23) and 86.9 (2.31) for the standard and RD arms, respectively. The standard dose was more effective than the RD against progression only in patients with multifocal disease (P=0.048). Twelve (4.8%) cystectomies were performed in the standard and 15 (6.1%) in the RD arm. Currently, 106 (21.2%) patients have died, but only 38 (7.6%) from bladder cancer, i.e. 20 (7.9%) in the standard and 18 (7.5%) in RD arm. Overall the disease-specific death rate was lower for those patients who completed the scheduled treatment. The cause-specific survival at 5 years did not differ between the arms (P=0.76) but there was a trend toward better cause-specific survival for patients with multifocal tumours in the standard arm. Toxicity differed between the arms, significantly more patients having no toxicity in the RD arm, and fewer having delayed instillations or withdrawing. However, severe systemic toxicity occurred even in patients treated with the RD, in a similar proportion to those receiving the standard dose. CONCLUSION: Overall, the RD gave similar results for recurrence and progression but with significantly less toxicity. However, patients with multifocal tumours fared better with the standard dose and there was a trend towards better recurrence rates in patients with high-risk tumours. We recommend continuing to use the standard dose for high-risk tumours, while we consider the reduced dose safe and effective for intermediate-risk lesions and for maintenance schedules.

Radical perineal prostatectomy without pelvic lymphadenectomy: selection criteria and early results.

PURPOSE: We evaluated the surgical efficacy of radical perineal prostatectomy and determined preoperative parameters to identify patients at low risk for nodal metastasis. MATERIALS AND METHODS: Of 155 men evaluated for radical perineal prostatectomy, 74 were assigned to a low risk category (prostate specific antigen less than 10 ng./ml., Gleason score less than 7). Of the patients 40 underwent laparoscopic lymph node dissection and 34 did not. This group was compared to 81 patients who underwent surgical staging and did not fit the low risk criteria. RESULTS: None of 74 patients in the low risk group had nodal metastasis, while metastasis was present in 5 of 81 (6.1%) who did not meet such parameters. Organ-confined disease was present in 71.6% of men with low risk criteria, which was a significantly different rate than the 51.9% found in the other 81 men. CONCLUSIONS: Radical perineal prostatectomy confers adequate cancer control and can be performed without pelvic node dissection in select patients.

[Is there a place for radical prostatectomy without lymphadenectomy?]. / Hay un lugar para la prostatectomía radical sin linfadenectomía?

OBJECTIVES: Herein we present the procedure we have followed to determine N+ low-risk factors which allow us to identify those patients with prostate cancer in whom radical perineal prostatectomy (RPP) can be performed without a previous staging lymphadenectomy, thereby maintaining the oncological principles but with less morbidity. METHODS: In a series of 88 patients who underwent RPP, we identified an N+ low-risk factor group; i.e., patients with clinically localized tumor of the prostate gland, a Gleason score of < or = 7 and PSA < or = 10 ng/ml. The foregoing criteria were based on the findings reported by Stamey and the status of the lymph nodes of our own series of radical prostatectomies. RESULTS: In 71 of the 88 patients with a follow up of more than one year, RPP was performed after laparoscopic pelvic lymphadenectomy. Of these 71 patients, 17 (19.3%) presented the above-mentioned low-risk characteristics and were all pN-. Since then, the subsequent patients who met this low-risk criteria (n = 17; 19.3% of the total) were submitted to RPP alone without previous staging lymphadenectomy. The rate of positive margins in this group was 17.6%, all cases maintaining PSA within feminization levels after a mean follow-up of 21.7 months. Considering the overall series, 38.6% of the patients could have avoided lymphadenectomy according to our criteria. CONCLUSIONS: We have found RPP without previous staging lymphadenectomy to be a valid therapeutic option for patients with clinically localized prostate cancer, preoperative PSA < or = 10 ng/ml and a Gleason score of < or = 7. According to our data, this group accounts for approximately 40% of the patients in whom radical prostatectomy had been recommended.

Neoadjuvant cisplatin chemotherapy before radical cystectomy in invasive transitional cell carcinoma of the bladder: a prospective randomized phase III study.

From November 1984 to April 1989, 122 patients with clinical T2-4a Nx-2 M0 transitional cell carcinoma of the bladder were entered in a prospective randomized trial to compare survival between a control group of 60 patients treated only with radical cystectomy (arm A) and a group of 62 patients treated with 3 cycles of 100 mg./m.2 neoadjuvant cisplatin before radical cystectomy (arm B). Secondary objectives of the trial were comparison of the disease-free interval and time to death, significance of response of the primary tumor to cisplatin, pattern of relapse and toxicity. As of April 1993 after a median followup of 78.2 months (range 48 to 101) no difference in survival between the control patients and those who received neoadjuvant cisplatin has been observed. The overall direct survival is 37.3% for arm A and 35.5% for arm B. The survival rate of the 109 patients who complied with the protocol is 38.2% for 55 patients of the control group and 40.7% for 54 patients of the cisplatin group. Survival rates of patients theoretically rendered free of disease by radical cystectomy (complete response pT0-4a, pN0-2, M0) is 43.7% for 40 control patients and 47.8% for 41 cisplatin treated patients. The time to relapse in complete response patients was significantly longer (p = 0.0298) for those who received cisplatin (arm A 13.1 months versus arm B 30.3 months). The time to death (cause specific) did not differ significantly between both groups overall (p = 0.1349) but it was significantly different between controls and responders (p = 0.0501). Preoperative cisplatin downstaged the primary tumor in 19 patients (33.9%), of whom 11 (19.6%) had no tumor in the cystectomy specimen (pT0) and 8 (14.3%) had superficial tumor (pTis pTa pT1). In 6 patients (9.7%) disease progressed during chemotherapy. The survival of the responders was significantly better than that of nonresponders (p = 0.0142), with specific death rate of 26.3% and 62.5%, respectively, and a median time to death of 43 months for responders and 30.5 months for nonresponders. Patients without nodal involvement (pN0) or with only 1 micrometastasis (pN1) fared significantly better (p = 0.0001) than those with major node invasion (pN2-4), irrespective of the treatment received. The survival rate is 48.6% for patients with pN0 disease, 37.5% for pN1 and 5% for pN2-4. Toxicity of cisplatin was minimal and there were no differences in perioperative morbidity between the arms.(ABSTRACT TRUNCATED AT 400 WORDS)

Improving the safety of BCG immunotherapy by dose reduction. Cooperative Group CUETO.

The preliminary results of a randomized, multicentre, prospective trial conducted by the Spanish Oncology Group (CUETO) are presented. The primary aim of the trial was to determine whether or not lowering the dose of bacillus Calmette-Guérin (BCG) could reduce toxicity without compromising efficacy. From February 1991 to June 1992, 500 patients with superficial bladder cancer (TaG2-3, T1G1-3) entered the trial. Of these patients, 252 were included in group A (BCG, 81 mg) and 248 in group B (BCG, 27 mg). There were no significant differences in clinical and pathological characteristics between the two groups. Following treatment, significant differences arose between groups A and B in local severe toxicity (22.6 vs. 4.2%, respectively; p < 0.01). Systemic toxicity was more common in group A than in group B (p < 0.01): pulmonary effects (2.3 vs. 0.4%), fever (26.9 vs. 12.9%) and malaise (16.2 vs. 8.4%), all p < 0.01. Regarding efficacy, 204 patients in group A and 210 in group B were evaluated after a mean follow-up of 18.6 months. No significant differences in recurrence rate (18.1 vs. 19.5%) or progression rate (2.4 vs. 4.8%) were found. However, in patients with superficial bladder cancer with high risk of recurrence and progression (carcinoma in situ and G3), caution must be exercised in selecting the dose.

The importance of separation of prostatic lobes in relief of prostatic obstruction by balloon catheter urethroplasty: studies in dogs and humans.

We performed balloon urethroplasty in six older normal dogs and 10 patients with benign prostatic hypertrophy to establish the mechanism by which this technique results in relief of bladder outlet obstruction. Thirty-millimeter balloon catheters were used in both the animal and human studies. Autopsy studies showed disruption of the anterior prostatic commissure in four of the six dogs, disruption of both anterior and posterior commissures in one dog, and no disruption in the remaining dog. In all 10 patients, cystoscopy and urethrography showed disruption of the anterior commissure. Separation of the prostatic lobes by disruption of the prostatic commissures may be the most important mechanism by which balloon urethroplasty relieves urethral obstruction.

[Adenocarcinoma of the kidney in children]. / Adenocarcinoma renal en la infancia.

Renal adenocarcinoma in infancy is a rare tumour. The presence of a case in our service has encouraged us to submit it and to carry out a review of the literature available.

Organization of the association cortical afferent connections of area 5: a retrograde tracer study in the cat.

The association (intrahemispheric) cortico-cortical afferent connections of area 5 were studied in the cat by means of retrograde tracing techniques involving horseradish peroxidase (HRP) free or wheat germ agglutinin-conjugated (WGA-HRP) or fluorochrome injections. Single or multiple injections were placed in different parts of areas 5a and 5b, the medial division of area 5 (5m), or in the anterior suprasylvian area (SsA). Labeled cells were plotted on projection drawings of the coronal sections and on two-dimensional "maps" of the cerebral cortex, which were produced according to an accurate and consistent procedure. The major findings of this study are: 1. All divisions of the anterior parietal cortex (areas 3a, 3b, 1, and 2) project to area 5 and to SsA. These projections, however, show marked differences in amount and topographical distribution, depending on the mediolateral and rostrocaudal location of the injections. 2. The motor cortex (areas 4 and 6) also projects heavily to area 5 and to SsA in a well-organized topographic fashion: Area 4 projects mainly upon areas 5a, 5m, SsA, and the medial part of 5b; area 6 projects mainly upon the lateral part of 5b and SsA. Moreover, the upper bank of the cruciate sulcus (areas 4 tau and 4 delta) projects to medial parts of area 5, and the lower bank (areas 4 tau, 6a alpha, and 6a beta) projects to lateral parts of area 5. 3. The somatosensory areas in the anterior ectosylvian gyrus and surrounding cortices (SIIm, SII, and SIV) are connected primarily with medial parts of area 5 (particularly 5a), and SsA. 4. Areas 7 and 7m and a number of visual areas (19, SVA, AmLS, PmLS, 21, 20, 18, ALS, and PLS) project in varying degrees to lateral parts of area 5b. Some of these areas also send weak to moderate projections to the medial part of 5b and the lateral part of 5a. 5. Sparse projections arising from the dorsolateral prefrontal, cingular, retrosplenial, granular insular, and suprasylvian fringe cortices were found to distribute in area 5 and SsA, particularly in lateral portions of 5b. 6. Quite abundant intrinsic connections also found, which were loosely organized according to a complex topographic pattern. On the basis of these and previous results (Avendaño et al., 1985), the identity of area 5 in the cat is discussed, and comparisons are made between this area and sectors of adjoining cortex of cat and primates.

Diffuse intratubular undifferentiated germ cell tumor in both testes of a male subject with a uterus and ipsilateral testicular dysgenesis.

A case of müllerian pseudohermaphroditism in a male subject with a uterus is described. The patient showed normal secondary sex characteristics as well as normal external genitalia, except for right cryptorchidism and a painful tumoral mass in the left testis. Examination of surgical specimens revealed a uterus attached to the left ductus deferens. Areas of seminoma and embryonal carcinoma were present in the left testis. In addition, there was a thin insufficiently collagenized albuginea that contained a cellular connective tissue resembling the ovarian stroma, as well as hypoplastic and atrophic seminiferous tubules. In the testicular parenchyma most of the seminiferous tubules located far away from the tumor possessed the atypical malignant germ cells characteristic of intratubular undifferentiated germ cell tumors. No spermatogenesis was seen. The right abdominal testis was atrophic and showed a normal albuginea. However, there was an undifferentiated germ cell tumor similar to that observed in the left testis. We describe the first case of a tumor in a scrotal testis of a male subject with a uterus. The occurrence of this tumor is discussed with regard to tubular dysgenesis present in both testes and supported by the intrinsically abnormal germ cells as well as by the immature Sertoli cells found in both testes.