The Z-shaped ileal neobladder after radical cystectomy: an 18 years experience with 329 patients.

UNLABELLED: Study Type - Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To evaluate the results in terms of functional results and morbidity of Z-shaped ileal neobladder performed in a single center. PATIENTS AND METHODS: 329 consecutive male patients who had an orthotopic bladder replacement using the Z-shaped ileal neobladder between May 1990 and January 2009. RESULTS: The mean age of the patients was 64.4 ± 9.6 years, with a mean follow-up of 59.4 ± 55 months. Eighty-three early complications in 80/294 patients (27.2%) occurred. The average Clavian rate of these early complications was 2.24. Among these, 12 complications in 12 patients (4.1%) were pouch-related, and 3 reoperations were required. Two patients died from cardiac complications. Sixty-three late complications in 60/294 patients (20.4%) were recorded. The average Clavian rate of these late complications was 2.98. Among these, 47 complications in 45/294 patients (15.3%) were pouch-related, and 18 reoperations were required, essentially for ureteral anastomosis stricture. Satisfactory daytime urinary continence was achieved in 92% of patients. Daytime continence was obtained within, on average, 6.8 ± 16.4 months. The interval between each daytime urination was 2.6 ± 0.8 h (median = 2.5 [1-5] h). Forty-four (15%) patients developed metabolic acidosis which only required oral medication. Satisfactory nocturnal urinary continence was achieved in 87% of patients. Night-time continence was obtained within, on average, 10.8 ± 22.4 months. Hyper-continence with subsequent need for CISC was observed in 4%. CONCLUSION: In our series of 329 patients, compared with the other techniques, the Z-shaped ileal neobladder had an 'expected' complication rate for this high risk surgery with satisfactory daytime and night-time continence in nine out of ten patients.

[Superficial grade G2 tumors of the bladder: recurrence, progression, prognosis]. / Tumeurs superficielles de vessie de grade G2: récidive, progression, pronostic.

OBJECTIVE: The primary objective of this study was to describe the course of a series of grade 2 noninvasive urothelial carcinomas and to determine their prognosis by establishing recurrence, progression and mortality rates The initial histological and endoscopic characteristics were analysed in order to identify risk factors for recurrence and progression towards detrusor invasion. MATERIAL AND METHODS: This retrospective study was conducted on 75 patients with initially grade 2 superficial bladder tumours. Tumours were initially multifocal in 47% of cases and were classified as follows: 52 pTa tumours (69%) and 23 pT1 tumours (31%). The mean follow-up was 58 months. RESULTS: After the initial endoscopic resection, 26 patients (3.9%) received adjuvant therapy by intravesical instillations. The overall recurrence and progression rates in this series were 67% and 7%, respectively. Twelve patients (16%) underwent cystectomy. The specific mortality rate was 2.6%. Among the initial prognostic criteria, only the multifocal nature was identified as a risk factor for recurrence and progression towards detrusor invasion. CONCLUSION: This study confirmed the uncertain prognosis of grade 2 superficial bladder tumours. These tumours have a high recurrence risk with a cystectomy rate of 16%. These tumours require surveillance identical to that of high-grade tumours, at least half-yearly for the first 3 years then annually thereafter.

After cystectomy, is it justified to perform a bladder replacement for patients with lymph node positive bladder cancer?

PURPOSE: After cystectomy for bladder cancer, when pelvic lymph nodes are positive, bladder replacement remains controversial. The aim of this study was to evaluate the outcome of patients who underwent neobladder replacement despite bladder cancer metastasis to the regional lymph nodes. MATERIALS AND METHODS: From 1981 to 1997, a total of 504 consecutive cystectomies for bladder cancer were performed at our institution. For 150 patients, pelvic lymphadenectomy were positive, nevertheless 71 patients underwent a neobladder replacement (50 N1 and 21 N2). The distribution of patients by clinical stage, according to the TNM 97 classification, was 4 T1, 14 T2, 32 T3 and 21 T4. No patient showed signs of metastasis on diagnosis. RESULTS: Five-year disease specific survival rate of the entire group (71 patients) was 46%. With a mean follow-up of 8.3 years (3.2-20 years), 25 patients (35%) were alive and free of disease (72% with day continence), five patients were alive with recurrence (three bone metastasis, one chest metastasis and one with local recurrence), 41 patients died, (three non-cystectomy related). Of the 46 patients who recurred, a total of eight patients had local recurrence. For five patients, a severe dysfunction of the plasty appeared: two needed definitive bladder drainage until they died, one patient became totally incontinent, one patient needed a conversion of the plasty to Bricker ileal conduit. For the remaining patient the tumor involvement provoked recto-plasty-cutaneous fistula. All these five patients died in the 6 months after the plasty dysfunction appeared. CONCLUSIONS: Although prognosis in bladder cancer metastasis to the regional lymph nodes has been reported to be poor, this study demonstrates that after cystectomy, it is justified to propose a neobladder replacement to well selected patients. Local recurrence only occurred in 11% of patients and there was no damage to enteroplasty function for nearly half of the patients, and considering benefit to the quality of life, orthotopic bladder substitution should be considered as the preferential diversion in this patient population.

Extracorporeal shock wave therapy in the treatment of Peyronie's disease: experience with standard lithotriptor (siemens-multiline).

OBJECTIVES: To assess in a prospective study whether extracorporeal shock wave therapy (ESWT) using a standard radioscopic location lithotriptor is effective in the treatment of Peyronie's disease. METHODS: Fifty-four patients were included in this prospective study. Before and after treatment, the angulation was calculated by auto-photography. Pain severity was assessed by a visual analog pain scale. A self-evaluation questionnaire (International Index of Erectile Function) was used. All patients had symptoms (35 had pain during erection and 51 angulation greater than 20 degrees ). The mean disease duration was 16 months. The mean angulation before treatment was 48 degrees (range 10 degrees to 100 degrees ). Twenty-four patients had erectile dysfunction (questionnaire score less than 18). The Multiline Siemens lithotriptor was used. The plaque was located by palpation, and 1 mL of contrast agent was injected. Scopic visualization was used. Each patient received a minimum of one session of ESWT (3000 shock waves, 7 kJ) applied to a flaccid penis. RESULTS: All patients completed the protocol. The tolerance and safety were excellent. Of the 35 patients with pain on erection, 31 (91%) noticed relief immediately after ESWT (mean reduction 2.9 on the visual analog pain scale) (P <0.00001). For 29 patients (53.7%), an improvement in angulation (greater than 10 degrees ) was observed, with a mean reduction of 31 degrees (P <0.001). For patients with erectile dysfunction, only 6 (25%) had an increased questionnaire score (greater than 4). Twenty-five patients thought the plaque was smoother. CONCLUSIONS: ESWT with a standard lithotriptor (without the mobile arm) in Peyronie's disease is a feasible, safe, and effective treatment for pain on erection and significantly improves the penile angle.