Frozen section analysis of ureteral margins in patients undergoing radical cystectomy for bladder cancer: differential impact of carcinoma in situ in the bladder on reliability and impact on tumour recurrence in the upper urinary tract.

BACKGROUND: Patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB) are at risk for upper urinary tract recurrence (UUTR), especially in case of carcinoma in situ (CIS). Data on the impact of CIS in the urinary bladder on ureteral tumour involvement or UUTR are conflicting. We presently evaluate the accuracy of intraoperative frozen section analysis (FSA) of the ureteral margin, the incidence of ureteral tumour involvement and their impact on UUTR in patients undergoing RC for UCB with versus without CIS of the bladder. MATERIAL AND METHODS: Between 2003 and 2007, 243 patients underwent RC in our department. 176 of these for UCB, either without CIS (n = 117, group I) or solitary/concomitant CIS (n = 59, group II). FSA was performed. Patients were followed up for UUTR. RESULTS: Overall, 403 ureteral margins--including re-resections--were analysed (group I, n = 232; group II, n = 171). One patient (0.85%) in group I and 21 patients (35.6%) in group II had tumour involvement of the ureter (p < 0.0001) at the time of RC. The false-negative rate of FSA compared to final histopathology was 0.4% (1/232) for group I and 2.9% (5/171) for group II, respectively. Mean duration of follow-up was 26 months (1-72). In group II, 2 patients (1.1%) had UUTR in the follow-up; both had initially positive and subsequently false-negative FSA. CONCLUSIONS: Tumour involvement of the ureter is found significantly more often in solitary or concomitant CIS of the bladder. Intraoperative ureteral FSA is accurate and should be recommended in these patients. Ureteral tumour involvement predisposes to UUTR especially with initial positive margins mandating careful follow-up.

Serum carcino-embryonic antigen (CEA) and its possible use as tumor marker for secondary tumors in urinary intestinal reservoirs.

OBJECTIVES: Serum carcino-embryonic antigen (CEA) has become a useful tumor marker in patients with colorectal adenocarcinoma. Patients who undergo uroenteric reconstruction, such as urinary diversion (UD), have an increased risk of developing malignant changes in their UD. We compared serum CEA levels in patients with different types of UD, evaluating long-term CEA changes and assessing its potential for use as a tumor marker of malignant transformation in the UD. MATERIALS AND METHODS: Serum CEA was evaluated 3 to 122 months after surgery in 177 patients with different types of UD and retrospectively analyzed. The normal range for CEA was 0.2-3.4 µg/l. No patient had a history of colorectal cancer. RESULTS: A total of 443 CEA samples from 177 patients were evaluated. CEA was elevated (up to 32 µg/l) in 122 samples (27.5%) from 59 patients (33.3%). Patients with Mainz Pouch II had significantly higher CEA levels (P = 0.037) than patients with other forms of UD. CEA levels increased significantly in the study population during follow-up (P = 0.0000007). Five of the patients (2.8%) developed a secondary neoplasm, 4 of whom had elevated CEA. Three neoplasms (urothelial cancer) were located outside the UD. Only 2 tumors were actually located in the UD: an urothelial cancer at the uretero-colonic anastomosis of the UD with normal CEA levels, and a colonic adenoma at the bottom of the UD with elevated CEA levels. No patient had adenocarcinoma in the UD. CONCLUSION: Elevated serum CEA is a common finding in patients with UD using bowel segments (33.3%), especially in patients with rectal reservoirs. Serum CEA has a tendency to increase over time in patients with UD but is not a valuable marker of secondary neoplasms in these patients.

Tumor thrombus of inferior vena cava in patients with renal cell carcinoma - clinical and oncological outcome of 50 patients after surgery.

BACKGROUND: To evaluate oncological and clinical outcome in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy. METHODS: We identified 50 patients with a median age of 65 years, who underwent radical surgical treatment for RCC and tumor thrombus of the IVC between 1997 and 2010. The charts were reviewed for pathological and surgical parameters, as well as complications and oncological outcome. RESULTS: The median follow-up was 26 months. In 21 patients (42%) distant metastases were already present at the time of surgery. All patients underwent radical nephrectomy, thrombectomy and lymph node dissection through a flank (15 patients/30%), thoracoabdominal (14 patients/28%) or midline abdominal approach (21 patients/42%), depending upon surgeon preference and upon the characteristics of tumor and associated thrombus. Extracorporal circulation with cardiopulmonary bypass (CPB) was performed in 10 patients (20%) with supradiaphragmal thrombus of IVC. Cancer-specific survival for the whole cohort at 5 years was 33.1%. Survival for the patients without distant metastasis at 5 years was 50.7%, whereas survival rate in the metastatic group at 5 years was 7.4%. Median survival of patients with metastatic disease was 16.4 months.On multivariate analysis lymph node invasion, distant metastasis and grading were independent prognostic factors. There was no statistically significant influence of level of the tumor thrombus on survival rate. Indeed, patients with supradiaphragmal tumor thrombus (n = 10) even had a better outcome (overall survival at 5 years of 58.33%) than the entire cohort. CONCLUSIONS: An aggressive surgical approach is the most effective therapeutic option in patients with RCC and any level of tumor thrombus and offers a reasonable longterm survival. Due to good clinical and oncological outcome we prefer the use of CPB with extracorporal circulation in patients with supradiaphragmal tumor thrombus. Cytoreductive surgery appears to be beneficial for patients with metastatic disease, especially when consecutive therapy is performed. Although sample size of our study cohort is limited consistent with some other studies lymph node invasion, distant metastasis and grading seem to have prognostic value.

Long-term results of a staged approach: continent urinary diversion in preparation for renal transplantation.

PURPOSE: We provide the long-term results of renal transplantation into continent urinary intestinal reservoirs as a planned 2-stage procedure. MATERIALS AND METHODS: Between November 1990 and January 2009, 18 patients underwent cadaveric or living related renal transplantation into continent urinary reservoirs (continent cutaneous diversion 16, orthotopic substitution 2). All patients were prospectively followed. RESULTS: Of these patients 15 are currently free of dialysis. At a mean followup of 89.2 months (range 2 to 188) 13 patients had a serum creatinine ranging from 0.6 to 3.1 mg/dl (mean 1.49) after the first transplantation. Two patients underwent a second transplantation 12 and 122 months after loss of the transplant for renal vein thrombosis and chronic allograft dysfunction, respectively. Two additional patients had to resume hemodialysis 62 and 109 months after renal transplantation. The second transplantation was delayed mainly due to compliance problems. One patient died of fulminant septicemia after laparotomy elsewhere for bowel obstruction with normal renal function before that episode. The continence mechanism needed correction in 3 patients, and 2 further revisions were required for ureteral kinking and lymphocele. The patients with orthotopic substitution (2) voided to completion and showed complete continence. All patients with cutaneous diversion were continent day and night with easy catheterization. CONCLUSIONS: This study is among the largest single series to date of renal transplantation into continent urinary diversions. Long-term followup confirms that this approach is a safe and socially well accepted treatment option in carefully selected patients.

Last resort in devastated bladder outlet: bladder neck closure and continent vesicostomy--long-term results and comparison of different techniques.

OBJECTIVES: To compare surgical techniques and long-term outcomes in patients undergoing bladder neck closure (BNC) and continent vesicostomy for devastated bladder outlet. METHODS: A total of 17 patients who underwent BNC, omental interposition, and continent vesicostomy between 1994 and 2008 were analyzed. Indication for surgery was recurrent anastomotic stricture combined with postradical prostatectomy incontinence (n = 10), postvulvectomy (n = 1), and neurogenic bladder dysfunction (n = 6). Diversion was performed in 8 patients with normal bladder capacity (>300 mL in adults) through a Mitrofanoff appendicovesicostomy (n = 4) or ileal intussusception valve (n = 4). Simultaneous ileocecal bladder augmentation was performed in 9 patients with primarily reduced bladder capacity, and either the in situ embedded appendix (n = 4) or an ileal intussusception valve (n = 5) served as the continent outlet. The stoma was placed in the lower abdomen using the "butterfly technique" (n = 8) or in the umbilicus (n = 9). RESULTS: Medium follow-up was 68 months (range: 12-129). Primary BNC was successful in all patients and primary continence rate was 82%. Three patients (18%) suffered from continence failure, caused by reduced bladder capacity in 2 cases. The third patient presented with an iatrogenic destruction of his Mitrofanoff appendicovesicostomy. These patients were successfully reconstructed by ileocecal bladder augmentation with an ileal intussusception valve as the continent outlet. Four patients (23%) developed stomal stenosis (3/8 with an abdominal stoma and 1/9 with an umbilical stoma). Patients with simultaneous bladder augmentation had higher bladder capacity. No patients developed ureteral obstruction. CONCLUSIONS: This technique is an effective, last resort treatment for patients with nonreconstructible bladder outlet.

Testis-sparing surgery versus radical orchiectomy in patients with Leydig cell tumors.

OBJECTIVES: To compare retrospectively the outcome of testis-sparing surgery (TSS) to radical orchiectomy (RO) in patients with Leydig cell tumor (LCT). METHODS: Between 1992 and 2008, 16 patients with LCT of the testis were identified. All but 1 tumor could be detected by ultrasonography. Alpha-fetoprotein and beta-human chorionic gonadotropin levels were normal in all patients. Eight patients underwent RO (mean age at surgery 42 years [27-61]; median tumor size 12.9 mm [10-25]) and the remaining 8 underwent TSS (mean age at surgery 34 years [18-49]; median tumor size 8.6 mm [4-23]). Staging (abdominal computed tomography and chest x-ray or thoracic computed tomography) was negative in all patients. RESULTS: Median follow-up was 77 months (17-186) after RO and 42 months (1-86 months) after TSS. There was no local recurrence or metastasis in patients after RO. A metachronous LCT was removed from the spermatic cord 29 months after TSS of the ipsilateral testis in 1 patient. Another patient underwent surgical exploration of the testis 31 months after ipsilateral TSS because of a suspicious lesion identified in ultrasonography; a tumor was ruled out by histopathology. CONCLUSIONS: In the medium term, TSS is a safe procedure in patients with LCT <25 mm.

Metanephric adenoma in a two-year-old child.

Metanephric adenomas in children are very rare. We present the case of a 2-year-old girl with a mass of the left kidney. The lesion was completely removed by nephron-sparing surgery. Histopathologic examination revealed a metanephric adenoma.

Solitary schwannoma of the glans penis.

Schwannomas of the penis are extremely rare. A 69-year-old man presented with a circumscribed asymptomatic tumor on the dorsum of the glans penis. Histopathologic examination of the surgical specimen showed a benign schwannoma.

Recurrent pelvic neuroblastoma in an adult patient.

BACKGROUND: Neuroblastoma is a common malignancy in children, but rarely occurs in adults. CASE REPORT: We report the case of a 39-year-old woman who was treated for her fourth recurrence of a pelvic neuroblastoma. CONCLUSIONS: Because of the rarity of these tumors during adolescence and adulthood, little information is available on the clinical course of patients with neuroblastoma in this age group. Currently there is no standard treatment for adult patients with neuroblastoma. Surgical resection and chemotherapy seem to be best of choice.

Chronic perforation of the urinary bladder by self-inserted foreign body.

We report on a 14-year-old girl with pyelonephritis, secondary to a foreign body, in her urinary bladder. A self-inserted pencil led to stone formation and bladder perforation at two sites. Eighteen months after insertion, the pencil was removed by suprapubic cystotomy.