Prediction of early (30-day) and late (30-90-day) mortality after radical cystectomy in a comprehensive cancer centre over two decades.

BACKGROUND: Radical cystectomy (RC) is associated with substantial postoperative mortality. In this study, we analyzed early (30-day; 30 M) and late (30-90-day; 30-90 M) mortality after RC in a Dutch tertiary referral center and determined factors associated with 30 M, 30-90 M and 90-day mortality (90 M). PATIENTS AND METHODS: We identified 823 patients who underwent RC for bladder cancer in the Netherlands Cancer Institute between 1997 and 2017. Predictive factors for mortality were analyzed to identify patients with a higher mortality risk. Multivariate logistic regression analysis was performed to examine the influence of patient, surgical and histopathological variables on 30 M, 30-90 M and 90 M. RESULTS: Thirty-day mortality was 1.9% and 90 M was 6.0%. Multivariable analysis showed that age (OR 1.08, 95% CI 1.01-1.1, p = 0.002) and ASA 3-4 (OR 3.57, 95% CI 1.25-10.16, p = 0.002) were significant predictors of 30 M while higher ASA score (OR 2.9, 95% CI 1.31-6.5, p = 0.009) and higher pathological T stage (OR 8.8, 95% CI 1.9-40.4, p = 0.005) were associated with 30-90 M. Risk of 90 M was increased in patients with ASA 3-4 (OR 2.4, 95% CI 1.2-4.9, p = 0.01), pT3-4 (OR 3.1, 95% CI 1.27-7.57, p = 0.01) and positive LNs (OR 2.5, 95% CI 1.25-4.98, p = 0.009). CONCLUSIONS: Patient-related factors predicted 30 M whereas both patient-related and cancer-related factors predicted 30-90 M. This suggests that patient mix, i.e. patient- vs. cancer-related factors for 30 M and 30-90 M, should be taken into account if mortality rates are to be compared between hospitals.

The colon shuffle: A modified urinary diversion.

AIM: To assess the results of a urinary diversion in patients who already have a colostomy or simultaneously require a (rectum) colon resection. The diversion is created from the distal part of the transected colon with a simultaneously created new colostomy contra-laterally (if necessary). This procedure is known in our institute as the 'colon shuffle'. MATERIALS AND METHODS: All patients who underwent a colon shuffle in the period of 2003 and 2013 in our institute (Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital) were identified. Comorbidity was scored using the Charlson comorbidity index. Local or systemic treatment prior to surgery was reported (e.g. external beam radiotherapy, systemic chemotherapy). Surgical complications were reported according to the Clavien-Dindo classification. RESULTS: Twenty-one patients (14 male; 7 female) underwent a colon shuffle procedure in our institute, with a mean age of 61.5 years. The majority (90.4%) of these patients had been subjected to radiotherapy on the pelvic region in the past. Although short-term complications (<30 days) were seen in 52.4% of these patients, major complications such as anastomotic leakage of the bowel and fecal peritonitis were not seen in this high-risk group of patients. CONCLUSION: The colon shuffle offers an elegant solution for patients who require a urinary diversion simultaneously with a colostomy or for patients who already have a colostomy from previous surgery.

Follow-up after cystectomy: regularly scheduled, risk adjusted, or symptom guided? Patterns of recurrence, relapse presentation, and survival after cystectomy.

AIMS: To evaluate the efficacy of follow-up based on the patterns of recurrence, relapse presentation and survival after cystectomy, and to define a risk adjusted follow-up schedule. PATIENTS AND METHODS: The records of 343 patients with regular follow-up after cystectomy were reviewed for primary site of recurrence, accompanying symptoms, means of recurrence diagnosis, and clinicopathological factors. Based on Cox proportional hazard models, and the results of imaging studies low and high risk groups are identified and a risk adjusted follow-up protocol is proposed. RESULTS: The risk of a recurrence was related to increasing pT, tumour positive lymph nodes, tumour positive surgical margins, and pre-operative dilatation of the upper urinary tract, and low and high risk groups were defined consequently. 84% of all recurrences occurred within 2 years, with only one recurrence beyond 2 years in the low risk group. Although the minority of all patients (34%) is asymptomatic at time of recurrence, symptomatic recurrences were adversely associated with survival. CT-scans and chest X-rays accounted for 90% of the diagnostic tools to detect a recurrence in patients without symptoms. CONCLUSIONS: Asymptomatic patients may benefit from early treatment after disease recurrence. A risk adjusted follow-up strategy based on stage of disease and additional clinicopathological factors can dichotomise patients at high and low risk for recurrence. The small benefit in survival after early detection has to be confirmed in future studies, and weighed against the available treatment options of recurrences and their subsequent costs.

Response to induction chemotherapy and surgery in non-organ confined bladder cancer: a single institution experience.

AIM: To evaluate the outcome of patients with locally advanced muscle-invasive and/or lymph node positive bladder cancer treated with induction chemotherapy and additional surgery. METHODS: All patients who were treated with induction chemotherapy in our institution between 1990 and 2010, were retrospectively evaluated using an institutional database. Induction chemotherapy consisted of methotrexate, vinblastine, doxorubicin and cisplatin (MVAC), or a combination of gemcitabine with either cisplatin or carboplatin (GC). RESULTS: In total 152 patients were identified, with a mean age of 59 years (range 31-76). One hundred and seven patients (70.4%) received MVAC, 35 patients received GC (23.0%) and 10 patients received GC after initial treatment with MVAC (6.6%). Median follow-up was 68 months (range 4-187 months). Overall 125 patients (82.2%) underwent cystectomy, whereas 12 patients (7.9%) received radiotherapy. Fifteen patients had no local treatment. Median overall survival was 18 months (95%CI 15-23 months). In 37.5% of patients with complete clinical response, residual disease was found at surgery (positive predictive value, PPV 62.5%). Complete pathological response was seen in 26.3% of patients, with a 5 year overall survival (OS) estimate of 54% (39%-74%). For patients with persisting node positive disease after induction chemotherapy and surgery OS was significantly worse (p < 0.0001). CONCLUSIONS: Complete clinical and/or pathological response to induction chemotherapy results in a significant survival benefit. The accuracy of the current clinical response evaluation after induction chemotherapy is limited. Although surgery may be important for staging and prognostic purposes, its role is unclear in node positive disease after induction chemotherapy.

Differences in histopathological evaluation of standard lymph node dissections result in differences in nodal count but not in survival.

OBJECTIVE: To analyse whether the reported differences in nodal yield at pelvic lymph node dissection (PLND) for bladder cancer, between two hospitals, are reflected in the survival rates. PATIENTS AND METHODS: We assessed follow-up data of all 174 patients (mean age: 62.7, median follow-up: 3 years) who underwent PLND between 1 January 2007 and 31 December 2009 at two different hospitals. PLND was performed according to a standardized template by the same urologists for comparable bladder cancer patients. Mean number of reported lymph nodes was 16 at hospital A versus 28 at hospital B. We compared the overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS) between both cohorts and performed a multivariate analysis. RESULTS: The cumulative probability for 2-year OS, DSS and RFS for hospital A are 61, 64 and 54 %, versus 58, 58 and 53 % for hospital B, respectively. Kaplan-Meier survival curves did not reveal statistically significant differences between both groups (OS: p log-rank = 0.75, DSS: p log-rank = 0.56, and RFS: p log-rank = 0.80). Also after adjustment for pT stage and neoadjuvant chemotherapy, survival was not significantly different between hospital A and hospital B. CONCLUSION: Despite differences in lymph node yield in PLND specimens, this study reveals no significant differences in survival outcomes between both hospitals. Standardized histopathological methods should be agreed upon by pathologists before integrating nodal yield and subsequent lymph node density as indicators of the quality of surgery and as prognostic factors.

Drenaje linfático del cáncer de próstata a través de la linfogammagrafía y el SPECT/TAC: su importancia en la técnica del ganglio centinela / Lymphatic drainage in prostate carcinoma assessed by lymphoscintigraphy and SPECT/CT: its importance for the sentinel node procedure

Objetivo. Valorar la técnica del ganglio centinela en relación con los diferentes patrones de drenaje linfático y con las áreas de linfadenectomía pélvica en pacientes con cáncer de próstata a través de la linfogammagrafía y el SPECT/TAC. Método. Se inyectó un total de 240 MBq de 99mTc-nanocoloide divididos en 4 dosis (una para cada cuadarante) mediante control ecográfico transrectal en 18 pacientes con cáncer de próstata con estadio superior a T2b. La inyección también fue controlada con una gammacámara portátil para asegurar que no se producía difusión del trazador fuera de la próstata. Tras la inyección, se realizaron imágenes planares a los 15min y 2h, junto a un SPECT-TAC a las 2h con cortes de 2mm. El mismo día, se realizó la técnica del ganglio centinela vía laparoscopia guiado por una sonda gamma y una gammacámara portátil. Resultados. Un total de 55 ganglios centinelas (GC) fueron visualizados. En 17/18 de los pacientes (94%) se observaron GC fuera de la fosa obturatriz. Se apreciaron 20 GC a lo largo de la arteria ilíaca externa (36%), 14 en la fosa obturatriz (25,4%), 6 en área de la ilíaca interna (11%) y 4 en la ilíaca común (7,2%). Se localizaron también 3 GC en la región presacra (5,4%), paraórtica (5,4%), y pararrectal (5,4%) y 2 a en región paravesical (3,6%). Se observaron metástasis en el GC en 6 pacientes (33%) y, en uno de ellos, un GC localizado alrededor de la artería ilíaca común fue el único con metástasis. Conclusión. El drenaje linfático de la próstata presenta una gran variabilidad individual, y con frecuencia se observan drenajes fuera del área pélvica. Con la técnica del GC, los GC situados fuera del área de rutina de la linfadenectomía pélvica pueden ser extirpados, estadificándose con mayor precisión al paciente(AU)

Purpose. The goal was to evaluate the sentinel node procedure in relation to different pathways of lymphatic drainage and the areas of pelvic lymphadenectomy in patients with prostate cancer assessed by lymphoscintigraphy and SPECT/CT study. Methods. Eighteen patients with prostate cancer of intermediate prognosis were injected with 240 MBq of 99mTc-nanocolloid in the peripheral zone of each quadrant of the prostate, guided by transrectal ultrasonography. Tracer administration was also controlled with a portable gamma camera to assure that there was no diffusion outside the prostate. The injection was followed by planar imaging at 15min. and 2h, performing a SPECT/CT study at 2h. with 2mm slices. On the same day, a laparoscopic sentinel node lymphadenectomy assisted by a gamma probe and a portable gamma camera was performed. Results. A total of 55 sentinel lymph nodes (SLNs) were visualized. In 17/18 of patients (94%) SLNs were observed outside the obturator region. Twenty SLNs (36%) were observed along the external iliac artery, 14 in the obturator fossa (25.4%), 6 in internal iliac area (11%) and 4 in common iliac region (7.2%). Three SLNs were visualized in presacral (5.4%), paraaortic (5.4%), and pararectal areas (5.4%) and two in paravesical region (3.6%). SLN metastases were found in 6 patients (33%), and in one of them, a SLN located along the common iliac artery, was the only one with metastases. Conclusion. Lymphatic drainage from the prostate has high individual variability, and direct drainage outside the pelvic area is observed frequently. With the SLN procedure, SLNs outside the routine area of lymphadenectomy can also be sampled to stage the patient more accurately(AU)

Short-term outcome after cystectomy: comparison of two different perioperative protocols.

AIM: To compare the outcome of two perioperative protocols with respect to postoperative management of cystectomy patients. PATIENTS AND METHODS: Between June 2007 and November 2008, 85 consecutive patients with bladder cancer were treated with cystectomy and urinary diversion. Patients were operated in two hospitals by four urologic surgeons. In protocol A, patients were enterally fed via a postpyloric tube while the nasogastric tube (NGT) was removed directly after cystectomy and selective decontamination of the digestive tract was given until normal oral intake. In protocol B, postcystectomy management consisted of total parenteral nutrition by a central venous line and NGT removal after 24 h. Hospital stay and complications were compared between the two hospitals. RESULTS: More than half of all patients (52%) developed one or more complications within 30 days after surgery, 37% in protocol A and 71% in protocol B (p = 0.002). Higher ASA score and protocol type were the only factors significantly associated with early complications in both uni- and multivariate analyses. Length of stay was significantly shorter with protocol A as compared to protocol B, 13 days versus 19 days (p = 0.006). CONCLUSIONS: Cystectomy and urinary diversion is a procedure with considerable risk of complications. Enteral nutrition might be advantageous as compared to parenteral nutrition, showing fewer complications and shorter hospital stay. A high ASA score is associated with more early complications. Selective bowel decontamination may have an additional role in preventing infectious complications after cystectomy.

Standard lymph node dissection for bladder cancer: significant variability in the number of reported lymph nodes.

PURPOSE: We compared the nodal yield after histopathological examination of extended bilateral pelvic lymph node dissection specimens for bladder cancer at 2 hospitals. Surgery at each hospital was done by the same 4 staff urologists using a standardized extended bilateral pelvic lymph node dissection template. MATERIALS AND METHODS: All consecutive patients with bladder cancer who underwent extended bilateral pelvic lymph node dissection from January 1, 2007 to December 31, 2009 were included in this study. Specimens were sent for pathological evaluation in a minimum of 2 packages per side. At the 2 pathology departments specimens were processed according to institutional protocols. RESULTS: A total of 174 patients with a mean age of 62.7 years were included in analysis. At hospital 1 a mean of 16 lymph nodes were found after dissection vs a mean of 28 reported at hospital 2 (p <0.001). No significant differences were found in the number of tumor positive lymph nodes (p = 0.65). Mean lymph node density at hospitals 1 and 2 was 9.3% and 3.9%, respectively (p = 0.056). CONCLUSIONS: Despite equal anatomical clearance by the same experienced surgeons we report a statistically significant difference between 2 pathology departments where the number of lymph nodes was evaluated after extended bilateral pelvic lymph node dissection for bladder cancer. Unless standardized methods are agreed on by pathologists, the number of reported lymph nodes as an indicator of surgical quality and lymph node density as a prognostic factor should be used cautiously.

Laparoscopic sentinel lymph node biopsy for prostate cancer: the relevance of locations outside the extended dissection area.

Objective. To assess the relevance of sentinel lymph nodes (SNs) outside the extended pelvic lymph node dissection area (e-PLND). Patients and Methods. Evaluation of our laparoscopic SN procedures for prostate cancer patients of intermediate prognosis. Retrospective data collection on the exact location of the excised SNs and the pathology results were analyzed. Results and Limitations. Of the 121 patients, 49 had positive lymph nodes. 37 patients (31%) had SNs outside the e-PLND template. Five of these nodes were tumor bearing but only twice exclusively so. Of the 14 patients considered for salvage treatment, 6 were node positive. 7 of these 14 patients (50%) had SNs outside the extended dissection area, yet none of these nodes were tumor positive. Limitations are those of a retrospective study. Conclusions. Laparoscopic SN biopsy may show SNs outside the e-PLND template in 31% of the patients. However, nodes that are exclusively positive in one of these areas are rare. For the dichotomy positive or negative nodes, the locations outside the e-PLND area are not often relevant. Nevertheless, when all positive nodes are to be treated by resection or radiotherapy, these locations are relevant. When considering salvage treatment for prostate cancer, the method is feasible.

Lymphatic drainage in prostate carcinoma assessed by lymphoscintigraphy and SPECT/CT: its importance for the sentinel node procedure.

PURPOSE: The goal was to evaluate the sentinel node procedure in relation to different pathways of lymphatic drainage and the areas of pelvic lymphadenectomy in patients with prostate cancer assessed by lymphoscintigraphy and SPECT/CT study. METHODS: Eighteen patients with prostate cancer of intermediate prognosis were injected with 240 MBq of (99m)Tc-nanocolloid in the peripheral zone of each quadrant of the prostate, guided by transrectal ultrasonography. Tracer administration was also controlled with a portable gamma camera to assure that there was no diffusion outside the prostate. The injection was followed by planar imaging at 15 min. and 2 h, performing a SPECT/CT study at 2 h. with 2 mm slices. On the same day, a laparoscopic sentinel node lymphadenectomy assisted by a gamma probe and a portable gamma camera was performed. RESULTS: A total of 55 sentinel lymph nodes (SLNs) were visualized. In 17/18 of patients (94%) SLNs were observed outside the obturator region. Twenty SLNs (36%) were observed along the external iliac artery, 14 in the obturator fossa (25.4%), 6 in internal iliac area (11%) and 4 in common iliac region (7.2%). Three SLNs were visualized in presacral (5.4%), paraaortic (5.4%), and pararectal areas (5.4%) and two in paravesical region (3.6%). SLN metastases were found in 6 patients (33%), and in one of them, a SLN located along the common iliac artery, was the only one with metastases. CONCLUSION: Lymphatic drainage from the prostate has high individual variability, and direct drainage outside the pelvic area is observed frequently. With the SLN procedure, SLNs outside the routine area of lymphadenectomy can also be sampled to stage the patient more accurately.

Intraoperative sentinel node identification and sampling in clinically node-negative renal cell carcinoma: initial experience in 20 patients.

PURPOSE: To apply single-photon emission computed tomography (SPECT) in combination with computed tomography (CT) for preoperative identification of sentinel lymph nodes (SNs) and to investigate surgical feasibility and safety of intraoperative sampling. METHODS: A retrospective combined interim analysis of 20 patients from two prospective trials who underwent injection of 99mTc-nanocolloid into the renal tumour for preoperative identification of SN with SPECT/CT and subsequent removal of the tumour and intraoperative sampling using a gamma probe and portable camera. Lymphadenectomy was completed locoregionally. Surgical approach, time, blood loss, intraoperative yield, Clavien complications and anatomical location of SN in correlation with preoperative imaging were evaluated. RESULTS: SPECT/CT detected SN in 14/20 patients (70%), including 4 patients with non-visualisation on planar lymphoscintigraphy. Twenty-six SNs were seen: 17 para-aortic (including interaorto-caval), 4 retrocaval, 1 hilar, 1 celiac trunc, 1 internal mammary and 2 mediastinal and pleural. These latter 4 nodes were not harvested according to protocol. All other SNs, except for 2 weakly radioactive interaorto-caval nodes, were identified and excised with a mean additional time of 20 min. None of the removed SN and locoregional nodes was tumour-bearing. CONCLUSIONS: Intraoperative SN identification and sampling in RCC with preoperative detection on SPECT/CT is surgically safe and feasible. SN from the kidney are mainly localised in the para-aortic region, but aberrant nodes receive direct drainage. Non-visualisation of SN appears in almost a third of the patients. Further studies are required to demonstrate whether accurate mapping of lymphatic drainage and extent of lymphatic spread may have diagnostic and therapeutic implications.

Intraoperative radioguidance with a portable gamma camera: a novel technique for laparoscopic sentinel node localisation in urological malignancies.

PURPOSE: Our aim was to assess the feasibility of intraoperative radioguidance with a portable gamma camera during laparoscopic sentinel node (SN) procedures in urological malignancies. METHODS: We evaluated the use of the intraoperative portable gamma camera in 20 patients: 16 patients with prostate carcinoma (PCC), 2 patients with renal cell carcinoma (RC) and 2 patients with testicular cancer (TC). Intra/peritumoural injection of (99m)Tc-nanocolloid ((99m)Tc) was followed by planar lymphoscintigraphy, SPECT/CT and marking of SN levels. Before laparoscopy a (125)I seed was fixed on the laparoscopic gamma probe as a pointer of SN seeking. The portable gamma camera was set to display the (99m)Tc signal for SN localisation and the (125)I signal for SN seeking. Matching of these signals on screen indicated exact SN localisation, and consequently this SN was removed. RESULTS: The mean injected dose was 218 MBq in PCC, 228 MBq in RC and 88 MBq in TC. Pelvic SN were visualised in all PCC patients, with uncommonly located SN in seven patients. SN metastases were found in seven patients (one in a uncommonly located SN). Both RC patients and TC patients had para-aortic SN, which were all tumour free. A total of 59 SN were removed. The portable gamma camera enabled real-time SN display/identification in 18 patients (90%). CONCLUSION: The use of a portable gamma camera in combination with a laparoscopic gamma probe incorporates intraoperative real-time imaging with improved SN identification in urological malignancies. This procedure might also be useful for SN identification of other deep draining malignancies.

Long-term survival after combined modality treatment in metastatic bladder cancer patients presenting with supra-regional tumor positive lymph nodes only.

AIMS: To evaluate if combined treatment should be offered to bladder cancer patients presenting with supra-regional lymph node metastases only and a clinical complete or partial response after chemotherapy. PATIENTS AND METHODS: We identified 14 patients with supra-regional lymph node metastases out of 394 patients with transitional cell carcinoma (TCC) treated in our institute with cystectomy and regional and supra-regional lymph node dissection between 1987 and 2007. Prior to cystectomy, neoadjuvant chemotherapy had been given. The patients received a total of four cycles of platinum-based chemotherapy. RESULTS: Five patients had a CR, nine patients had a PR after neoadjuvant chemotherapy. Histopathological proof of complete response in the bladder was confirmed in all five cases. One of these five patients had a CR in the bladder but pelvic lymph nodes still contained vital tumor. Five patients had no tumor in the lymph nodes, whereas four had tumor in the lymph nodes. Eleven patients died due to bladder cancer, seven of them within 1 year after cystectomy. The 3- and 5-year disease-specific survival rates were 36% (95% CI: 10-60%) and 24% (95% CI: 0-49%). Mean follow-up was 2.5 years. CONCLUSIONS: Combination therapy consisting of neoadjuvant chemotherapy and surgery in selected patients with tumor positive supra-regional lymph nodes only can result in durable long-term survival rates (24% 5-year survival). Response evaluation after neoadjuvant chemotherapy might play a decisive role in the selection of patients undergoing subsequent surgical removal of all known tumor sites.

Clinical outcomes after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy) in 44 patients.

PURPOSE: We describe the functional outcome on erectile function, continence and voiding, and local and distant cancer recurrence rates in 44 patients after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy). MATERIALS AND METHODS: A total of 44 males underwent cystectomy with preservation of the prostate, seminal vesicles and vasa deferentia, after which a Studer type neobladder was anastomosed to the prostate. Oncological outcome (disease specific survival, distant and local recurrence rates) and functional results (continence, voiding, erectile function) were determined. RESULTS: At a median followup of 42 months, 13 (30%) patients died of cancer. All 13 experienced widespread disease, which was combined with a pelvic recurrence (pelvic recurrence rate 6.9%) in 3. The 3-year survival according to pathological stage was 86% for pT 2N0 or lower, 63% pT3N0 and 39% for node positive tumors (anyT Npos). Prostate cancer was diagnosed in 1 patient 5 years after treatment, and recurrent carcinoma in situ in the prostatic urethra in another patient. Complete daytime and nighttime continence was achieved in 95.3% and 74.4%, respectively. Incontinence during day and night could be managed by 1 pad per day/night in 4.7% and 20.9%, respectively, while 4.7% needed more than 1 pad per night. Erectile function could be determined in 40 patients, and potency was maintained in 77.5%, impaired in 12.5% and absent in 10%. CONCLUSIONS: Functional results with regard to erectile function and urinary continence after prostate sparing cystectomy are good. Oncological results have been promising, but need to be confirmed after longer followup and in larger trials.

Penis conserving treatment for T1 and T2 penile carcinoma: clinical implications of a local recurrence.

PURPOSE: We evaluated our experience with primary tumor treatment for T1 and T2 penile squamous cell carcinoma and discussed the clinical implications of a local recurrence. MATERIALS AND METHODS: The primary tumor treatment and clinical course of 257 patients with T1 or T2 penile carcinoma were evaluated. Primary tumor treatment consisted of penis preservation in 157 and (partial) amputation in 100 patients. Median followup was 106 months (range 16 to 541). RESULTS: The 5-year local recurrence-free estimate after penis preservation was similar for T1 and T2 tumors (log rank test p = 0.1) and overall 63% (CI: 54%-72%) compared to 88% (CI: 81%-95%) for partial amputation (log rank test p = 0.0003). In case of a local recurrence after penis preserving treatment, local control could be achieved in 94% (51 of 54) of cases. Of patients with T1 tumors treated with penis preservation, regional recurrence developed in 33% (7 of 21) of patients with local recurrence compared to only 6% (3 of 47) of patients without local recurrences (Fisher's exact test p = 0.005). Of the patients with T2 tumors treated with penis preservation, regional recurrence developed in 27% (9 of 33) of patients with local recurrence compared to 27% (12 of 45) of patients without local recurrence (chi-square test p = 0.96). Of 10 patients with a local recurrence after partial amputation of the penis, 9 died of disease. CONCLUSIONS: The incidence of local recurrence increases with penis preservation but can be treated accurately in most cases. Local recurrences can signify lymphatic regional spread. A local recurrence after penile amputation carries a poor prognosis.

Neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin for histologically proven lymph node positive bladder cancer.

PURPOSE: We gained insight into the effect of neoadjuvant chemotherapy and subsequent surgery in patients with bladder cancer with tumor positive lymph nodes. MATERIALS AND METHODS: A total of 52 patients with histologically proven positive lymph nodes (by lymph node dissection or aspiration cytology) were treated with chemotherapy and post-chemotherapy surgery in case of partial or complete response. We evaluated response in the primary tumor and lymph nodes, long-term clinical outcome, and clinicopathological features potentially predictive of survival. RESULTS: Complete response, partial response and stable/progressive disease were attained in 29%, 57% and 14%, and resulted in a 5-year survival of 42%, 19% and 0%, respectively. Objective response (HR 4.1), especially complete response (HR 8.0), was independently associated with survival. The prognostic values of lymph node status and bladder tumor status after methotrexate, vinblastine, doxorubicin and cisplatin were evaluated separately. A tumor negative bladder combined with tumor negative nodes were associated with improved survival (HR 4.4) as was a tumor negative lymph node region in the presence of residual bladder disease (HR 2.8). All patients with post-chemotherapy tumor positive nodes died within 2 years. In resected specimens residual disease was found in 4 of 15 clinically complete responders while no tumor could be detected in 3 of 29 clinically assessed as partial responders. CONCLUSIONS: Response to chemotherapy is associated with improved survival, and our data suggest that lymph node status after methotrexate, vinblastine, doxorubicin and cisplatin is more important than local tumor status in this aspect. In the absence of reliable noninvasive methods, post-chemotherapy surgery in this series was the most adequate method of response evaluation and in limited partial responders led to long-term progression-free survival.

Clinical outcomes after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy) in 44 patients.

PURPOSE: We describe the functional outcome on erectile function, continence and voiding, and local and distant cancer recurrence rates in 44 patients after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy). MATERIALS AND METHODS: A total of 44 males underwent cystectomy with preservation of the prostate, seminal vesicles and vasa deferentia, after which a Studer type neobladder was anastomosed to the prostate. Oncological outcome (disease specific survival, distant and local recurrence rates) and functional results (continence, voiding, erectile function) were determined. RESULTS: At a median followup of 42 months, 13 (30%) patients died of cancer. All 13 experienced widespread disease, which was combined with a pelvic recurrence (pelvic recurrence rate 6.9%) in 3. The 3-year survival according to pathological stage was 86% for pT 2N0 or lower, 63% pT3N0 and 39% for node positive tumors (anyT Npos). Prostate cancer was diagnosed in 1 patient 5 years after treatment, and recurrent carcinoma in situ in the prostatic urethra in another patient. Complete daytime and nighttime continence was achieved in 95.3% and 74.4%, respectively. Incontinence during day and night could be managed by 1 pad per day/night in 4.7% and 20.9%, respectively, while 4.7% needed more than 1 pad per night. Erectile function could be determined in 40 patients, and potency was maintained in 77.5%, impaired in 12.5% and absent in 10%. CONCLUSIONS: Functional results with regard to erectile function and urinary continence after prostate sparing cystectomy are good. Oncological results have been promising, but need to be confirmed after longer followup and in larger trials.

Acquired smooth-muscle hamartoma of the scrotum: a histological simulator?

BACKGROUND: In three cases of chronic scrotal lymphedema, histological and immunohistochemical changes were observed that were strikingly similar to an exceedingly rare lesion reported previously under the name of acquired smooth-muscle hamartoma (ASMH) of the scrotum. The clinical context indicated that the cases were reactive rather than hamartomatous in nature. MATERIALS AND METHODS: The histological and immunohistochemical findings of the three cases were compared to macroscopically normal scrotal specimens obtained during sex reassignment surgery in seven male-to-female transsexuals. RESULTS: Compared to the seven controls, the three cases of chronic scrotal edema revealed a marked increase of dartos smooth-muscle tissue and of connective tissue of the scrotal skin and underlying soft tissues. Still, even the normal amount of scrotal smooth-muscle tissue may easily be misinterpreted as smooth-muscle hyperplasia. CONCLUSIONS: Chronic scrotal lymphedema may induce hyperplasia of the dartos muscle, resulting in a histological appearance previously described as ASMH. This indicates that ASMH may not always represent a later onset of abnormality similar to congenital smooth-muscle hamartoma but, rather, may constitute a histological simulator.

Sexuality preserving cystectomy and neobladder (SPCN): functional results of a neobladder anastomosed to the prostate.

OBJECTIVES: In order to preserve the sexual functions in patients in need of a cystectomy, a feasibility study has been performed. METHODS: In 24 male patients the seminal vesicles and the prostate were left in situ and a Studer type neobladder was anastomosed to the lateral edge of the prostate. RESULTS: Storage and voiding strongly resembled the patterns reported in neobladder patients with the anastomosis directly to the urethra. Four of the 24 males needed to perform clean intermittent catheterisation (CIC). All but one patients had daytime continence. Three patients needed a pad at night. Five patients had erectile dysfunction, of whom two responded well to sildenafil treatment, one had good rigiscan measured nightly erectile function and one had poor erections prior to the operation. Half of the patients had antegrade ejaculation, two patients reported sometimes antegrade and sometimes retrograde ejaculation. CONCLUSION: This feasibility trial showed that in the majority of our patients the remaining prostate does not interfere with micturition and the sexual functions were preserved.