Fluoroscopically guided percutaneous suprapubic cystostomy for long-term bladder drainage: an alternative to surgical cystostomy.

Percutaneous large-bore suprapubic cystostomy catheters were placed under fluoroscopic guidance in 60 patients as an alternative to surgical cystostomy. Foley catheters (16-20 F) were placed in 57 of the patients in a one-stage procedure. Ten-French catheters were initially placed in three patients because of difficulty in dilating percutaneous tracks because of obesity (one patient) or dense scar tissue (two patients). Three weeks later, 18-F Foley catheters were placed in these three patients when mature tracks had developed, making dilation easier. Minor complications occurred in three patients, including superficial track bleeding in two and urosepsis in one. Fifteen patients were lost to follow-up. Suprapubic catheters provided excellent long-term drainage (range, 0.5-36 months; mean, 16 months; median, 18 months) in the remaining 45 patients. The authors conclude that percutaneous suprapubic catheter placement is a safe and effective procedure that provides excellent long-term bladder drainage.

Preliminary results in invasive bladder cancer with transurethral resection, neoadjuvant chemotherapy and combined pelvic irradiation plus cisplatin chemotherapy.

Preliminary data are presented of a clinically feasible pilot study to select a significant subgroup of patients among those with muscle-invading bladder tumors for local cure and bladder preservation, while also to offer all patients the possibility of preventing the development of distant metastases. Transurethral debulking surgical resection was combined with neoadjuvant methotrexate, cisplatin and vinblastine chemotherapy plus 2 additional courses of cisplatin and 4,000 cGy. If tumor was found on cystoscopic re-evaluation by biopsy and for cytology after cisplatin and partial irradiation (4,000 cGy.) immediate cystectomy was advised. If tumor was not found consolidation by a radiotherapy boost to a total of 6,480 cGy. plus 1 additional course of cisplatin was given. Of 53 consecutive patients the planned treatment was completed in 42 (79%). With a median followup of 26 months (range 15 to 42 months), 72% of all entered patients were alive, 70% have not required cystectomy and 74% have not had distant metastases. Among the 42 patients who completed the planned protocol chemotherapy dose reductions were required in 39% for stomatitis, bone marrow depression and/or renal dysfunction. There were 2 serious complications but no treatment-related sepsis, deaths or significant renal dysfunction. Eight patients underwent immediate radical cystectomy because of positive biopsy and/or cytology results after 4,000 cGy., while 34 completed full chemotherapy and radiotherapy without any significant bladder or bowel injury. Of 42 patients 22 (52%) have maintained the bladder without any recurrence, and of those selected for full chemotherapy and radiotherapy this number increased to 65%. To date 12 patients have persistent or recurrent bladder tumors: 5 (15%) had invasive tumors treated by cystectomy and 7 (21%) had carcinoma in situ treated by intravesical therapy. The true success of this or other selective bladder-preserving treatments will require 3 to 5 years of followup to be confident that such treatment has sterilized the bladder of cancer. This feasibility study has been clinically practical, modestly well tolerated and encouraging for the significant proportion of patients with a sustained complete response and for the 70% over-all survival rate at 2 years. To evaluate critically the efficacy of methotrexate, cisplatin and vinblastine chemotherapy in the prevention of occult distant micrometastases and in increasing the rate of successful bladder preservation, in May 1988 we began a randomized phase 3 trial with and without neoadjuvant methotrexate, cisplatin and vinblastine chemotherapy.

Percutaneous, large-bore, suprapubic cystostomy: technique and results.

A technique to insert large-bore suprapubic cystostomy catheters (18-French or larger) percutaneously, under radiologic imaging guidance, is described in 15 men who required long-term drainage of the bladder. This single-stage procedure is carried out under local anesthesia with optional IV sedation. It consists of rapid enlargement of the percutaneous track by means of a balloon dilatation catheter followed by insertion of a self-retaining Foley cystostomy catheter through a peel-away sheath. No complications associated with the placement of the catheters occurred, and long-term patient compliance has been satisfactory. Our results suggest that percutaneous, large-bore suprapubic cystostomy may be a preferred alternative to surgical cystostomy.

Primitive neuroectodermal tumor (immature teratoma) of testis.

The malignant neuroectodermal tumor is a recently described distinctive form of monodermal teratoma of the ovary. The first known example of this rare tumor occurring in the testis is reported.

Primary adenocarcinoma of urinary bladder.

We reviewed the clinical course and pathologic findings of 17 patients with adenocarcinoma of the urinary bladder at Massachusetts General Hospital between 1962 and 1978. The 12 men and 5 women were between thirty-eight and eighty-six years old (mean, sixty years). Five patients had urachal adenocarcinoma, 8 had pure adenocarcinoma, and 4 had mixed adenocarcinoma and transitional cell carcinoma. Twelve of 17 patients (71 per cent) had muscle invasion (T2-T3), and none had evidence of regional or distant metastases at initial presentation. The mean follow-up was four years. The treatment modalities included transurethral resection alone in 3 patients, radical cystectomy in 4, simple cystectomy in 2, salvage radical cystectomy in 1, and partial cystectomy in 7, 3 of whom also received radiation therapy. Over-all crude three and five-year survival rates were 60 per cent and 27 per cent, respectively; patients with invasive disease did poorly regardless of treatment modality. Five of 8 patients who died had evidence of metastatic disease, and only 1 patient with invasive disease was alive more than five years. However, 2 of 3 patients with invasive urachal adenocarcinoma who had preoperative radiotherapy plus partial cystectomy are free of disease at thirty-eight and sixty months.

The influence of perinephric fat involvement on survival in patients with renal cell carcinoma extending into the inferior vena cava.

Records of patients with renal cell carcinoma extending into the inferior vena cava were reviewed. Patients with nodal metastases or distal spread were excluded, leaving 19 cases available for analysis. The over-all 3 and 5-year survival rates were 56 and 38 per cent, respectively, but a striking difference in survival was observed when those patients with perinephric fat involvement (T3ac) were separated from those whose tumours had not penetrated through the renal capsule (T3c). The 3 and 5-year survival rates for patients with T3ac tumors were 14 and 0 per cent, compared to 82 and 67 per cent for patients with T3c tumors. Patients with T3ac tumors had metastases earlier (mean 13 months) than patients with T3c tumors (mean 22 months). The over-all mean survival duration was 50 months. However, the mean survival duration of patients with T3ac tumors was 17 months, compared to 75 months for patients with T3c tumors.

Intravesical therapy of low stage bladder carcinoma with mitomycin C: comparison of results in untreated and previously treated patients.

There were 28 patients with superficial bladder carcinoma (Ta, Tl or TIS) entered into protocols for intravesical therapy with mitomycin C. Of the 28 patients 16 had failed previously on thio-tepa (group A), 7 had responded successfully to thio-tepa (group B) and 5 had never received thio-tepa (group C). There were 5 complete responses and 9 failures to mitomycin C therapy in group A. There were 5 and 4 complete responses to mitomycin C therapy in groups B and C, respectively. The treatment plan consisted of the instillation of 40 mg. mitomycin C in 40 cc water weekly for 8 weeks. Because of severe local irritative symptoms 3 of the 28 patients did not complete the course of therapy. In another patient a diffuse body rash developed after the third instillation. Mitomycin C seems effective in ablating low stage bladder carcinoma, although it is less effective in patients who have failed prior thio-tepa therapy.

Transitional cell carcinoma of renal pelvis.

Sixty-eight patients with transitional cell carcinoma of the renal pelvis were studied with respect to clinical presentation, tumor grade, stage and location, subsequent development of other urothelial tumors, and patient survival. Of the 66 patients with adjacent mucosa available for evaluation, 63 (95 per cent) had abnormal findings with severe dysplasia and CIS common in the high-grade, high-stage tumors. Twenty-eight patients (41 per cent) had transitional cell carcinoma previously, concomitantly, and/or subsequently, and in 14 patients (21 per cent) subsequent bladder tumors developed. Because of the relatively high tumor recurrence rate in the ureter (16 per cent) in patients who underwent subtotal ureterectomies, nephrectomy and complete ureterectomy including a bladder cuff should be the operation of choice in patients with carcinoma of the renal pelvis.

Ta and T1 bladder cancer: location, recurrence and progression.

An analysis of 58 patients who presented with their first superficial bladder tumour(s) stage Ta or T1 and who were followed prospectively is presented. Tumour characteristics which correlated well with the likelihood of new tumour occurrence were invasion of lamina propria, multiplicity, size equal to or greater than 3 cm and abnormal selected mucosal biopsies. Positive urinary cytology and higher grade tumours correlated, though less strongly. Development of higher grade or stage in subsequent tumours (i.e. progression) was associated with initial tumour multiplicity. While initial tumours were rarely found on the dome (5.2%), new tumour occurrences involved the dome in 29% of patients.

Prognostic factors in carcinoma of the ureter.

The records and pathological slides of 60 patients with ureteral cancer were reviewed with particular attention being paid to the tumor-adjacent mucosa. Mucosal abnormalities increased as grade and stage increased but their presence did not correlate with survival nor with the presence of urothelial tumors elsewhere, that is previous, concomitant and subsequent tumors. Patients with papillary and solid tumors survived equally well. Survival among patients with stage B tumors was better than that reported previously (82 per cent survived 5 years).

A longitudinal study of patients with superficial bladder carcinoma successfully treated with weekly intravesical thio-tepa.

Herein is reported further results of a prospective clinical investigation to determine the effect of weekly intravesical bladder instillation of thio-tepa in the treatment of superficial bladder cancer. Patients with superficial bladder carcinoma were treated according to 2 protocols. The first protocol consisted of patients with persistent tumor who were treated with weekly thio-tepa for 8 weeks. Of the 33 patients 18 responded to this therapy, and they and 24 other patients who had been rendered free of tumor by transurethral resection alone were assigned to the second protocol in which patients either were treated with monthly instillations of thio-tepa or they were observed every 3 months in a prescribed fashion. Monthly thio-tepa instillations had no significant effect in lowering the recurrence rate in either group. However, in the patients who had responded to weekly thio-tepa benefit was noted in terms of 1) fewer recurrences, with 8 of 18 (44 per cent) previously pre-treated patients having a recurrence versus 19 of 24 patients (79 per cent) previously untreated, 2) delay in tumor recurrence with an interval free of tumor of 15.1 months in pre-treated patients versus 4.3 months in the untreated group and 3) diminished frequency of new tumors (0.33 recurrences yearly) in comparison to the untreated group (1.78 recurrences yearly). The remaining patients are free of tumors at 15.7 months average followup.