Intravesical seeding of upper urinary tract urothelial carcinoma cells during nephroureterectomy: an exploratory analysis from the THPMG trial.

OBJECTIVE: The Pirarubicin Monotherapy Study Group trial was a randomized Phase II study that evaluated the efficacy of intravesical instillation of pirarubicin in the prevention of bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma. This study conducted further analysis of the Pirarubicin Monotherapy Study Group cohort, focusing on intravesical seeding of cancer cells. METHODS: Using the data from the Pirarubicin Monotherapy Study Group trial, bladder recurrence-free survival rates and factors associated with bladder recurrence in the control group were analyzed. RESULTS: Of 36 patients in the control group, 14 with positive urine cytology had more frequent recurrence when compared with the 22 patients with negative cytology (P = 0.004). Based on the multivariate analysis in the control group, voided urine cytology was an independent predictive factor of bladder recurrence (hazard ratio, 5.54; 95% confidence interval 1.12-27.5; P = 0.036). Of 72 patients in the Pirarubicin Monotherapy Study Group trial, 31 had positive urine cytology. Among the 31 patients, 17 patients who received pirarubicin instillation had fewer recurrences when compared with 14 patients who received control treatment (P = 0.0001). On multivariate analysis, pirarubicin instillation was an independent predictor of better recurrence-free survival rates in the patients with positive urine cytology (hazard ratio, 0.02; 95% confidence interval, 0.00-0.53; P = 0.018). Of 21 patients with bladder recurrence, 17 had recurrent tumor around cystotomy or in the bladder neck compromised by the urethral catheter, supporting the notion that tumor cells seeded in the injured urothelium. CONCLUSIONS: Intravesical instillation of pirarubicin immediately after nephroureterectomy significantly reduced the bladder recurrence rate in patients with positive voided urine cytology. The results suggest that intravesical seeding of upper urinary tract urothelial carcinoma occurs during nephroureterectomy.

Prospective randomized phase II trial of a single early intravesical instillation of pirarubicin (THP) in the prevention of bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma: the THP Monotherapy Study Group Trial.

PURPOSE: We evaluated the efficacy of a single early intravesical instillation of pirarubicin (THP) in the prevention of bladder recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma (UUT-UC). PATIENTS AND METHODS: From December 2005 to November 2008, 77 patients clinically diagnosed with UUT-UC from 11 institutions participating in the Tohoku Urological Evidence-Based Medicine Study Group were preoperatively enrolled in this study. Patients were randomly assigned to receive or not receive a single instillation of THP (30 mg in 30 mL of saline) into the bladder within 48 hours after nephroureterectomy. Cystoscopy and urinary cytology were repeated every 3 months for 2 years or until the occurrence of first bladder recurrence. RESULTS: Seventy-two patients were evaluable for efficacy analysis, 21 of whom had a subsequent bladder recurrence. Significantly fewer patients who received THP had a recurrence compared with the control group (16.9% at 1 year and 16.9% at 2 years in the THP group v 31.8% at 1 year and 42.2% at 2 years in the control group; log-rank P = .025). No remarkable adverse events were observed in the THP-treated group. Based on multivariate analysis, THP instillation (hazard rate [HR], 0.26; 95% CI, 0.07 to 0.91; P = .035) and open surgery (HR, 0.28; 95% CI, 0.09 to 0.84; P = .024) were independently predictive of a reduced incidence of bladder recurrence. CONCLUSION: In this prospective randomized phase II study, a single intravesical instillation of THP seemed to reduce bladder recurrence after nephroureterectomy. A phase III, large-scale, multicenter study is needed to confirm these observations.

Suprapubic versus transurethral bladder drainage after radical prostatectomy: impact on patient discomfort.

We evaluated the feasibility and the benefits of total prostatectomy with suprapubic cystostomy drainage instead of a urethral Foley catheter. Of 65 consecutive total retropubic prostatectomies, 42 were carried out with the suprapubic cystostomy, and 23 with the urethral Foley catheter. Patients were asked postoperatively to complete a 5-cm visual analog scale on pain intensity related to the catheter and to urination after catheter removal. No problem related to cystostomy per se was observed. In the cystostomy group, over 85% and 69% of men perceived no urinary symptoms during catherization and no painful urination after catheter removal, respectively; whereas in the Foley group, 91% and 65% perceived those symptoms (P < 0.001 and P < 0.01, respectively). These findings suggest that urethral catheter-free prostatectomy is a good alternative to that with a urethral Foley catheter, and it gives patients an improved quality of early postoperative life.

Survival of metastatic germ cell cancer patients assessed by international germ cell consensus classification in Japan.

BACKGROUND: As a risk classification system of metastatic germ cell tumors, the International Germ Cell Consensus (IGCC) classification was proposed in 1997 and has received broad approval. Since the IGCC classification was based on patients treated between 1975 and 1990, we aimed to investigate whether survival has improved for more recently treated Japanese patients. METHODS: We analyzed 296 patients with metastatic germ cell tumors treated at seven hospitals in Japan between 1990 and 2001. These cases are classified as good, intermediate or poor prognosis groups by the IGCC classification. The 5-year progression-free and the 5-year overall survivals were calculated for each prognosis group. RESULTS: The median follow-up period of all patients was 53 months. In 227 non-seminomatous germ cell tumor cases, the 5-year progression-free survival (95% confidence interval) for good (n = 55), intermediate (n = 106) and poor (n = 66) prognosis was 96% (91-100), 71% (62-80) and 52% (39-65) (P < 0.001), respectively. The 5-year overall survival was 94% (88-100), 81% (73-89) and 61% (49-73) (P < 0.001), respectively. In 69 seminoma cases, the 5-year progression-free survival for good (n = 64) and intermediate (n = 5) prognosis was 78% (67-89) and 80% (45-100) (P = 0.98), respectively. The 5-year overall survival was 90% (82-99) and 80% (45-100) (P = 0.49), respectively. CONCLUSIONS: There was a trend of increase in survival for any risk groups and, in particular, large increase in survival for patients with a poor prognosis. This increase is most likely attributed to more effective chemotherapy regimens and more extensive care in the experienced institutes.

Acute renal failure as a result of bilateral ureteral obstruction by Candida albicans fungus balls.

A 73-year-old male with a history of diabetes mellitus was admitted to our hospital for acute renal failure. An ultrasonogram revealed bilateral hydronephrosis, which worsened despite insertion of a bladder catheter. Nephrostomy catheters were positioned bilaterally, and Candida albicans was found in the urine culture. The patient was successfully treated with intermittent direct irrigation and i.v. antifungal agent therapy. Since 1977, approximately 50 cases of fungus balls or fungal bezoars in the urinary tract have been reported, but the majority of these cases have been characterized by unilateral ureteral or bladder involvement. Herein, we report a case of acute renal failure as a result of bilateral ureteral obstruction by Candida albicans fungus balls.

Health-related quality of life after radical prostatectomy in Japanese men with localized prostate cancer.

PURPOSE: We evaluated retrospectively health-related quality of life (HRQOL) after radical prostatectomy (RP) in Japanese men with localized prostate cancer. METHODS: The study was based on self-reported HRQOL of 280 patients. Patients were divided into seven groups: time 0 (T0), baseline before operation; T1, 1-3 months after RP; T2, 4-6 months after RP; T3, 7-12 months after RP; T4, 13-24 months after RP; T5, 25-36 months after RP; and T6, more than 36 months after RP. We measured the general and disease-specific HRQOL using the RAND 36-item Health Survey 1.0 (SF-36) and the University of California, Los Angeles Prostate Cancer Index (UCLA PCI). RESULTS: The general HRQOL of the postoperative groups was assessed by SF-36. The postoperative groups showed almost the same or higher scores than those of the baseline group. Urinary function scores decreased substantially after surgery. In contrast, there was no difference in urinary bother between the baseline and postoperative groups. Sexual function deteriorated substantially in all postoperative groups. Similarly, the sexual bother score significantly deteriorated after RP. The sexual bother score of men aged 65-years or younger was significantly worse than that of their counterparts in the T1-2 groups. CONCLUSION: Despite reports of problems with sexual activity and urinary continence, general HRQOL was mostly unaffected by RP. Although there was a substantial decrease in urinary function, recovery from urinary bother was rapid. Since the deterioration of sexual function was marked through the postoperative period, careful attention should be paid to this issue during preoperative counseling, especially for younger patients.

Urethral recurrence following neobladder in bladder cancer patients.

Risk factors of urethral recurrence after neobladder in bladder cancer patients were studied. Between 1977 and 2001, 73 patients (male 58, female 15) underwent neobladder as a treatment for bladder cancer. The observation time after cystectomy ranged from 2 to 254 months (median 60.5). Ten (17.2%) of 58 male patients had urethral recurrence and of the 10, 8 patients had multiple bladder cancers including bladder neck. Urethral recurrence was found by macrohematuria, follow-up cystourethroscopy, and inguinal lymph node swelling. Only one who complained of macrohematuria had positive urinary cytology. Of 58 male patients, 5 underwent total nephroureterectomy for renal pelvic or ureteral cancer before radical cystectomy, and 3 of the 5 had urethral recurrence. Two of 10 patients with urethral recurrence died with cancer, and they had renal pelvic or ureteral cancer. The five-year cause specific survival was 83% for patients with urethral recurrence, and 79% for those without urethral recurrence, respectively. Urethral recurrence did not have a significant effect on survival. The patients with multiple bladder cancers including bladder neck, and renal pelvic or ureteral cancer before radical cystectomy, have high risks for urethral recurrence. Urinary cytology has limited value for the detection of urethral recurrence.

[Treatment of metastatic germ cell tumors with etoposide and cisplatin as first line chemotherapy].

PURPOSE: The efficacy and toxicity of two-drug therapy (etoposide and cisplatin, EP) in patients with metastatic germ cell tumors were investigated. PATIENTS AND METHODS: Between December 1996 and November 1999, 18 patients with metastatic germ cell tumors (6 seminomas and 12 non-seminomas, Stage II 8, Stage IIIA 2, Stage IIIB 6, Stage IIIC 2) were treated by 3-5 cycles of induction chemotherapy regimen (EP). Etoposide and cisplatin were administrated in doses of 100 mg/m2 and 20 mg/m2, respectively, on days 1 to 5 and then repeated from day 21. After tumor markers obtained normal levels, one or two additional cycles of EP were continued. Patients showing evidence of residual tumor mass underwent debulking surgery as early as possible. RESULTS: At the end of EP therapy, 4 (22%) of the 18 patients achieved complete remission and 14 patients (78%) showed partial remission. Seven patients of partial remission were treated by excision of residual abnormalities: 6 had pathologically necrotic debris in the resected specimen and 1 had teratoma, and these 7 patients all achieved complete remission. Four other patients achieving partial remission were followed without surgical excision and have had no evidence of disease progression. Remaining three patients achieving partial remission received salvage chemotherapy with or without adjunctive surgery, resulted in complete remission in 2 patients and partial remission in 1 patient. EP demonstrated to have less treatment-related toxicity compared with that of EBP. Follow up studies ranging from 12 to 47 months (median, 29.6) showed that one patient experienced a relapse from complete remission at 13 months and was salvaged by chemotherapy and surgery. Finally, thirteen patients (72%) who achieved complete remission are alive and disease-free and 5 patients (28%) showing partial remission are alive with negative tumor markers and no evidence of relapse. CONCLUSION: These results suggests that EP is an efficacious and less toxic first line regimen for good-prognosis patients with metastatic germ cell tumors.

Adrenal metastasis from renal cell carcinoma: significance of adrenalectomy.

BACKGROUND: The present study examined adrenal metastasis resulting from renal cell carcinoma (RCC), with the aim of assessing the need for routine ipsilateral adrenalectomy during radical nephrectomy. METHODS: Ipsilateral and contralateral adrenal metastases were investigated in 256 patients with RCC who had undergone radical nephrectomy from 1977 to 1996 at the Tohoku University School of Medicine. RESULTS: Twelve of the 256 patients (4.7%) had adrenal metastasis. Ten of these 12 patients had progressed to disseminated disease with very poor prognosis. Two patients who had solitary adrenal metastases remained disease-free for 21 and 7 years. Four patients showed metastases to the contralateral adrenal gland. Adrenal metastases in seven of 12 patients were identified by pre- or postoperative computed tomography (CT), and in another five macroscopically during surgery. CONCLUSIONS: Adrenalectomy was regarded as a possible curative treatment for patients with solitary adrenal metastasis. However, the incidence of this kind of metastasis was minimal and contralateral adrenal metastases may occur in RCC cases. We therefore believe that adrenalectomy should only be performed if radiographic evidence reveals metastases in the adrenal gland or if gross disease is present at the time of nephrectomy.

Gamma-knife radiosurgery for brain metastasis of renal cell carcinoma: results in 42 patients.

BACKGROUND: The present study provides data from clinical experience with gamma-knife radiosurgery (GK) in patients with brain metastasis from renal cell carcinoma (RCC) and shows the value of this less invasive treatment modality. METHODS: Forty-two patients received GK. Twenty of the 42 cases had multiple brain metastases. Extracranial metastases were observed in the lung (38 cases), bone (12 cases), liver (9 cases), lymph node (5 cases) and skin (6 cases). RESULTS: Neurological symptoms seen in 40 patients were rapidly improved after GK in 32 patients (80%). Magnetic resonance imaging (MRI) evaluation after GK in 32 patients showed the disappearance of brain tumor in 9 patients (28%). Complete response was obtained by GK in tumors up to 30 mm in diameter. Repeated GK for newly developed lesions was conducted in 11 patients. Extracranial tumor resection was conducted in 7 cases (lung: 3, skin: 2, liver: 1, adrenal: 1). Chemo-radiotherapy or immunotherapy was effective in 8 cases (lung: 5, liver: 2, bone: 1). The actual one-, two- and three-year survival rates were 44.9%, 16.8%, and 11.2%, respectively. The median survival time was 12.5 months. In univariate analysis, the patients with successfully treated extracranial metastases had significantly better prognosis. In multivariate analysis, the patients with Karnofsky performance scale (KPS) > or = 80%, who were treated by GK more than once and obtained complete response (CR) or partial response (PR) by GK, had significantly better prognosis. CONCLUSION: Gamma-knife radiosurgery for RCC is an effective non-invasive modality of treatment. It offers a high local control rate and an improved quality of life and survival rate.