Modified technique to prevent complications related to stoma and ileoureteral anastomosis in patients undergoing ileal conduit diversion.

OBJECTIVES: To introduce a modified technique for preventing complications related to stoma and ileoureteral anastomosis in patients undergoing ileal conduit diversion. METHODS: A urinary stoma was created intracorporeally and was pulled out to the abdominal wall through a retroperitoneal tunnel. The ileal conduit was fixed by nonabsorbable sutures that incorporated all abdominal wall fascia and the bowel seromuscular layer. The terminal ureter was spatulated and anastomosed to the conduit in an end-to-side fashion by a continuous lock-stitch suture after stoma maturation and conduit fixation. A 24F multiorifice catheter was introduced into the ileal conduit as a stent, but a ureteral stent was not used. The peritoneum underlying the stoma was preserved intact, and the ureters and the conduit were completely extraperitonealized. A urine collection device was attached to the matured stoma immediately after surgery. RESULTS: The modified technique was used in 56 consecutive patients who underwent ileal conduit diversions. The median operative time was 327 minutes. No early complications, such as urine or intestinal leakage, occurred. Two patients, however, developed ileus. The median follow-up was 36 months. Forty-five patients survived disease-free, whereas 11 died during the follow-up. There were no stoma-related complications or stenosis at the ileoureteral anastomotic site. No metabolic complications were observed and renal function was normal in all patients. CONCLUSIONS: Complications related to stoma and ileoureteral anastomosis in patients undergoing ileal conduit diversion can be prevented using our modified technique. However, further clinical investigation is required to confirm the advantage and long-term effects of our modified technique.

[Clinical outcomes after modified radical cystectomy in the treatment of 188 patients with invasive bladder cancer].

BACKGROUND AND OBJECTIVE: Radical cystectomy and urinary diversion is universally accepted as the most effective treatment for muscle invasive bladder cancer, but the operation is complicated, time-consuming and causes many complications. This study was to summarize our experience and clinical outcomes of modified radical cystectomy in the treatment of patients with muscle invasive bladder cancer. METHODS: In total 188 patients with invasive bladder cancer treated in the Department of Urology, Sun Yat-sen University Cancer Center from January 2000 to December 2007 with modified radical cystectomy and urinary diversion were analyzed retrospectively. Patients were followed up for 2 to 97 months, with a median of 31 months. RESULTS: The operative time was 120-525 min, with a median of 300 min. Blood transfusion was required in 39.9% of the patients. There was no operation-related death. The 5-year recurrence free and 5-year overall survival rates were 74.9% and 71.5%, respectively. The 5-year and overall survival were 82.5% and 82.8% for patients with organ-confined bladder cancer, 19.0% and 34.3% for patients with extravesical extension of bladder cancer, 82.2% and 79.1% for lymph node-negative patients, and 25.2% and 11.4% for lymph node positive patients. CONCLUSIONS: Modified radical cystectomy and urinary diversion is an effective and safe approach in treating muscle invasive bladder cancer. The efficacy of radical cystectomy is limited for the treatment of patients with extravesical extension of bladder cancer and lymph node positive patients.

Upper urinary tract dilation due to conglutination of intraluminal distal ureters after orthotopic neobladder with split-cuff nipple ureteral reimplants: early results of 8 cases.

OBJECTIVE: We reviewed our experience with dilation of the upper urinary tract caused by the conglutination of distal ureters after orthotopic neobladder reconstruction using the split-cuff nipple ureteral reimplant technique. MATERIALS AND METHODS: From January 2000 to April 2007, 250 consecutive patients underwent radical cystectomy and orthotopic neobladder reconstruction. Ureterointestinal anastomosis was performed using the split-cuff nipple technique in 291 renoureteral units. The patients from a single center were followed up for a mean period of 8 months (range 1-22) after surgery. We incised the conglutination band using a transurethral endoscope. Patient characteristics, endoscopic technique, measurement of serum creatinine levels, and results of ultrasonography, cystoscopy, and excretory urography were collected. RESULTS: Hydronephrosis was found in 8 patients (14 renoureteral units) due to the conglutination of the distal ureters to each other (n = 6) or to the neobladder wall (n = 2). After the incision procedure, seven patients had obvious improvement in renal function and hydronephrosis, and their symptoms disappeared. In 1 patient, hydronephrosis developed again because of ureteroenteric stenosis after 7 months and was resolved by open surgical revision. The hydronephrosis had improved greatly in this patient by 5 months after revision. CONCLUSION: Conglutination of the distal ureters is a cause of hydronephrosis after orthotopic neobladder reconstruction using the reimplant technique with the split-cuff nipple. Cystoscopy is mandatory in following up patients who have hydronephrosis with the split-cuff nipple ureteral reimplant technique, not only to confirm the diagnosis but to treat the complication by incising the conglutination band. Continued follow-up is required to evaluate the long-term results of this treatment.

[Efficacy of modified retroperitoneal lymph node dissection for testicular nonseminomatous germ cell tumors].

BACKGROUND & OBJECTIVE: Retroperitoneal lymph node dissection(RPLND) is one of the main modalities for nonseminomatous germ cell tumors (NSGCTs). RPLND has achieved relatively high efficacy for stage I/II NSGCTs. Currently, the postoperative complication rate of conventional RPLND is relatively high. This study was to summarize therapeutic efficacy of modified RPLND for stageI/II NSGCTs, thus to explore the reasonable therapy strategy for those diseases. METHODS: Clinical data of 31 patients with stage I/II NSGCTs underwent RPLND from Aug.2003 to Aug.2007 in Sun Yat-sen University Cancer Center, were retrospectively analyzed. All cases received modified RPLND after radical orchidectomy. Four cases received two to three cycles of BEP (bleomycin,etoposide and cisplatin) chemotherapy prior to RPLND. Thirteen cases received one to five cycles of adjuvant cisplatin-based chemotherapy after primary RPLND. RESULTS: The mean operating time was 147 min (rang 120-200 min) and the mean blood loss was 116 ml (rang 50-300 mL) of modified RPLND. The mean number of dissected lymph nodes sent for pathological examination was 15 (rang 3-40). Retroperitoneal lymph node metastases were confirmed in 15 cases, two of which were fibrosis. According to the pathologic classification after operation, there were 16 cases at stage I, six cases at stage IIA, six cases at stage IIB, and three cases at stage IIC. There was no occurrence of perioperational and postoperational complications. The mean follow-up time was 33 months, ranged eight to 58 months. Twenty-nine patients achieved tumor-free survival, without elevation of blood alpha-fetal protein (AFP) or human chorionic gonadotropin (HCG). One patient developed postoperative recurrence in the retroperitoneum 17 months after operation. After receiving two cycles of salvage therapy, his serum AFP and beta-HCG returned to normal ranges. Another patient had metastasis in the liver and lung six months after operation, but achieved complete response after six cycles of adjuvant cisplatin-based chemotherapy. Antegrade ejaculation was preserved in 96.8% of patients. The mean operative time was 175 vs. 143 min(P=0.002), and the blood loss was 200 vs.104 mL in the group with and without preoperative chemotherapy, respectively(P<0.001). CONCLUSIONS: Modified RPLND achieves satisfactory results for stageI/II NSGCTs patients. It decreases damages to normal organs as well as causes less perioperative and postoperative complications compared to conventional PRLND.

[Expression and clinical significance of Bmi-1 protein in bladder cancer].

BACKGROUND & OBJECTIVE: At present, the molecular mechanisms of development and progression of bladder cancer are still poorly understood. This study was to explore the expression and significance of Bmi-1 in bladder cancer, and analyze its correlations to clinicopathologic features and prognosis of bladder cancer. METHODS: The expression of Bmi-1 protein in 137 specimens of bladder cancer and 30 specimens of normal bladder tissues was detected by SP immunohistochemistry, and its correlations to clinicopathologic features and prognosis of the patients were analyzed. RESULTS: The positive rate of Bmi-1 protein was significantly higher in bladder cancer than in normal bladder tissues (54.3% vs. 16.7%, P<0.05). The positive rate of Bmi-1 protein was 20.6% in grade G1 bladder cancer, 54.3% in grade G2 bladder cancer, and 78.8% in grade G3 bladder cancer, with significant difference (P<0.05). It was significantly lower in superficial bladder cancer than in invasive bladder cancer (32.5% vs. 81.5%,P<0.05). The expression intensity of Bmi-1 was related to tumor size, classification, TNM stage and prognosis (P<0.05), but not to tumor number and tumor recurrence (P>0.05). The patients were followed up for 44-86 months, with a median of 66 months. The 5-year survival rate was significantly higher in superficial bladder cancer patients than in invasive bladder cancer patients (89.6% vs. 39.2%, P<0.05), and higher in Bmi-1-negative patients than in Bmi-1-positive patients (78.5% vs. 50.8%,P<0.05). CONCLUSIONS: Bmi-1 protein is highly expressed in bladder cancer. Detecting Bmi-1 protein is helpful for diagnosis and prognostic evaluation of bladder cancer.

[Clinical analysis of stage I pediatric testicular yolk sac tumors: a report of ten cases].

BACKGROUND & OBJECTIVE: At present, pediatric testicular yolk sac tumor is hard to be diagnosed at early stage, and the treatment strategy for this disease after radical inguinal orchiectomy is uncertain. This study was to summarize our experience in diagnosing and treating clinical stage I pediatric testicular yolk sac tumors. METHODS: Clinical data of ten patients with clinical stage I pediatric testicular yolk sac tumors treated from July 2001 to June 2007 were analyzed. RESULTS: Testicular masses with low or uneven echoes were detected by B ultrasound in 11 testes of ten patients. The serum level of alpha fetoprotein (AFP) was increased in nine patients. Radical inguinal orchiectomy (RIO) was performed for all patients whereas chemotherapy was not administered preoperatively. Pathology examination was used to confirm the diagnosis of yolk sac tumor. One patient with vascular invasion and another one with bilateral testicular yolk sac tumor received cisplatin-based adjuvant chemotherapy. Retroperitoneal lymph node dissection (RPLND) was not performed in these patients. No recurrence was found in nine patients during follow-up with a mean of 3 years. The patient with bilateral testicular tumor had retroperitoneal and lung metastases at 23 months after adjuvant chemotherapy, and achieved complete remission again after salvage chemotherapy. CONCLUSIONS: With the combination of B ultrasound and serum AFP level, we can assess and diagnose stage I pediatric testicular yolk sac tumor. RIO could be used to treat it with good outcomes, while RPLND is not necessary. Chemotherapy is recommended to treat patients with high-risk of relapse.

[Clinical analysis of 14 cases of urachal carcinoma].

BACKGROUND & OBJECTIVE: Urachal carcinoma is a rare malignancy. This study was to summarize our clinical experience in the diagnosis and treatment of urachal carcinoma. METHODS: Fourteen cases of urachal carcinoma treated from May 1994 to April 2007 at Cancer Center and The First Affiliated Hospital of Sun Yat-sen University were retrospectively reviewed and analyzed. RESULTS: The most common complaints of the 14 patients were hematuria and irrigative bladder symptoms. Cystoscopy mainly revealed broad-based tumors located at the dome of the bladder. Soft-tissue masses between the bladder dome and the abdominal wall were detected by imaging examinations; the wall of the bladder was often invaded. Thirteen patients were found adenocarcinoma, the other one was malignant stromal cell tumor. Seven patients underwent extensive partial excision of the bladder, among which one case developed local recurrence 24 months after operation, while the other six cases were followed up for 14-120 months, with a median follow-up of 42 months without recurrence. Three patients underwent radical bladder resection and urinary diversion, two of which were followed up for 16 months and 84 months respectively without recurrence, while the other one died from surgical complications 3 months after operation. One case underwent partial cystectomy at another hospital developed recurrence 10 months after operation. Three advanced cancer patients received chemotherapy, two of which achieved progression free survival for seven and eight months respectively, while the other one died three months after chemotherapy. The one- and five-year survival rates were 85.7% and 61.2%, respectively. CONCLUSIONS: Extensive partial excision of the bladder is recommended for urachal carcinoma. Radical removal of the tumor during the first treatment and comprehensive therapies for advanced cancer patients and patients with recurrence or metastasis after operation are critical to improve the treatment efficacy of urachal carcinoma.

[Local Castleman's disease: a report of 17 cases with literature review].

BACKGROUND & OBJECTIVE: Castleman's disease (CD), also named angiofollicular lymph node hyperplasia or giant lymph node hyperplasia, is an uncommon reactive lymphadenopathy with unknown causes. This study was to report clinical features and therapeutic outcomes of 17 cases of local Castleman's disease (LCD), review literatures to improve the diagnosis and management of CD. METHODS: Clinical data of 17 LCD patients, treated in Cancer Center of Sun Yat-sen University from Aug. 1995 to Jul. 2006, were reviewed. RESULTS: There were 3 cases with and 14 cases without clinical symptoms. A single lymph node or aggregation of multiple lymph nodes was observed in a single location. The longest diameters of involved lymph nodes ranged from 1.2 to 10.4 cm. The lesions were located in the neck (11 cases), mediastinum (3 cases), lung (1 case), mesentery (1 case), adrenal region (1 case). Fifteen cases were hyaline vascular type, 1 case was plasma cell type and 1 case was mixed type; all were confirmed pathologically. One hyaline vascular type LCD patient had splenomegaly, hypoalbumin (25.6 g/L), hyperglobulin (80.0 g/L) and positive fecal occult blood. One plasma cell type LCD patient had anemia (95.0 g/L), positive urine protein and positive fecal occult blood. The other 15 patients had normal laboratory results. All patients underwent complete surgical resection. The duration of follow-up ranged from 1 to 129 months with a median of 25 months. Fifteen followed-up patients were all alive without recurrence. CONCLUSIONS: LCD patients mainly have lymphadenectasis in a single location, no clinical symptoms and normal laboratory results, with a majority of hyaline vascular type. Although CT is helpful for the diagnosis of LCD, the final diagnosis depends on pathologic examination. LCD patients can live long without recurrence after complete surgical resection of the tumor.

[Expression and clinical significance of survivin and PTEN in adrenal tumors].

BACKGROUND & OBJECTIVE: Since the histomorphology of adrenal tumor is very special, it is difficult to assess the malignancy of the tumors. This study was to explore the expression and clinical significance of Survivin and PTEN proteins in adrenal tumors. METHODS: The expression of Survivin and PTEN in 116 specimens of adrenal tumors, including 39 cases of cortex adenoma, 22 cases of cortex adenocarcinoma, 35 cases of pheochromocytoma, and 20 cases of malignant pheochromocytoma, were detected by LSAB immunohistochemistry. RESULTS: The positive rate of Survivin protein was 75.0%, and that of PTEN protein was 93.1%. The expression intensity of Survivin was correlated to that of PTEN in adrenal tumors (r=-0.486, P<0.05). The expression intensity of Survivin and PTEN in adrenal tumors were not related to patient's age, sex, tumor position, and so on (P>0.05). The expression intensity of Survivin was significantly lower in adrenal cortex adenoma than in adrenal cortex adenocarcinoma (P<0.05), and was significantly lower in pheochromocytoma than in malignant pheochromocytoma (P<0.05). The expression intensity of PTEN was related to the differentiation of adrenal tumor. The expression intensity of PTEN was significantly higher in adrenal cortex adenoma than in adrenal cortex adenocarcinoma (P<0.05), and was significantly higher in pheochromocytoma than in malignant pheochromocytoma (P<0.05). The expression of Survivin protein and PTEN protein was correlated to the prognosis of adrenal cortex adenocarcinoma and malignant pheochromocytoma: the higher the expression intensity of Survivin protein and the lower the expression intensity of PTEN protein, the worse the patient's prognosis (P<0.05). CONCLUSION: The expression of Survivin and PTEN proteins are closely related to the prognosis of adrenal tumors.

[Transabdominal radical nephrectomy for renal cell carcinoma: an experience on 155 patients].

BACKGROUND & OBJECTIVE: Renal cell carcinoma (RCC) is a common urologic malignant tumor. Radical nephrectomy is the major treatment for RCC. Approaching route selection, lymphadenectomy selection, and lymphadenectomy extension are debated. This study was to summarize our experience on transabdominal radical nephrectomy for RCC. METHODS: A total of 155 RCC patients were treated with radical nephrectomy and regional lymphadenectomy between Oct. 1999 and Dec. 2005 in Cancer Center of Sun Yat-sen University. The duration of operation, the amount of bleeding, the duration of postoperative hospitalization, complications, and survival rates of the patients were reviewed. RESULTS: No patient died during operation. The median duration of operation was 155 min (range, 60-360 min). The median amount of bleeding was 200 ml (range, 50-10,000 ml). Sixteen patients received RBC transfusion with a mean of 11.5 units (1 unit of RBC is extracted from 200 ml whole blood). In 23 (14.8%) patients, the amount of bleeding was more than 500 ml; 5 of the 23 patients underwent inferior vena cava thrombectomy, with median bleeding of 1 100 ml (range, 100-6,000 ml). The median duration of postoperative hospitalization was 15 days (range, 6-46 days). The intraoperative complications, treated intraoperatively without sequelae, included 2 cases of spleen injury, 1 case of inferior vena cava and duodenal injury, and 2 cases of vessel injury. The postoperative complications, cured conservatively, included 1 case of heart failure and 2 cases of incomplete ileus. The patients were followed up for 1-78.6 months, with a median of 20.0 months. The 1-, 3-, and 5-year overall survival rates were 93.2%, 84.1%, and 74.8%, respectively. The 1-year overall survival rates were 100% for stage I and stage II patients, 88.2% for stage III, and 53.8% for stage IV. The 3-year overall survival rates were 89.7% for stage I, 95.5% stage II, 75.6% for stage III, and 44.9% for stage IV. The 5-year overall survival rates were 89.7% for stage I, 86.8% for stage II, and 0% for stage IV. CONCLUSIONS: Radical nephrectomy via transperitoneal route, with benefits of early ligating the renal vessels and easy to perform lymphadenectomy, has certain effect on RCC with less severe complications. It may be a standard surgical procedure for RCC.

[Surgical treatment for 217 patients with bladder transitional carcinoma].

BACKGROUND & OBJECTIVE: Bladder transitional cell carcinoma (TCC) is the most common cancer among urogenital neoplasms. Surgical operation is the most effective therapy for TCC. This study was to explore surgical treatment for TCC and its clinical significance. METHODS: Clinical data, including disease-free survival, recurrence and death, of 217 TCC patients who had received different surgical procedures were retrospectively analyzed. RESULT: After a median follow-up of 30 months, 195 patients were free of disease, recurrence was observed for 56 times. Fourteen patients died: 13 of them died of progressive disease, and 1 died of renal failure. None death occurred in patients with stage T1 or grade I tumor. The overall 2-year survival rate was 89.6%. The survival rate and disease-freely survival rate were negatively correlated to stage and grade of the tumors. The prognosis of stage T1 and T4 patients had no correlation to surgical procedures. For stage T2 and T3 tumors, the prognosis of the patients who received radical cystectomy was significantly better than that of the patients who received organ sparing procedure. CONCLUSIONS: The organ sparing treatment is safe for patients with early stage and well differentiated TCC. Radical cystectomy should be done in time for patients with advanced and poorly differentiated TCC.

[Nephron-sparing surgery for localized kidney neoplasms--a report of 25 cases].

BACKGROUND & OBJECTIVE: Nephron-sparing surgery (NSS) was initially used in treating bilateral renal cell carcinoma (RCC) or RCC in a solitary functioning kidney with good effectiveness. The satisfied long-term outcome was also obtained in patients with unilateral localized RCC and a normal contralateral kidney after NSS. This paper was to report our experiences in treating localized renal tumor with NSS. METHODS: From Nov. 1999 to Dec. 2004, 25 patients were diagnosed with localized RCC preoperatively, and treated with NSS. During operation, renal circulation was temporarily interrupted in 8 patients, surface cooling of the kidney with ice slush was performed in 3 patients, frozen section pathology was performed in 16 patients. RESULTS: The operation was technically successful in all cases. The median operating time was 129 min (ranged 65-205 min). The mean blood loss was 310 ml (ranged 100-800 ml) with 1 case of blood transfusion. Except for 1 case of urinary fistula which was cured conservatively, there was no other postoperative complication. Intraoperative pathology confirmed that the surgical margin of all cases were negative. Of the 25 cases, 19 were renal clear cell carcinoma, 2 were renal granular cell carcinoma, 4 were hamartoma. The pathologic stage was pT1N0M0 in 21 patients. The mean follow-up time was 22 months (ranged 6-55 months). No local tumor recurred, and all patients survived disease-freely. CONCLUSIONS: NSS is effective in treating localized RCC. We recommend NSS to patients with unilateral localized, but not center, kidney tumor less than 4 cm and a normal contralateral kidney.

[Treatment of adult prostate sarcoma: a report of six cases with literature review].

BACKGROUND & OBJECTIVE: Primary adult prostate sarcoma is rare. Most patients come to hospital with huge pelvic tumors. Treatment for this disease remains controversial. We reported our experience of treating 6 cases of adult prostate sarcoma, and explore reasonable therapy strategy with literature review. METHODS: Six adult patients with prostate sarcoma were treated in our hospital, 5 underwent cystoprostatectomy combined with urinary diversion, 1 underwent total pelvic exenteration combined with urinary diversion and colostomy; 3 had preoperative intervention to embolize bilateral internal iliac artery, 4 received postoperative radiotherapy. The recent 11 reports published in China with a total of 62 cases were reviewed, 32 of them had radical surgery. The pertinent literatures from other countries were also reviewed. RESULTS: Of our 6 patients, 1 survived with no evidence of disease for 33 months; 1 survived with recurrent tumor for 18 months; 4 died of recurrent sarcoma 5-40 months after surgery. In the whole group of 62 patients, 1-, and 2-year survival rates were 59%, and 34%. CONCLUSION: Up to now, radical surgery is the most effective treatment for adult prostate sarcoma.

[Total cystectomy and neobladder for women patients with invasive bladder cancer: a report of eight cases].

BACKGROUND & OBJECTIVE: Although total cystectomy plus neobladder is widely used, with good outcome, to treat men patients with invasive bladder cancer, the experience of treating women patients with the same therapy is limit. This study was designed to investigate the outcome of total cystectomy plus sigmoid neobladder for women patients with invasive bladder cancer. METHODS: Clinical data of 8 women with invasive bladder cancer, who underwent total cystectomy plus sigmoid neobladder from Jan. 2002 to Oct. 2003 in Cancer Center of Sun Yat-sen University, were retrospectively analyzed. RESULTS: The operations were technically successful in all cases. The mean follow-up was 18 months (ranged 6-24 months). Six patients survived disease-freely;2 developed pelvic metastasis 6 and 12 months after operation respectively. All patients could actively urinate, 4 were continent day and night, 4 were continent at daytime with mild nocturnal incontinence. Mild hydronephrosis was detected in 1 patient 3 months after operation, which disappeared spontaneously 3 months later. Renal function and serum electrolytes were normal in all cases. CONCLUSIONS: Total cystectomy plus sigmoid neobladder could manage invasive bladder cancer in women patients, and the new bladders function well. But night continence in women patients is not as good as that in men patients.

[Initial results of intra-arterial chemotherapy for poorly differentiated bladder transitional cell carcinoma].

BACKGROUND & OBJECTIVE: Bladder cancer is the most common disease among urogenital tumors, and poorly differentiated bladder transitional cell carcinoma (BTCC) tends to recur, progress, and metastasize. This paper was to report our experiences in intra-arterial chemotherapy as adjuvant and palliative therapy for poorly differentiated BTCC. METHODS: Twenty-four patients with BTCC of grade 3 were treated with intra-arterial chemotherapy of GC regimen (gemcitabine plus cisplatin). Among them, 21 had post-operative adjuvant intra-arterial chemotherapy for 3 cycles, 3 advanced cases had palliative intra-arterial chemotherapy for 6 cycles. RESULTS: All patients were followed-up for 6-20 months. The mean follow-up was 12 months for 21 patients received adjuvant treatment, 1 developed pelvic metastasis, the others survived without evidenced tumors. Of 3 advanced cases, 1 with CR survived disease-freely for 8 months; 1 with PR survived progression-freely for 6 months; 1 with PR died of tumor relapse 13 months after chemotherapy. No serious complication was observed after intra-arterial chemotherapy. CONCLUSIONS: Intra-arterial chemotherapy is effective in managing poorly differentiated BTCC.