Orthotopic ileal neobladder in male patients: functional outcomes of 66 cases.

BACKGROUND: Orthotopic urinary diversion has become the preferred form of bladder reconstruction after cystectomy. We report on our experience with 66 male patients undergoing this procedure from November 1990 to February 1998. METHODS: A neobladder was constructed using an ileal segment with a Hautmann type bladder. Complications were assessed and subdivided into early and late types. Voiding function was evaluated in terms of voiding pattern and continence. Median follow up was 19.5 (range 3.5-87.7) months. RESULTS: There was one (1.5%) perioperative death. The most frequent pouch-related and unrelated early complications were persistent urine leak (7.6%) and prolonged ileus (16.7%), respectively, the majority of cases of which were managed conservatively. Analysis of late complications revealed 6.2% ureteroileal stenosis and 1.5% urethrointestinal stenosis rates, but no case of bladder stone formation. Of the 61 patients in whom voiding function was evaluable, 95.1% achieved excellent daytime continence, while only 67.2% had night-time continence. With regard to posture at voiding, 23 (37.7%) voided in a sitting position. Three of the patients (4.9%) were unable to void and required regular intermittent catheterization. CONCLUSIONS: An orthotopic neobladder can be constructed with acceptable morbidity and excellent functional results. We believe that orthotopic urinary diversion offers an attractive alternative to a bladder substitute when cystectomy is required.

Voiding function of orthotopic ileal neobladder in women.

OBJECTIVES: Although the advent of orthotopic lower urinary reconstruction in women is a major achievement in the evolution of urinary diversion, the mechanism of voiding dysfunction remains incompletely understood. We report on the voiding function of ileal neobladder in 12 female patients. METHODS: A neobladder was constructed using an ileal segment. Voiding function was evaluated in terms of voiding pattern and continence. Chain cystography was performed postoperatively to detect the existence of urethral angulation. Median follow-up was 33.2 months (range 8.4 to 77.4). RESULTS: Of the 1 2 patients, 10 (83.3%) achieved excellent daytime continence, and 6 (50%) had nighttime incontinence despite regular voiding during the night. Three patients (25%) sometimes or often performed self-catheterization because of difficulty in urinating. One patient (8.3%) was unable to void and required regular intermittent catheterization. Chain cystogram revealed urethral angulation in the 3 patients with difficulty in urinating or hypercontinence. CONCLUSIONS: An orthotopic neobladder can be constructed in women with excellent functional results. Urethral angulation appears to be one of the main mechanisms for voiding dysfunction, and further studies on the functional anatomy of the female urethra are needed to improve the voiding function of the orthotopic neobladder in women.

Clinical experience of orthotopic urinary reservoirs in male patients with bladder cancer.

Between 1988 and 1996, 23 male patients with bladder cancer underwent bladder substitution after cystectomy, using either the hemi-Kock, Hautmann, and Reddy procedures. The mean postoperative follow-up period was 36 months, with a range of 3 to 85 months. There were no perioperative deaths, and early postoperative complications occurred in 7 patients (30%); transient urine leak from the pouch in 4, wound infection in 3 and pyelonephritis in 2 patients. Twenty-two of the 23 patients (96%) were continent during the day, while 7 (30%) had nocturnal incontinence. All 3 patients with the Reddy procedure had nocturnal incontinence. Complete continence was preserved in 70% of the patients. Dysuria was seen in 4 patients, including retention in 1 patient. Late complications included urethral stricture in 3, wound hernia in 2, metabolic acidosis in 1, stone in the pouch in 1, and gallbladder stone in 1 patient. However, reoperation was necessary in 1 patient for internal urethrotomy and 1 patient for removal of a stone in the neobladder. Mild degree of hydronephrosis and unilateral reflux were seen in 3 patients each, and followed up conservatively. No urethral recurrence has occurred and only 1 patient died of cancer. The need for reoperation was very low and the high reservoir capacity resulted in continence from the beginning in most patients. We considered the neobladder useful as an alternative form of urinary diversion in selected cases.

[Intravesical instillation of epirubicin hydrochloride in superficial bladder tumor--prophylactic and therapeutic instillation for carcinoma in situ].

Between May 1990 and May 1993 we performed intravesical instillation of epirubicin hydrochloride (EPI) to 52 patients with superficial bladder tumor after transurethral resection. Indications of these instillations were classified into 3 groups. Group 1 was for carcinoma in situ (CIS) or the CIS other than the original tumor, group 2 was for multiple tumors, and group 3 was for pT1G3 tumor. Intravesical instillations of the drug were given weekly for 10 weeks and close follow-up examinations were performed routinely. Group 1 was treated for CIS, whereas group 2 and group 3 were prophylactic instillations. The disease-free rate in group 1 was 67%, and that in group 2 and group 3 was 77% at 12 months, and 42% at 24 months according to the Kaplan-Meier method. The major side effects of the instillations were bladder irritation, hematuria and pyuria. However, we experienced 5 patients with severe side effects; 2 of atrophic bladder and 3 of hemorrhagic cystitis. Although this study was conducted retrospectively, these findings suggest that intravesical instillations of EPI can be as effective as other drugs, such as mitomycin C, and doxorubicin, by adding the maintenance instillation or by elevating the drug density and shortening the instillation time.

Interstitial laser coagulation for benign prostatic hyperplasia: preliminary clinical results.

We report our early experience in the clinical application of interstitial laser coagulation of the prostate (ILCP) in the treatment of benign prostatic hyperplasia (BPH). Neodymium: YAG laser energy is transmitted via a specially designed interstitial thermotherapy light-guide. The light guides were inserted transurethrally into each lobe of the prostate by direct puncture, under direct visualization. The prostatic urethra is preserved during the procedure. From December 1993 to March 1994, 37 patients with symptomatic BPH were treated with ILCP. Treatment outcome was evaluated by the International Prostatic Symptom Score (I-PSS), flow rate, postvoided residual urine volume and quality of life score. Significant improvement in I-PSS and peak flow rate was observed at 3 months: I-PSS decreased from a mean of 19.3 to 10.4, and the peak flow rate increased from a mean of 7.2 to 9.4 ml/sec (p < 0.0001). The mean postvoided residual urine volume significantly decreased from 91 to 47 ml (p < 0.01). Two days after ILCP the serum prostate-specific antigen had increased by 860%, evidence of the significant tissue damage produced by laser irradiation. The quality of life score significantly decreased from a mean of 4.8 to 2.1 (p < 0.0001). No serious side-effects were observed. The early clinical results suggest that ILCP is safe and effective as a treatment of BPH and is less invasive than some other methods.

Mini-laparotomy staging pelvic lymph node dissection for localized prostate cancer.

We report our early experience with mini-laparotomy staging pelvic lymph node dissection (PLND) for clinically localized prostate cancer. We have used virtually the same original technique described by Steiner and Marshall. A 5 cm lower midline abdominal incision provides excellent exposure, allowing complete PLND under direct visualization. If radical retropubic prostatectomy is indicated by the state of the pelvic lymph nodes, this can be performed only by extending the same incision. Nine patients with histologically proven prostate cancer underwent mini-laparotomy staging PLND. The average intraoperative time for mini-laparotomy PLND was 33 minutes (range, 25-50 minutes). The intraoperative blood loss was 44 ml (range, 20-90 ml). The mean number of pelvic lymph nodes removed was 6.9 (range, 5-10 nodes) on the right and 10.8 (range, 8-21 nodes) on the left. Eight patients underwent immediate radical retropubic prostatectomy and one had radiation therapy. There were no complications directly related to the mini-laparotomy staging PLND. Mini-laparotomy staging PLND is an attractive alternative to laparoscopic PLND, especially for patients at low risk of lymph node metastasis.

Intra-arterial infusion chemotherapy in combination with a biscoclaurine alkaloid, Cepharanthin, to treat bone metastasis arising from renal cell carcinoma.

A 64-year-old man with iliac bone metastasis from left renal cell carcinoma was treated by intra-arterial infusion chemotherapy using vinblastine and epirubicine in combination with a biscoclaurine alkaloid, Cepharanthin. A good response was confirmed by computed tomography scan and the symptoms related to the metastatic lesion were much improved. Partial resection of the left iliac bone was performed when no viable cancer cells were found in the metastatic lesion.