Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center.

BACKGROUND: The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients. METHODS: We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS. RESULTS: Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20-101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11-235) vs. 50 ivMEQ (7-277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14-2.45; p = 0.009) and CSS (HR = 1.53, 1.04-2.25; p = 0.030) on multivariable analyses. CONCLUSIONS: Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

Implications of Definitive Prostate Cancer Therapy on Soft Tissue Margins and Survival in Patients Undergoing Radical Cystectomy for Bladder Urothelial Cancer.

PURPOSE: We evaluated the possibility of an existing link between definitive prostate cancer treatment and its effect on positive soft tissue surgical margins at radical cystectomy. A secondary objective was to determine whether definitive prostate cancer treatment was associated with bladder cancer survival end points. MATERIALS AND METHODS: There were 749 patients who underwent radical cystectomy between 2000 and 2013. After excluding females and patients with nonurothelial histologies 561 men were identified, of whom 69 (12.3%) received single or multimodal definitive prostate cancer treatment. Univariate and multivariable logistic regression was used to determine an association between clinical and pathological features such as definitive prostate cancer treatment and positive soft tissue surgical margins. Cox regression models and competing risk regression were used to investigate the impact of definitive prostate cancer treatment and positive surgical margins on survival. RESULTS: The median age of the male population was 70.0 years. There were 57 cases of positive soft tissue surgical margins in our cohort of 561 men (10.2%). Of men who underwent previous definitive prostate cancer treatment 20 of 69 (29.0%) had positive surgical margins compared to 37 of 492 (7.5%) who never received definitive prostate cancer treatment (p <0.0001). Brachytherapy, radiotherapy, hormonal therapy and radical prostatectomy significantly increased the rate of positive margins. Brachytherapy (OR 5.8), radiotherapy (OR 2.7) and hormonal therapy (OR 5.1) remained independent predictors of positive margins on multivariate analysis. Positive margins were associated with negative effects on recurrence-free (HR 3.1), cancer specific (HR 4.1) and overall survival (HR 2.8). CONCLUSIONS: Patients with a history of definitive prostate cancer treatment are at increased risk for positive soft tissue surgical margins. Positive margins significantly impact bladder cancer recurrence-free, cancer specific and overall survival following radical cystectomy. Careful patient counseling and surgical planning are crucial when treating patients undergoing radical cystectomy who have a history of definitive prostate cancer treatment.

Patient and disease-specific factors and their influence on urinary reconstruction choice at a referral center.

PURPOSE: To evaluate potential socioeconomic and demographic factors that may influence or be associated with various types of urinary reconstruction (UR) following a radical cystectomy (RC) accounting for existing clinical variables. METHODS: There were 828 patients that underwent a RC and UR between 2000 and 2013. After excluding patients that did not meet medical or surgical criteria for a continent urinary reconstruction (CUR-orthotopic neobladder or continent catheterizable pouch), there were 714 patients available for analysis. Socioeconomic and demographic data along with disease-specific variables were recorded preoperatively and analyzed to determine a correlation with a particular type of UR. RESULTS: Non-continent urinary reconstruction (ileal conduit or cutaneous ureterostomies) and CUR accounted for 78.3 % (559/714) and 21.7 % (155/714) of UR following RC, respectively. On univariate analysis, younger age, marital status, employment status, type of insurance, ASA score, and preoperative glomerular filtration rate were significantly associated with CUR (p < 0.01). Travel distance, race, and education level were not factors for UR type. Additionally, there was no significant difference between males and females receiving a CUR. On multivariate analysis, older age [odds ratio (OR) 0.85, p < 0.01], marital status (OR 0.28, p < 0.01), insurance status (OR 0.22, p = 0.04), and higher ASA score (OR 0.50, p < 0.01) remained independent predictors of those less likely to receive a CUR. CONCLUSION: Predictable socioeconomic and demographic influences exist between the choice of UR after RC. Increasing age corresponds to a decreasing likelihood of receiving a CUR. No significant difference was seen between men and women in undergoing a CUR.

Ureteral replacement and onlay repair with reconfigured intestinal segments.

PURPOSE: Ureteral loss represents a surgical challenge to provide low pressure drainage while avoiding urinary stasis and reflux. The ideal replacement should optimize drainage while minimizing absorption, allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract. We reviewed our experience with ureteral repair, focusing on the use of reconfigured intestine. We report what is to our knowledge the novel use of reconfigured intestine as an onlay flap on the preserved ureteral segment and as a circumferential interpositioned segment. MATERIALS AND METHODS: A total of 16 ureters were repaired in 4 men and 9 women using reconfigured ileum, colon or appendix. Mean patient age was 45 years (range 26 to 66). The etiology of the ureteral defect was iatrogenic in 8 patients, retroperitoneal fibrosis in 3, trauma in 3 and ureteritis cystica in 1. Mean defect length was 10 cm (range 5 to 20) in the 10 right and 6 left ureters, and the defect was proximal in 3, mid in 4, distal in 7 and panureteral in 2. Ureteral replacement was performed using a segment of ileum in 13 cases or colon in 1. The segment was detubularized and reconfigured according to the Yang-Monti principle and used as a complete retubularized interposed segment in 7 cases or as an onlay flap on the opened ureter without resection in 7. Also, 2 ureters were reconstructed with an incised appendiceal flap onlayed over the preserved ureteral plate. At a mean followup of 44 months (range 12 to 78) all patients underwent antegrade nephrostogram, followed by renal scan and upper tract imaging. RESULTS: All patients tolerated the procedure without initial bowel or urinary tract complications. In 1 patient who had received radiation a ureteral fistula developed to a blind Hartmann pouch at 9 months, requiring repair. Ultimately, cystectomy was done for irradiation cystitis (onlay group). Another patient with bilateral obstruction at presentation lost unilateral renal function during 5 years. Urinary drainage was achieved in all 14 remaining renal units with preservation of function, as shown on renal scan. Patients reported minor mucous production without renal colic or stone formation. CONCLUSIONS: Long ureteral defects require tissue replacement when bladder flaps do not suffice. Ureteral replacement can be achieved by reconfigured intestinal segments, which are readily mobilized and secured as interposed segments or as an onlay flap on the preserved ureter. A relatively short segment can be used to repair a lengthy defect along any segment of ureter, also allowing for nonrefluxing reimplantation.

Salvage surgical resection for isolated locally recurrent inguinal lymph node metastasis of penile cancer: international study collaboration.

PURPOSE: We assessed the merit of performing salvage inguinal lymph node dissection in those infrequent cases of penile cancer with locally recurrent inguinal lymph node metastases in the absence of other suspected sites of disease. MATERIALS AND METHODS: A total of 20 patients were retrospectively identified as having undergone salvage inguinal lymph node dissection for locally recurrent penile cancer. Patients were previously treated with primary inguinal lymph node dissection with curative intent. At the time of salvage inguinal lymph node dissection, superficial and deep inguinal lymph node dissection was performed with resection outside of the standardized surgical template if there was inguinal recurrence outside of this region. RESULTS: All cases were primary penile squamous cell carcinomas. Median time to recurrence from initial inguinal lymph node dissection was 7.7 months (range 3.1 to 35.0). At salvage inguinal lymph node dissection a median of 3 lymph nodes (range 1 to 17) was resected with a median of 2 (range 1 to 7) nodes positive for malignancy. Median overall survival after salvage inguinal lymph node dissection was 10.1 months (95% CI 1.9-18.3) and median disease specific survival after salvage inguinal lymph node dissection was 16.4 months (95% CI 5.1-27.8). Of the initial 20 patients 9 have no evidence of disease (median followup 12.0 months, range 7.1 to 70.1). Postoperative complications developed in 11 patients, including wound infections in 6, postoperative severe (debilitating) lymphedema in 4 and seroma in 1. CONCLUSIONS: Salvage inguinal lymph node dissection is a potentially curative treatment in patients with penile cancer with locally recurrent inguinal lymph node metastases in the absence of occult disease. Patients undergoing such salvage surgery should be informed of the high likelihood of postoperative complications.

A single-institution experience with metallic ureteral stents: a cost-effective method of managing deficiencies in ureteral drainage.

INTRODUCTION: The limitations of traditional ureteral stents in patients with deficiencies in ureteral drainage have resulted in frequent stent exchanges. The implementation of metallic stents was introduced to improve the patency rates of patients with chronic upper urinary tract obstruction, obviating the need for frequent stent exchanges. We report our clinical experiences with the use of metallic ureteral stents in the management of poor ureteral drainage. MATERIALS AND METHODS: Fifty patients underwent metallic ureteral stent placement from 2009 to 2012. Stent failure was defined as an unplanned stent exchange, need for nephrostomy tube placement, increasing hydronephrosis with stent in place, or an elevation in serum creatinine. Stent life was analyzed using the Kaplan-Meier methodology, as this was a time dependent continuous variable. A cost analysis was similarly conducted. RESULTS: A total of 97 metallic stents were placed among our cohort of patients: 63 in cases of malignant obstruction, 33 in the setting of cutaneous ureterostomies, and 1 in an ileal conduit urinary diversion. Overall, stent failure occurred in 8.2% of the stents placed. Median stent life was 288.4 days (95% CI: 277.4-321.2 days). The estimated annual cost for traditional polymer stents (exchanged every 90 days) was $9,648-$13,128, while the estimated cost for metallic stents was $4,211-$5,313. CONCLUSION: Our results indicate that metallic ureteral stent placement is a technically feasible procedure with minimal complications and is well tolerated among patients. Metallic stents can be left in situ for longer durations and provide a significant financial benefit when compared to traditional polymer stents.

A preliminary report on the usage of an intracorporal antibiotic cast with synthetic high purity CaSO4 for the treatment of infected penile implant.

INTRODUCTION: Currently, the surgical treatment of infected penile prostheses is complete removal and either immediate salvage procedure, which carries a significant infection risk, or delayed implantation. With delayed implantation the risk of infection is lower, but the patient loses penile length and width due to corporal fibrosis. AIM: We present our experience with the use of a novel temporary synthetic high purity calcium sulfate (SHPCaSO4) component that acts as a "spacer" at the time of removal of an infected prosthesis while providing constant delivery of local antibiotic elution to the infected area. MAIN OUTCOME MEASURES: Demonstrate that the use of a novel material, SHPCaSO4, can be an innovative way to bridge the gap between removal of an infected penile implant and delayed reimplantation. METHODS: Two patients (Patient A and B) presented with pain and erythema and were found to have infected malleable penile prosthesis. Both underwent removal of all infected components, and sent for tissue culture. The SHPCaSO4 was mixed with vancomycin and tobramycin, allowed to set up for 5 minutes, and then injected into the corporal space followed by closure with 2-0 Vicryl sutures. The injected SHPCaSO4 was palpable in the penile shaft both proximally and distally, as an "intracorporal casts." RESULTS: Patients denied pain postoperatively. Delayed implantation occurred at 6 weeks for patient A. This went uneventful and a new three-piece inflatable implant was inserted. Patient B underwent salvage placement of right malleable implant at 15 weeks, and here significant corporal fibrosis was encountered. Patients have had no infection since their delayed implantation (mean follow-up 4 months). CONCLUSIONS: Data in reference to SHPCaSO4 shows that this product dissolves in approximately 4-6 weeks. This may account for the difference in the ease of delayed implantation between the two patients. Further investigation is warranted.

Ventral phalloplasty.

PURPOSE: To present the surgical technique of ventral phalloplasty as an adjunct procedure to the classic prosthetic surgery. MATERIALS AND METHODS: In this video we demonstrate how to perform a ventral phalloplasty in a patient that has undergone a penile prosthesis implantation. Our technique consists of: delineation of the penile scrotal web, excision of this redundant skin, and re-approximation of the wound to mimic the natural median raphe. RESULTS: The ventral phalloplasty improves the perception of phallic length, as well as patients' satisfaction after prosthetic surgery. CONCLUSION: Penile length perception is the main concern of patients that have undergone penile prosthesis implantation. In this video we demonstrate that the ventral phalloplasty can improve perception of phallic length, and can be an important adjunct to the classic prosthetic surgery.

Cutaneous ureterostomy technique for adults and effects of ureteral stenting: an alternative to the ileal conduit.

PURPOSE: We present surgical modifications that improved the outcome of cutaneous ureterostomies. MATERIALS AND METHODS: A total of 310 patients with a median age of 71 years (range 38 to 88) underwent cutaneous ureterostomy as urinary diversion. Median followup was 25 months (range 1 to 172). The technique included 1) transposition of the left ureter above the inferior mesenteric artery, 2) mobilization of the ileocecal segment with repositioning above each terminal ureter, 3) abdominal wall hiatus fixation with 4 angle sutures and 4) YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. In the 161 group 1 patients (59.1%) the Double-J® stents were removed in less than 3 months. Stents remained longer than 3 months in the 111 group 2 patients (40.8%). RESULTS: Of the 272 patients ureteral obstruction developed in 36 (13.2%). Ureteral obstruction was on the right side in 6 patients (2.2%), on the left side in 27 (9.9%) and bilateral in 3 (1.1%). Ureteral obstruction was treated with restenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). Ureteral obstruction developed on the right side, on the left side and bilaterally in 3.7%, 13.7% and 1.82% of the patients in group 1, and in 0%, 4.5% and 0%, respectively, of those in group 2. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p = 0.01). CONCLUSIONS: As with other types of urinary diversion, left ureteral obstruction is a common complication of bilateral cutaneous ureterostomies. Long-term stenting for greater than 3 months and the applied surgical modifications improved the clinical outcome of this type of urinary diversion.

Salvage spiral sling techniques: alternatives to manage disabling recurrent urinary incontinence in females.

PURPOSE: Females with recurrent stress urinary incontinence after anti-incontinence surgery represent a therapeutic challenge. In our experience and that of others standard sling procedures have occasionally failed to correct these problems. We determined the effectiveness of various spiral sling techniques used in these cases to manage pipe stem urethras in which conventional slings had failed. MATERIALS AND METHODS: Between January 2007 and July 2008 we evaluated 30 female patients with persistent stress urinary incontinence after multiple failed anti-incontinence procedures. Preoperative and postoperative evaluation consisted of history, physical examination, number of pads, Stamey score and quality of life questionnaires. RESULTS: We followed 28 patients a minimum of 15 months (range 15 to 18). Mean patient age was 60 years (range 36 to 84). At presentation patients had undergone a mean of 3.5 prior vaginal procedures (range 1 to 6) and used a mean of 7 pads daily (range 3 to 12). Of the patients 21 received a synthetic spiral sling, 5 received an autologous spiral sling (rectus fascia in 3 and fascia lata in 2) and 3 received a lateral spiral sling. Mean pad use decreased to 0.9 daily (range 0 to 2, p<0.05). Postoperative mean Stamey score decreased from 2.6 to 0.3 (p<0.05). Complications included unilateral vesical perforation in 3 patients with a contralateral lateral spiral sling. The overall success rate was 72%. CONCLUSIONS: Salvage spiral sling techniques are a satisfactory alternative treatment for refractory stress urinary incontinence. When synthetic material cannot be used, autologous tissue can provide similar results. When the bladder is perforated unilaterally, a lateral spiral sling can be used on the contralateral side.

Morbidity associated with nonemergent hysterectomy for placenta accreta.

OBJECTIVE: The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta. STUDY DESIGN: This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009. RESULTS: Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation. CONCLUSION: Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

Disabling complications with slings for managing female stress urinary incontinence.

OBJECTIVE: To report an increase in the referral of patients with disabling complications after the failure of conservative therapy, their presentation, final surgical management and clinical outcome, following the use of non-autologous slings (NAS), currently the primary surgical procedure for managing stress urinary incontinence (SUI) in women. PATIENT AND METHODS: Thirty-eight patients (mean age 64 years) required surgical management for disabling complications after placing a NAS for SUI. Sling types were synthetic (25), xenografts (six) and allografts (four). Twenty (53%) patients presented with bladder outlet obstruction, 13 (34%) with sling erosion, three (8%) with worsened SUI, and two (5%) with unobstructive severe urgency and frequency. RESULTS: The sling was dissected and incised with no complication in 19 of 20 patients. One had a posterior urethral defect during sling dissection. Twelve patients (60%) acquired normal voiding and were continent. Among the 13 patients who had the sling dismantled and urethrolysis, two had recurrent or persistent SUI, two de-novo urgency/frequency and one developed osteitis pubis. Three patients with disabling SUI received a pubovaginal sling placed proximal to the bladder neck, and had an overall improvement in their urinary control with no retention. Two unobstructed patients with urgency and frequency did not improve with anticholinergic medication and pelvic floor therapy, and are now candidates for botulinum toxin injection or neurostimulation. CONCLUSIONS: The complication rate with periurethral NAS for managing SUI in females is substantial. Patients with refractory urgency/frequency after the sling need a complete evaluation with cystoscopy and video-urodynamics. Obstruction and erosion are the commonest problems and require surgical correction.

Visualization of the neurovascular bundles and major pelvic ganglion with fluorescent tracers after penile injection in the rat.

OBJECTIVE: To evaluate whether fluorescent tracers can consistently label the neurovascular bundles (NVBs) and major pelvic ganglion (MPG) after an intracavernosal penile injection, as the reported incidence of erectile dysfunction (ED) in men after radical prostatectomy (RP) is 55-65% and thus preservation of erectile function, sparing one or both of the NVBs remains one of the most vital factors. MATERIALS AND METHODS: Male Sprague-Dawley rats (3 months old) received penile injections (20 microL; seven rats/group) of either deionized water (DW), Fluoro-Gold (FG), Fast-Blue (FB), Fluoro-Ruby (FR) or green fluorescent pseudorabies virus (GF-PRv). The rats were killed at 2, 3 and 14 days after injection and the NVBs and MPG were harvested and placed directly under fluorescence light. Image analysis was done by computer, coupled to a microscope equipped with a digital camera. Each NVB and MPG were analysed for its staining pattern and consistency. RESULTS: When compared with the FB, FR and GF-PRv rats, the FG-injected rats had better staining of the NVB at 2, 3 and 14 days after injection. Under x200, FG highlighted the axons of the cavernous nerve (CN) and cell bodies (MPG). This indicates that FG injection into the penis induced the strongest CN labelling (positive staining) at 2 and 3 days after injection as compared with FB-, FR- and GF-PRv-injected rats. CONCLUSION: FG injection into the penis has consistent retrograde staining of the NVBs and MPG after 3 days. Therefore, we predict that FG could potentially be used to improve the identification of the NVB in other models. However, further studies need to be carried out before these tracers can be used in humans.

Subarachnoid hemorrhage as complication of phenylephrine injection for the treatment of ischemic priapism in a sickle cell disease patient.

INTRODUCTION: Ischemic priapism (IP) is a urologic condition, which necessitates prompt management. Intracavernosal injection of phenylephrine is a usual treatment modality utilized for the management of these patients. Aim. We present a case of subarachnoid hemorrhage following intracavernosal injection of phenylephrine for IP in a patient with sickle cell disease. METHODS: We analyzed the degree of subarachnoid hemorrhage in our patient after intracavernosal injection of phenylephrine. The patient had an acute rise in blood pressure during corporal irrigation. This was followed by the onset of severe headache. Computed tomography (CT) scan confirmed the diagnosis of a subarachnoid hemorrhage. MAIN OUTCOME MEASURE: Subarachnoid hemorrhage associated with intracavernosal injection of phenylephrine. Result. A 23-year-old African American male with a history of sickle cell disease presented with a painful penile erection. The patient was started on intravenous fluids, oxygen by nasal canula, and analgesic medication. After this, a blood gas was obtained from his left corpora cavernosa. This was followed by normal saline irrigation and injection of phenylephrine. The patient complained of a sudden, severe "terrible headache" immediately following the last injection, and noncontrast CT scan of the head was obtained and a subarachnoid hemorrhage was noted. The patient was admitted for observation and no significant changes were noted. CONCLUSIONS: Intracavernosal injection of phenylephrine for the management of IP can be associated with several possible complications. We present our single case complicated with the formation of a subarachnoid hemorrhage. The patient was treated conservatively and had no long-term neurologic sequelae. Davila HH, Parker J, Webster JC, Lockhart JL, and Carrion RE. Subarachnoid hemorrhage as complication of phenylephrine injection for the treatment of ischemic priapism in a sickle cell disease patient.

Survival Outcomes Associated With Female Primary Urethral Carcinoma: Review of a Single Institutional Experience.

BACKGROUND: Primary urethral carcinoma (PUC) is rare, and standard treatment recommendations are lacking. We examined the variation in treatments and survival outcomes of female PUC at a single, tertiary referral cancer center. METHODS: Records of women with PUC referred to our multidisciplinary genitourinary oncology service between 2003 and 2017 were reviewed. Clinical, demographic, pathologic, primary and salvage therapy details, and overall (OS) and recurrence-free survival (RFS) were recorded. Survival outcomes were analyzed for the entire cohort, and cases of locally-advanced (≥ T2 tumor), non-metastatic PUC were evaluated according to treatment intensity. Multimodal treatment (cystourethrectomy + concomitant therapy) was compared with non-multimodal therapy. Contingency analyses and Kaplan-Meier estimates were performed. RESULTS: Thirty-nine women with PUC were identified. In total, median OS was 36 months (95% confidence interval, 10.6-61.4 months). Twenty-four had T3 to T4 disease, 12 were node-positive, and 3 had distant metastases. Histology included 22 adenocarcinomas, 11 urothelial, 5 squamous, and 1 neuroendocrine. Patients with locally advanced, non-metastatic disease (n = 25) had significantly reduced OS (36 vs. 99 months; P = .016) and RFS (46 months vs. unmet; P = .011) compared with patients with locally confined tumors. Approximately one-half of locally advanced cases were managed with multimodal therapy (4 with neoadjuvant therapy + cystourethrectomy, 8 with cystourethrectomy + adjuvant therapy, and 1 with chemoradiation + consolidative cystourethrectomy). Multimodal therapy had nonsignificant longer OS (36 vs. 16 months) and RFS (58 vs. 16 months), P > .05. CONCLUSIONS: Locally advanced female PUC has relatively poor survival outcomes. Although we observed a nonsignificant interval improvement in survival with multimodality therapy, the treatment paradigm is inconsistent. Because it is a rare disease, collaborative multi-institutional studies are needed.

Extended cytoreduction of intraabdominal metastatic ovarian cancer in the left upper quadrant utilizing en bloc resection.

OBJECTIVE: The objective of the study was to describe the development of and experience with a technique for en bloc resection of left upper quadrant intraperitoneal metastatic ovarian cancer. STUDY DESIGN: From May 7, 2002-August 14, 2004, 6 women underwent en bloc resection of extensive tumor contiguously involving the omentum, colon, gastrocolic ligament and spleen. This represents about 5% of all cytoreductive operations performed during that time. Four of the 6 had received neoadjuvant chemotherapy. RESULTS: A description of the technique is included in the text. Two women required partial gastrectomy and partial pancreatectomy. Separate segmental resection or subtotal colectomy was performed in 3 women. Cytoreduction was optimal in all 6 cases. Significant complications occurred in 3 of the women. Disease-free survival ranged from 2-12 months. CONCLUSION: In highly selected patients undergoing cytoreductive surgery for ovarian cancer, en bloc resection of extensive left upper quadrant intraabdominal tumor may be a reasonable method for accomplishing optimal cytoreduction.

Robotic Assisted Laparoscopic Partial Cystectomy as Treatment for Pseudosarcomatous Fibromyxoid Tumor of the Bladder.

This case is of a 26 year old female evaluated for gross hematuria and suprapubic pain found to have a large bladder tumor. She subsequently underwent successful robotic assisted laparoscopic partial cystectomy. Pathology revealed pseudosarcomatous fibromyxoid tumor, an uncommon lesion that occurs most frequently among young females and must be distinguished from other malignant lesions, as treatment may differ. Partial cystectomy via robotic approach has never been described in the literature as a treatment option for this type of bladder lesion. In this case, the patient did exceptionally well upon follow-up. As such, robotic assisted laparoscopic partial cystectomy is presented a viable option for treatment of select patients with pseudosarcomatous fibromyxoid tumor.

Change in Management Based on Pathologic Second Opinion Among Bladder Cancer Patients Presenting to a Comprehensive Cancer Center: Implications for Clinical Practice.

OBJECTIVE: To evaluate the incidence and degree of change from a pathologic second opinion of bladder biopsies at a Comprehensive Cancer Center that were initially performed at referring community hospitals. The secondary objective was to determine the impact the potential changes would have on a patient's treatment. MATERIALS AND METHODS: Dedicated genitourinary pathologists reviewed 1191 transurethral biopsies of the bladder and/or prostatic urethra from 2008 to 2013. Major and minor treatment changes were defined as altering recommendations for cystectomy, systemic chemotherapy, or primary cancer diagnosis, and alterations in intravesical regimens, respectively. RESULTS: There were 326/1191 patients (27.4%) with a pathologic change on second opinion: grade (62/1191, 5.2%), stage (115/1191, 9.7%), muscle in the specimen (29/1191, 2.4%), presence or absence of carcinoma in situ (34/1191, 2.9%). Outside pathology did not address the presence or absence of lymphovascular invasion in 620/759 (81.7%) of invasive cases (≥cT1), of which 35/620 (5.6%) had lymphovascular invasion. There were 212 mixed, variant, or nonurothelial histologies detected in 199/1191 (16.7%) patients, with 114/212 (53.7%) resulting in reclassification by our pathologists. Potential treatment alterations accounted for 182/1191 (15.3%) of cases, with 141/1191 (11.8%) imparting major changes. There were 82/1191 (6.8%) changes in recommendation for a radical cystectomy, 38/1191 (3.2%) had a complete change in primary tumor type, and 21/1191 (1.8%) for change in chemotherapy regimen. CONCLUSION: The amount and degree of pathologic changes and its potential impact on treatment emphasize the importance of bladder cancer patients having their histology reviewed by genitourinary-dedicated pathologists. In our cohort, 15.3% of patients could see a treatment alteration, with 11.8% being a major change.

Primary Ewing sarcoma of the kidney: a symptomatic presentation and review of the literature.

The objective of this review is to discuss the unique nature of primary renal Ewing sarcoma, including incidence, presentation and management. We also report on a common pattern of presentation, consisting of acute flank pain mimicking a renal stone colic, with or without hydronephrosis, and a renal mass discovered during imaging studies of renal Ewing sarcoma. We present our case of renal Ewing sarcoma along with imaging and pathological analysis. We also performed a retrospective review of all cases of renal Ewing sarcoma using PubMed. A total of 48 cases of renal EWS sarcoma have been reported and analyzed in this review. A mean age of 30.4 years was found along with a 61% male predominance. The mean survival was 26.14 months with a lower median survival in patients with advanced metastatic disease. Primary Ewing sarcoma of the kidney is rare. The diagnosis of primary renal EWS can be difficult and is based on a combination of electron microscopy, immunohistochemistry, chromosomal analysis, fluorescence in situ hybridization (FISH) and light microscopy.

A large cellular angiofibroma of the male pelvis presenting with obstructive voiding: A case report and review of the literature.

Cellular angiofibromas (CAF) are rare, benign soft-tissue tumours. The diagnosis of CAF is important given the heavy resemblance to other tumours. Herein, we describe a case of a rapidly growing, very large (13.5 cm) CAF located in the deep pelvis of a middle-aged male who presented with difficulty voiding.