Longer time to radical cystectomy in patients treated with neoadjuvant chemotherapy is associated with worse oncological outcomes.

BACKGROUND: Current muscle-invasive bladder cancer (MIBC) guidelines recommend not delaying radical cystectomy (RC) >3 months after diagnosis as it decreases overall survival (OS). However, literature investigating the impact of delay in RC in patients who receive NAC is limited, especially on a population-based level. OBJECTIVE: To investigate the association between time from diagnosis of MIBC to RC (TTRC) in patients with urothelial bladder cancer (UBC) treated with NAC and RC and 1) 2-year OS and 2) pathological lymph node status (pN+) in a population-based cohort. METHODS: Patients were selected from the Netherlands Cancer Registry. The study included 237 patients with cT2-T4aN0M0 UBC, treated with NAC and RC between November 2017 and October 2019. Association between TTRC and OS was assessed using multivariable Cox regression analyses. Schoenfeld and Martingale residuals were used to investigate the proportional hazards assumption and whether a cut-off in the TTRC could be identified. Association between TTRC and pN+ was assessed using multivariable logistic regression analyses. RESULTS: Median TTRC was 23 weeks (interquartile range (IQR) 19-26). 2-year OS was 67% (95%CI 59%-74%). Each week of delay in the TTRC was independently associated with 2-year OS (HR 1.06; P = 0.03) in the Cox regression analysis. The sensitivity analyses, defining TTRC as the time between last cycle of NAC and RC, revealed that each week of delay between NAC and RC was associated with 2-year OS (Hazard ratio (HR) 1.13; P < 0.0001), and with pN+ (Odds ratio (OR) 1.21; P = 0.01) in the Cox and logistic regression analyses, respectively. CONCLUSIONS: A longer TTRC is associated with worse oncological outcomes in patients treated with NAC and RC.

[Visualisation of the ejaculatory tract in a patient with empyema of the seminal vesicles]. / Een patiënt met empyeem van de zaadblazen.

BACKGROUND: Fever and malaise without the possibility of an adequate anamnesis has a broad differential diagnosis. Under these conditions in male patients several rare urogenital disorders need to be considered. CASE DESCRIPTION: A 26-year-old mentally disabled young man was examined because of a fever, altered behaviour and elevated infection parameters. A CT-scan of the abdomen showed signs of prostatitis. Transrectal ultrasonography was performed under general anaesthesia to rule out a prostatic abscess. This showed prominent, dilated seminal vesicles. Under transurethral sight, large amounts of pus was drained from the ejaculatory ducts by digital rectal examination (unique video). Intravenous antibiotic therapy was continued and the patient successfully recovered. CONCLUSION: Acute bacterial prostatitis is diagnosed based on the clinical presentation of the patient. When there is fever without a focus or no recovery following antibiotic therapy, an abscess of the prostate or empyema of the seminal vesicles should be considered.

What can we learn from studying plastic debris in the Sea Scheldt estuary?

The Sea Scheldt estuary has been suggested to be a significant pathway for transfer of plastic debris to the North Sea. We have studied 12,801 plastic items that were collected in the Sea Scheldt estuary (Belgium) during 3 sampling campaigns (in spring, summer, and autumn) using a technique called anchor netting. The investigation results indicated that the abundance of plastic debris in the Scheldt River was on average 1.6 × 10-3 items per m3 with an average weight of 0.38 × 10-3 g per m3. Foils were the most abundant form, accounting for >88 % of the samples, followed by fragments for 11 % of the samples and filaments, making up for <1 % of the plastic debris. FTIR spectroscopy of 7 % of the total number of plastic debris items collected in the Sea Scheldt estuary (n = 883) revealed that polypropylene (PP), polyethylene (PE), and polystyrene (PS) originating from disposable packaging materials were the most abundant types of polymers. A limited number of plastic debris items (n = 100) were selected for non-destructive screening of their mineral element composition using micro-X-ray fluorescence spectrometry (µXRF). The corresponding results revealed that S, Ca, Si, P, Al, and Fe were the predominant mineral elements. These elements originate from flame retardants, mineral fillers, and commonly used catalysts for plastic production. Finally, machine learning algorithms were deployed to test a new concept for forensic identification of the different plastic entities based on the most important elements present using a limited subset of PP (n = 36) and PE (n = 35) plastic entities.

Survival outcomes of patients with muscle-invasive bladder cancer according to pathological response at radical cystectomy with or without neo-adjuvant chemotherapy: a case-control matching study.

OBJECTIVES: To assess survival of patients with muscle-invasive bladder cancer (MIBC) who underwent radical cystectomy (RC) with or without neo-adjuvant chemotherapy (NAC) according to the pathological response at RC. METHODS: 965 patients with MIBC (cT2-4aN0M0) who underwent RC with or without NAC were analyzed. Among the collected data were comorbidity, clinical and pathological tumor stage, tumor grade, nodal status (y)pN, and OS. Case-control matching of 412 patients was performed to compare oncological outcomes. Kaplan-Meier curves were created to estimate OS for patients who underwent RC with or without NAC, and for those with complete response (pCR), partial response (pPR), or residual or progressive disease (PD). RESULTS: Patients with a pCR or pPR at RC, with or without NAC, had better OS than patients who had PD (both p values < 0.001). Moreover, the incidence of pCR was significantly higher in patients receiving NAC prior to RC than in patients undergoing RC only (31% versus 15%, respectively; p < 0.001). Case-control matching displayed better OS of patients who underwent RC with NAC, median survival not reached, than of those who underwent RC only, median 4.5 years (p = 0.023). CONCLUSIONS: This study showed that patients with MIBC who underwent NAC with RC had a significant better OS than those who underwent RC only. The proportion of patients with a pCR was higher in those who received NAC and RC than in those who were treated by RC only. The favorable OS rate in the NAC and RC cohort was probably attributed to the higher observed pCR rate.

Novel urinary biomarkers ADXBLADDER and bladder EpiCheck for diagnostics of bladder cancer: A review.

Non-muscle-invasive bladder cancer (NMIBC) is accompanied with high incidence and recurrence rates. The extensive need for cystoscopic follow up causes substantial patient discomfort and leads to a high economic burden. Cytology of exfoliated tumor cells in urine is not able to safely reduce or replace the amount of cystoscopies. Here, we give a short overview of established urinary biomarkers and review 2 novel urinary biomarkers, ADXBLADDER and Bladder EpiCheck, for their clinical utility in NMIBC. A Pubmed literature search was performed on the subject of urinary biomarkers for NMIBC. The performance of urinary cytology and established biomarkers Nuclear matrix proteins (NMP22), BTA, UroVysion, and ImmunoCyt was evaluated. The performance of novel biomarkers ADXBLADDER and Bladder EpiCheck was critically reviewed. Based on available clinical studies, established urinary biomarkers have no clear role in the diagnosis or follow-up of NMIBC. Three available prospective studies of ADXBLADDER (2 studying initial diagnosis and 1 follow-up study) reported overall sensitivity (45%-73%) and negative predictive values (NPV) (74%-100%) superior to cytology, with reasonable specificity (70%-73%). Four follow-up Bladder EpiCheck studies reported overall sensitivity (62%-90%) and NPV (79%-97%) superior to cytology, with a high specificity (82%-88%). For detection of high grade recurrences, sensitivity, and NPV of both novel biomarkers were even higher, with a sensitivity and NPV of 76% to 88% and 99% respectively for ADXBLADDER and 79% to 95% and 99% respectively for Bladder EpiCheck - Novel urinary biomarkers ADXBLADDER and Bladder EpiCheck have better sensitivity and NPV, but worse specificity than cytology in the follow-up of NMIBC. In the future, these biomarkers might reduce the amount of follow-up cystoscopies, for instance via an intermittent follow-up scheme alternating between cystoscopy and biomarker testing. The main biomarker objective should be to rule out high grade tumor recurrence without the need for any invasive procedures. Nevertheless, the clinical implementation of these biomarkers in the follow up of NMIBC has to be further investigated in prospective randomized trials for low as well as high grade tumors.

Neoadjuvant treatment for muscle-invasive bladder cancer: The past, the present, and the future.

BACKGROUND: Approximately half of patients who undergo radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) will succumb to metastatic disease. We summarize the evidence for neoadjuvant radiation (NAR), chemo (NAC), and immunotherapy (checkpoint inhibition) prior to RC for MIBC. MATERIALS AND METHODS: Data were obtained by a search of PubMed, ClinicalTrials.gov, and Cochrane databases for English language articles published from 1925 up to 2017. RESULTS: NAC usage has increased over the last decade, while NAR is rarely administered. Although NAR results in downstaging, its impact on survival is inconclusive. Based on level I evidence, cisplatin-based NAC (CB-NAC) is considered standard of care in cT2-4aN0M0 MIBC. NAC results in a 6% absolute 10-year overall survival (OS) benefit. In-depth analyses of key randomized controlled trials showed that failure to correct for uniform staging, surgical variation, and patient selection compromises the ability to identify factors predictive of response to NAC. The benefit appears to be restricted to patients downstaged to ypT1N0 or less. In these patients, 5-year OS is 80% to 90%. Regarding a number needed to treat of 17, most patients with cT2-4aN0M0 MIBC will be exposed to toxicity without benefit. Possible approaches to reduce overtreatment are suggested in this article and include patient selection, the chosen NAC regimen, and emerging molecular data to predict responsiveness to NAC. Neoadjuvant immunotherapy with checkpoint inhibitors is a promising future perspective currently under investigation. CONCLUSIONS: Past studies on NAR show inconclusive results and NAR is rarely administered. Instead, CB-NAC is advised in eligible patients with cT2-4aN0M0 MIBC prior to RC. In the near future, predictive biomarkers will be the key to tailor the use of CB-NAC and reduce harm to nonresponders.

What determines treatment satisfaction of patients with type 2 diabetes on insulin therapy? An observational study in eight European countries.

OBJECTIVE: Patients with type 2 diabetes (T2DM) on insulin therapy are less satisfied with their diabetes treatment than those on oral hypoglycaemic therapies or lifestyle advice only. Determinants of satisfaction in patients with T2DM on insulin therapy are not clearly known. The aim of this study was to determine the association of treatment satisfaction with demographic and clinical characteristics of patients with T2DM. DESIGN: For this study we used data from the GUIDANCE (Guideline Adherence to Enhance Care) study, a cross-sectional study among 7597 patients with T2DM patients from Belgium, France, Germany, Ireland, Italy, Sweden, the Netherlands and the UK. The majority of patients were recruited from primary care. Treatment satisfaction was assessed by the Diabetes Treatment Satisfaction Questionnaire (DTSQ, score 0-36; higher scores reflecting higher satisfaction). To determine which patient characteristics and laboratory values were independently associated with treatment satisfaction, a linear mixed model analysis was used. PARTICIPANTS: In total, 1984 patients on insulin were analysed; the number of included patients per country ranged from 166 (the Netherlands) to 384 (Italy). RESULTS: The mean DTSQ score was 28.50±7.52 and ranged from 25.93±6.57 (France) to 30.11±5.09 (the Netherlands). Higher DTSQ scores were associated with having received diabetes education (ß 1.64, 95% CI 0.95 to 2.32), presence of macrovascular complications (ß 0.76, 95% CI 0.21 to 1.31) and better health status (ß 0.08 for every one unit increase on a 0-100 scale, 95% CI 0.07 to 0.10). Lower DTSQ scores were associated with more frequently perceived hyperglycaemia (ß -0.32 for every 1 unit increase on a seven-point Likert scale, 95% CI -0.50 to -0.13), and higher glycated haemoglobin (ß -0.52 for every percentage increase, 95% CI -0.75 to -0.29). CONCLUSIONS: A number of factors including diabetes education, perceived and actual hyperglycaemia and macrovascular complications are associated with treatment satisfaction. Self-management education programmes should incorporate these factors for ongoing support in patients with T2DM.

Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series

ABSTRACT Objective: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly ( (≥75 years) versus 51 younger (<75 years) patients. patients. Materials and Methods: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry. Results: Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for younger and elderly patients respectively. Conclusions: Our results suggest that LRC is feasible in elderly patients, where a non-surgical treatment is usually favoured.

Pathological downstaging and survival after induction chemotherapy and radical cystectomy for clinically node-positive bladder cancer-Results of a nationwide population-based study.

BACKGROUND: Induction chemotherapy (IC) for clinically node-positive bladder cancer is applied without clinical evidence of improved outcome. Our objective was to compare complete pathological downstaging (pCD) and overall survival (OS) for IC versus upfront radical cystectomy (RC) in cT1-4aN1-3M0 urothelial carcinoma (UC). METHODS: This population-based study included 659 cN+ patients treated with RC between 1995 and 2013. IC was applied in 212 (32%) patients. We defined pCD as ≤(y)pT1N0 at RC. Multivariable analyses were preformed to identify independent predictors of pCD and OS. RESULTS: In cN1 and cN2-3 patients, 31% and 19% of patients proved to be pN0 at upfront RC. In cN1, pCD was achieved in 39% following IC versus 5% for upfront RC (P < 0.001). In cN2-3 UC, rates were 27% versus 3% (P < 0.001). Three-year OS for pCD and ypCD were 81% and 84%, respectively. Three-year OS rates were 66% versus 37% (cN1) and 43% versus 22% (cN2-3), again in favour of IC (P < 0.001). In multivariable analyses, IC was associated with pCD (Odds ratio, 14; 95% confidence interval [CI], 7.4-25) and a 53% decreased risk of death (Hazard ratio [HR], 0.47; 95% CI, 0.36-0.61). Indication bias and unequal distributions of factors associated with OS (e.g. patients proceeding to RC) limit interpretation of our results. CONCLUSIONS: Patients with clinical nodal involvement should not be neglected. Up to 1/4 of patients with cN+ disease had pN0 at upfront RC. Moreover, IC followed by RC for clinically node-positive UC was associated with improved pathological downstaging compared with RC alone. A potential OS benefit for IC needs to be validated in a randomised trial. TAKE HOME MESSAGE: IC followed by RC for clinically node-positive UC is associated with improved pathological downstaging compared with RC alone. A potential OS benefit for IC needs to be validated in a randomised trial.

Variations in pelvic lymph node dissection in invasive bladder cancer: A Dutch nationwide population-based study during centralization of care.

OBJECTIVES: To assess temporal trends in radical cystectomy (RC) and pelvic lymph node dissection (PLND) and the effect of centralization of care in the Netherlands between 2006 and 2012. PATIENTS AND METHODS: This nationwide population-based study included 3524 patients from the Netherlands Cancer Registry who underwent RC as the primary treatment for cT1-4a, N0 or Nx, M0 urothelial carcinoma. Annual application rates of PLND, median LNC, and rates of node-positive disease (pN+) were compared by linear-by-linear association. Multivariable logistic regression was performed to identify patients׳ and hospital characteristics associated with PLND and LNC≥10, and to study associations between LNC and pN+disease. RESULTS: In total, 3,191 (91%) patients had PLND during RC and the use increased from 84% in 2006 to 96% in 2012 (P<0.001). Owing to centralization of care in 2010 (at least 10RCs/y/hospital), significantly more patients were treated in high-volume hospitals (≥20RC per year) in 2011 and 2012. PLND use was highest in males, younger patients and in academic, teaching, and high-volume hospitals (≥20RC per year). In 2012, PLND application rates were comparable for academic, teaching, and nonteaching hospitals (P = 0.344). Median LNC increased from 7 in 2006 to 13 in 2012 (P<0.001), 55% had an LNC≥10 (63% in 2012). Furthermore, lymph node count (LNC)≥10 was associated with cT3-4a and, pN+disease, R0 and treatment in academic, teaching, or high-volume hospitals (≥20RC per year). Rate of pN+disease increased from 18% to 24% between 2006 and 2012 (P = 0.014). This trend was significantly associated with increased LNC on a continuous scale (odds ratio = 1.03). CONCLUSIONS: After centralization of care, PLND during RC for cT1-4a, N0 or Nx, M0 urothelial carcinoma has become standard in all types of Dutch hospitals. The increase in LNC between 2006 and 2012 was associated with a higher incidence of pN+disease and suggests more adequate template extension and adherence to contemporary guidelines in recent years.

Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series.

OBJECTIVE: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly (≥75 years.) versus 51 younger (< 75 years.) patients. MATERIALS AND METHODS: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry. RESULTS: Median age difference between LRC groups was 9.0 years (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (< 500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for youn¬ger and elderly patients respectively. CONCLUSIONS: Our results suggest that LRC is feasible in elderly patients, where a non¬-surgical treatment is usually favoured.

Perioperative treatment and radical cystectomy for bladder cancer--a population based trend analysis of 10,338 patients in the Netherlands.

BACKGROUND: In Europe, population-based data concerning perioperative treatment (PT) and radical cystectomy (RC) are lacking. We assessed temporal trends in PT (neoadjuvant chemotherapy [NAC], neoadjuvant radiotherapy [NAR], adjuvant chemotherapy [AC], adjuvant radiotherapy [AR]) and RC in the Netherlands and identified patients' and hospital characteristics associated with PT. METHODS: This nationwide, retrospective, population-based study included cTa/is, T1-4, N0-3, M0-1 bladder cancer patients from the Netherlands Cancer Registry who underwent RC with curative intent between 1995 and 2013. PT-administration over time was compared with chi-square tests. Multivariable logistic regression analyses were performed to identify characteristics associated with PT usage. The sub-groups cT2-4N0M0 and cT2-4, N0 or NX, M0 or MX were separately analysed. RESULTS: In total, 10,338 patients met inclusion criteria. Eighty-six percent did not receive PT, 7.0% received NAC (or induction chemotherapy [IC]), 3.2% NAR, 1.8% AC, and 2.1% AR. NAC usage increased from 0.6% in 1995 to 21% in 2013 (p < 0.001), application of NAR decreased from 15% to 0.4% (p < 0.001). Usage of AC and AR in 2013 was <1.5%. Comparable temporal trends were found in 6032 patients staged cT2-4N0M0. Multivariable logistic regression analysis revealed that younger age, ≥ cT3, ≥ cN1 and treatment in academic/teaching hospitals were associated with NAC or IC (all p < 0.05). CONCLUSIONS: The increase in NAC administration in the Netherlands reflects a slow but steady adoption of evidence-based guidelines over the last two decades. Considerable variability in patients' and hospital characteristics in the likelihood of receiving NAC exists. Conversely, NAR, AR and AC are hardly administered anymore.

Lymph node count at radical cystectomy does not influence long-term survival if surgeons adhere to a standardized template.

INTRODUCTION: Multiple bladder cancer studies report that the number of removed lymph nodes (lymph node count [LNC]) at radical cystectomy (RC) is positively associated with survival. Although these reports suggest that LNC can be used as a proxy for surgical quality, all studies used variable or inconsistent pelvic lymph node dissection (PLND) templates. We therefore wished to establish whether LNC at RC influences survival if surgeons adhere to a standardized PLND template. MATERIALS AND METHODS: We included 274 patients who underwent RC from January 2005 until December 2012. All RCs were performed in either one of 2 hospitals (hospital A or B) by the same 4 urologists (all from hospital A) and a standardized PLND template was applied. PLND specimens were processed by 2 independent pathology departments (hospital A and B). We used Cox regression analysis to investigate the prognostic value of LNC adjusted for patient characteristics. We also compared LNC between hospitals and surgeons and investigated the effect of both the variables on overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). RESULTS: Median LNC was 17 (interquartile range = 12). At a median follow-up of 64.3 months, there was no association between LNC and OS (P = 0.328), CSS (P = 0.645), or DFS (P = 0.450). Median LNC was higher in hospital B than in hospital A (20.0 vs. 16.0, P = 0.003). Median LNC varied significantly among surgeons (12-20, P<0.001). Neither the hospital of surgery nor the surgeon performing PLND influenced OS (P = 0.771 and P = 0.982, respectively), CSS (P = 0.310 and P = 0.691, respectively), or DFS (P = 0.256 and P = 0.296, respectively). CONCLUSION: If surgeons adhere to a standardized template, LNC at RC does not affect long-term survival.

Oncologic outcome after laparoscopic radical cystectomy without neoadjuvant or adjuvant therapy with a median follow-up of 32 months.

INTRODUCTION: We report the oncological outcome after laparoscopic radical cystectomy (LRC) and standard laparoscopic pelvic lymph node dissection (PLND) without neoadjuvant or adjuvant therapy in the treatment of bladder cancer with a median follow-up of 32 months. MATERIALS AND METHODS: From September 2006 to January 2011, 40 consecutive patients underwent an LRC and standard laparoscopic PLND, and were included in this prospective observational cohort study. No patient received neoadjuvant or adjuvant therapy. Demographic, perioperative, complication, histopathologic and survival data were collected and analyzed. RESULTS: The 2002 TNM staging for the tumors were: pT0, 4 cases; pTis, 5 cases; pT1, 4 cases; pT2, 7 cases; pT3, 13 cases; pT4, 7 cases. Positive surgical margins were reported in 3 patients (7.5%) and lymph node involvement in 9 patients (23.7%). No patient was lost to follow-up. The overall, cancer-specific and recurrence-free survival rates were 53, 73 and 70% with a median follow-up of 32 months. Eleven patients (27.5%) died of metastatic disease or local recurrence. Nonorgan-confined disease (≥pT3) and primary lymph node involvement (pN+) were significantly associated with worse overall, cancer-specific and recurrence-free survival rates. CONCLUSION: We report acceptable mid-term and promising long-term oncological outcome after LRC and standard laparoscopic PLND without neoadjuvant or adjuvant therapy.

What about conventional laparoscopic radical cystectomy? Cost-analysis of open versus laparoscopic radical cystectomy.

PURPOSE: To assess direct healthcare costs for open radical cystectomy (ORC) vs laparoscopic radical cystectomy (LRC) with ileal conduit. PATIENTS AND METHODS: A series of 44 and 42 patients undergoing ORC and LRC with ileal conduit were retrospectively analyzed at a single institution from January 2005 to January 2012. The ORC and LRC procedures were performed by two independent surgical teams; there was no selection in patients. Data on patient demographics, perioperative outcome parameters, complications, and readmissions were gathered retrospectively in the ORC series and prospectively in the LRC series. Direct healthcare costs were evaluated for operating room occupation, disposable surgical equipment, blood transfusions, hospital stay according to intensity of care, and readmission days. RESULTS: Mean and median evaluated total direct healthcare costs per patient did not differ significantly and were 17,534€ and 16,511€ in the LRC group and 22,284€ and 15,909€ in the ORC group. Excess costs for disposable surgical equipment and operating room occupation within the LRC group were compensated for as a result of shorter hospital stay, lower number of blood transfusions, and intensive-care admissions. Minor and major complication rates were comparable between groups. CONCLUSION: Within our series, LRC is a cost neutral minimally invasive alternative to ORC without comprising quality of care and with beneficial perioperative outcomes.

Transperitoneal laparoscopic radical nephrectomy in a patient with severe scoliosis.

OBJECTIVE: To report the first case of a left transperitoneal laparoscopic nephrectomy in a patient with a severe left convex lumbar scoliosis and to elaborate on the technical difficulties of this procedure. METHODS: The surgical procedure was performed by an experienced laparoscopic surgeon after rigorous pre-operative visualization of the altered visceral and vascular abdominal anatomy. A transperitoneal laparoscopic approach with an open introduction technique according to Hasson and a caudo-cranial dissection of the left renal hilum were performed to prevent major vascular and visceral injury in this challenging surgical procedure. RESULTS: The operation time was 102 minutes and the estimated blood loss was 100 mL. The surgeon was able to complete the transperitoneal laparoscopic radical nephrectomy without complications. CONCLUSION: Transperitoneal laparoscopic radical nephrectomy in patients with severe spinal deformities is feasible, but should only be performed by experienced laparoscopic surgeons to ensure patient safety and cancer control.

[Necrotic bladder following radiotherapy for cervical carcinoma]. / Blaasnecrose na radiotherapie voor cervixcarcinoom.

BACKGROUND: In contrast to proctitis, vaginitis and acute radiation cystitis are late complications of pelvic radiation therapy, rare, more severe and irreversible. CASE DESCRIPTION: A 66-year-old patient presented with progressive renal failure ten years after radiotherapy for carcinoma of the cervix. Ultrasound investigation revealed a bilateral hydroutereronefrosis (grade 4), with narrowing of the ureterovesical junctions and a diffuse thickening of the urinary bladder wall. Biopsy of the bladder wall showed extended necrosis. The diagnosis was a necrotic bladder with bilateral ureteral stenosis without local symptoms. Lifelong renal urinary drainage was indicated. CONCLUSION: Late obstructive urological complications, such as bladder necrosis and urethral obstruction, are rare following radiotherapy for cervical carcinoma. Ultrasound follow-up can contribute to the early detection of these complications and intervention can prevent further loss of renal function; however, this would not be cost-effective because of the low incidence rate and because these complications appear in the long term.