Communication between the pathologist and urologist. Focus on prostate cancer.

Open communication between the pathologist and surgeon is crucial for optimum patient care and job satisfaction. Communication must occur in both directions and should include a free exchange of clinical information and explanation of the thought processes used by both physicians. Various means can improve communication, and the authors focus on the special clinical problems posed by prostate cancer diagnosis and treatment.

Quality of life and sexuality following radical prostatectomy in patients with prostate cancer who use or do not use erectile aids.

OBJECTIVES: It is well established that prostate cancer patients undergoing radical prostatectomy may experience disruptive side effects, most notably urinary incontinence and erectile dysfunction. The purpose of this study is to compare relevant outcomes between patients awaiting radical prostatectomy for prostate cancer and patients who already underwent the surgery, taking into account type of prostatectomy and use of erectile aids. METHODS: We compared self-reports of global quality of life, sexuality, urinary continence, and physical capabilities in 86 nerve-sparing patients, 89 standard-prostatectomy patients, 74 prostatectomy patients who used erectile aids, and a comparison group of 45 patients awaiting radical prostatectomy. RESULTS: Regardless of type of surgery, use of erectile aid, or preoperative status, most patients reported good quality of life. The best outcomes in sexuality were reported by patients who used erectile aids, who appeared similar in sexuality to patients awaiting surgery. When differences were detected, standard prostatectomy patients who did not use erectile aids scored worse in most areas of sexuality than nerve-sparing patients who did not use erectile aids. There were no differences in frequency of urinary leakage among the three surgery subgroups. CONCLUSIONS: Although most patients reported problems in sexual and urinary function, global quality of life does not appear to be compromised following radical prostatectomy. Findings suggest that postsurgical sexuality differs depending on type of prostatectomy and use of erectile aids, while urinary function is similar across surgery groups. We conclude that erectile aids should be offered routinely to patients who are ineligible for nerve-sparing surgery or experience erectile difficulties following the nerve-sparing procedure.

Management and evaluation of localized amyloidosis of the bladder: two case reports.

Localized amyloidosis of the bladder is a rare cause of hematuria, which is often confused with bladder cancer. We present case histories of two patients which illustrate the evaluation and management of this entity. The diagnosis is usually made with biopsy and subsequent pathologic examination. Conservative management is attempted initially but must be individualized according to the clinical course of each patient. Transurethral resection will suffice in most instances but occasionally cystectomy is indicated to control local disease.

Management of complex urologic injuries.

The management of complex urologic trauma requires considerable experience and familiarity with reconstructive techniques. The goal should always be maximum preservation of normal function, with the fewest serious complications. Ideally these cases are treated by a multidisciplinary team rather than the trauma surgeon alone.

Management of carcinoma of the bladder.

Carcinoma of the bladder (CaB) is a common tumor of the genitourinary tract. In the United States in 1997, CaB was second in frequency of occurrence and third in mortality among genitourinary tumors. This tumor has a well-documented history of environmental and industrial causative factors. The strongest etiologic risk factors include the use of tobacco, which is thought to be responsible for half of the CaB diagnosed in men in the United States, and some arylamines. In the past 30 years, there has been major improvement in the survival of patients with this disease. Multiple factors were responsible for this accomplishment and they include: 1) better understanding of the natural history of CaB, 2) development of immunohistochemical analysis helpful in defining prognostic factors, 3) improved imaging and nonimaging diagnostic modalities helpful in making earlier diagnosis and better defining the true anatomical extent of the tumor, 4) development of more effective therapy for carcinoma in situ, 5) major improvement in surgical techniques resulting in better treatment outcomes, and 6) the wide use of adjuvant chemotherapy. Major stress has been placed on the quality of life of patients treated for CaB. Quality of life was improved by optimizing surgical, radiation, and medical treatment techniques. The two most important factors producing this quality-of-life improvement include: 1) the use of organ-preserving therapy in properly selected patients that involves the use of a multimodality therapeutic approach with transurethral resection, radiation therapy, and chemotherapy; and 2) the ability to treat selected men and women with radical cystectomy followed by orthotopic reconstruction that allows patients nearly physiologic voiding. Current research efforts are directed toward better patient selection for appropriate therapy which is expected to increase patient survival and improve quality of life. Of particular importance in the selection of this optimal therapy in patients with CaB is a wide application in the clinical practice of important recent advances in molecular genetics.

Quality of life with reconstruction.

Quality-of-life considerations were one of the main driving forces behind the development of continent urinary diversion. However, the field of formal quality-of-life study that allows us to document these aspects of treatment is still relatively young. In the past decade, a number of quality-of-life studies of cystectomy patients have been undertaken, with somewhat mixed results. Many of these studies have been limited by small patient numbers, and the differences in the various treatment groups, for example, in age and comorbidities. Most have shown that overall quality of life after cystectomy remains good for most patients, with the expected problems with urinary diversion and sexual dysfunction. However, few differences between the diversion groups have been demonstrated, suggesting that patients adapt to whatever is required of them. One large study from Germany did find significant improvement in several aspects of quality of life in patients with continent diversion. Patient education, exploration of the pros and cons of the various alternatives, and active patient participation in the treatment decisions seem to be key to postoperative satisfaction.

Radical cystectomy in the elderly patient.

A total of 77 patients 65 or more years old underwent radical cystectomy with urinary diversion for invasive bladder cancer during a 10-year interval. The preoperative medical condition of the patients, operative mortality and morbidity, and preliminary survival data are reviewed by age group. Two-thirds of the patients had previous medical or surgical problems that increased the surgical risk. The over-all mortality rate was 3.9 per cent. Early complications occurred in 31 per cent of the patients, with an increased risk of complication associated with previous illness and major pelvic surgery, and preoperative radiation therapy. The complication rate was not related directly to age, with patients 65 to 69 and more than 75 years old having lower rates than those 70 to 74 years old. The 3-year survival rate free of disease ranged from 58 per cent in the youngest group to 39 per cent in the oldest group, which is comparable to survival statistics for younger patients undergoing cystectomy. Only 5 patients have died of intercurrent illness, while 20 have died of metastatic disease.

Technique of left adrenalectomy for autotransplantation to the caudate nucleus in Parkinson's disease.

Autotransplantation of the adrenal medulla to the caudate nucleus is a new neurosurgical treatment under investigation for severe Parkinson's disease. The success of the procedure is reliant partly on the ability of the urologist to remove the adrenal gland safely and atraumatically with minimal morbidity. We describe our technique using a posterior 12th rib approach, which is extrapleural and extraperitoneal. In the initial 10 patients there was no significant morbidity from the operation and all patients were discharged from the hospital within 3 to 7 days postoperatively. The importance of using a no touch technique in mobilizing the gland is emphasized, since any hemorrhage within the adrenal medulla may make it impossible to recover the tissue for stereotactic implantation. Hemorrhage occurred in 1 of our patients, who was elderly and obese. The technique described allows for adequate exposure while maintaining acceptably low morbidity from the procedure.

Preservation of ejaculation through a modified retroperitoneal lymph node dissection in low stage testis cancer.

We studied ejaculatory function in 47 patients who underwent modified retroperitoneal lymph node dissection for nonseminomatous germ cell tumors of the testis from 1983 to 1989. Our goal was to assess the effectiveness of a modified node dissection in preserving ejaculatory function while eliminating the risk of retroperitoneal recurrence. There were 13 left and 34 right tumors. Of the patients 45 had clinical stage A cancer, and 2 had clinical stage B2 disease and received preoperative chemotherapy. The template method of dissection was used, which spares the preaortic area below the inferior mesenteric artery, including the sacral promontory. Average operating time was 3 hours 40 minutes. There was no operative mortality. Spontaneous recovery of ejaculation occurred in 38 patients (81%), more commonly with right (88%) than with left dissections (62%). The mean interval to recovery of ejaculation was 5 months (92% within 12 months). Five patients (10%) had recurrence, with a mean followup of 28 months. All recurrences were in the lungs 4 to 8 months after retroperitoneal lymph node dissection, and all patients were salvaged with chemotherapy and are disease-free. We confirmed that a modified template-type retroperitoneal lymph node dissection can be accomplished safely with preservation of ejaculation in more than 80% of the patients without increasing the risk of local recurrence.

Squamous cell carcinoma of the bladder associated with cyclophosphamide therapy for Wegener's granulomatosis: a report of 2 cases.

Cyclophosphamide has been used to treat a variety of malignant and nonmalignant diseases. The association of this agent with the development of urothelial tumors has been well documented. Although most bladder cancers associated with prior cyclophosphamide therapy are transitional cell carcinoma, to our knowledge there have been 6 reports of cyclophosphamide-induced squamous cell carcinoma of the bladder. We report 2 additional cases of squamous cell carcinoma of the bladder that occurred in patients after cyclophosphamide treatment for Wegener's granulomatosis. Any patient with a history of prolonged cyclophosphamide ingestion needs careful long-term monitoring of the lower urinary tract, since there is at least a 9-fold increase in the incidence of lower urinary tract malignancy in such patients.

Radical cystectomy and lower urinary tract reconstruction after cardiac allograft transplantation.

The risk of a malignancy developing as a consequence of long-term immunosuppression after allograft transplantation is well documented. To our knowledge we report on the first cardiac allograft recipient to undergo radical cystectomy with lower urinary tract reconstruction using a continent Kock ileal reservoir with bilateral ureteroileal urethrostomy for squamous cell carcinoma that developed 4 years after transplantation.

Hydronephrosis as a prognostic indicator in bladder cancer patients.

PURPOSE: Pathological stage is the standard measure of prognosis in patients who have undergone radical cystectomy for bladder cancer. Despite the development of new imaging techniques, clinical staging for bladder cancer continues to be inaccurate. We investigated whether the presence of unilateral or bilateral upper tract obstruction could accurately predict advanced cancer stage (extravesical extension, stage greater than p3b or N+). MATERIALS AND METHODS: A retrospective study of 415 patients diagnosed with transitional cell carcinoma of the bladder who were treated with radical cystectomy between 1983 and 1993 was conducted. All patients were followed for survival. The criteria for analysis included hydronephrosis status (no obstruction, unilateral, bilateral) as well as pathological stage of the tumor. RESULTS: Of 415 patients 72% presented with no, 22.7% unilateral and 5.3% bilateral obstruction. Our results showed a significant correlation between hydronephrosis and advanced cancer stage (p <0.0001), and decreased patient survival (p <0.0001). More than 90% of patients with bilateral obstruction had disease with extravesical extension. Of the patients with unilateral obstruction a third had disease confined to the bladder with a significant proportion confined to the bladder mucosa. CONCLUSIONS: The presence of unilateral or bilateral hydronephrosis is a clinical datum that is already available to help accurately stage bladder tumors. The presence of bilateral obstruction is an ominous sign, while a significant proportion of patients presenting with unilateral obstruction have disease confined to the bladder.

Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral kock pouch.

PURPOSE: Radical cystectomy for bladder cancer is associated with many changes in bodily function with sexual and urinary dysfunction most prevalent. However, little research has been done on how efforts to improve erectile function relate to quality of life. Also, the psychological benefits associated with continent urinary diversion have not been fully explored. We compared long-term quality of life outcomes among 3 urinary diversion groups, and between patients who had and had not received an inflatable penile prosthesis. MATERIALS AND METHODS: The 224 participating patients completed 4 self-reporting questionnaires, including the profile of mood states, and adapted versions of the sexual history form, body image dissatisfaction scale and quality of life questionnaire. We compared self-reports of emotional distress, global quality of life, sexuality, body image dissatisfaction, urinary diversion problems, and problems with social, physical and functional activities in patients with advanced bladder cancer who underwent urinary diversion, including an ileal conduit in 25, cutaneous Kock pouch in 93 and urethral Kock pouch in 103. Patients who had or had not received an inflatable penile prosthesis after cystectomy were also compared in regard to quality of life variables. RESULTS: Regardless of type of urinary diversion the majority of patients reported good overall quality of life, little emotional distress and few problems with social, physical or functional activities. Problems with urinary diversion and sexual functioning were identified as most common. After controlling for age analysis of variance showed no significant differences among urinary diversion subgroups in any quality of life area. However, t tests controlling for age indicated that penile prosthesis placement was significantly associated with better sexual function and satisfaction. CONCLUSIONS: Quality of life appears good in these long-term survivors of advanced bladder cancer. The type of urinary diversion does not appear to be associated with differential quality of life. Findings suggest that physicians may wish to discuss urinary diversion problems and sexual dysfunction as long-term correlates of radical cystectomy for bladder cancer. Furthermore, they may also wish to discuss the option of erectile aids in men with erectile dysfunction after cystectomy.

Xanthogranulomatous cystitis as a cause of elevated carcinoembryonic antigen mimicking recurrent colorectal cancer. Report of a case.

We report a case of xanthogranulomatous cystitis that developed in a patient with a history of colon cancer. While undergoing adjuvant chemotherapy with fluorouracil and levamisole, rising carcinoembryonic antigen (CEA) levels and the appearance of a pelvic mass, suspicious for recurrent cancer, were identified. Exploratory laparotomy demonstrated the presence of a benign condition of the bladder, xanthogranulomatous cystitis, which was resected by partial cystectomy. CEA levels have normalized. This is the first reported case of xanthogranulomatous cystitis producing an elevated CEA level.

The Kock ileal neobladder: updated experience in 295 male patients.

PURPOSE: Since 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993. MATERIALS AND METHODS: Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence was individually evaluated via a detailed patient questionnaire. RESULTS: The pouch related early and late complication rates were 7.2 and 11.6%, respectively, and pouch related abdominal reoperation rates were 0.0 and 1.4%, respectively. Analysis of late pouch related complications revealed 4.1% stone formation and 2.4% afferent nipple stenosis rates, and only 1 case (0.3%) of ileal urethral anastomotic stricture. Of the patients 87 and 86% reported good or satisfactory daytime and nighttime continence, respectively. With regard to age, while overall continence was similar, a significantly greater percentage of patients younger than 70 years experience good daytime and nighttime continence relative to the older counterparts. Of the patients 5% perform regular intermittent catheterization and 2.7% required an artificial urinary sphincter due to unacceptable continence. CONCLUSIONS: The Kock orthotopic ileal neobladder can be constructed with minimal morbidity and extraordinary functional results. We strongly advocate its use when possible.

Salvage radical cystoprostatectomy and orthotopic urinary diversion following radiation failure.

PURPOSE: Salvage surgery followed by lower urinary tract reconstruction is a viable therapeutic option for patients in whom definitive radiation therapy for localized bladder or prostate cancer has failed. Improvements in surgical technique and postoperative care have significantly improved overall outcome. An enhanced understanding of the rhabdoid sphincteric mechanism responsible for maintaining urinary continence following cystoprostatectomy has helped make the orthotopic neobladder the procedure of choice for patients requiring lower urinary tract reconstruction. We describe our experience with salvage surgery and orthotopic bladder substitution following failed radical radiation therapy. MATERIALS AND METHODS: We evaluated the complications of 18 patients in whom definitive radiation therapy (total minimum dose 60 Gy. or greater) for bladder or prostate cancer had failed. All patients underwent a salvage procedure with creation of an orthotopic neobladder. RESULTS: Operative characteristics, postoperative outcomes and postoperative complications related or unrelated to urinary reconstruction were similar between irradiated and nonirradiated patients. Good day and night continence following surgery was reported by 67 and 56% of irradiated patients, respectively. Patients with poor postoperative continence were successfully treated with the placement of an artificial urinary sphincter. CONCLUSIONS: Salvage surgery with orthotopic urinary reconstruction is a safe, effective procedure that provides a functional lower urinary tract in patients in whom definitive pelvic radiation therapy has failed.

Radical cystectomy for elderly patients with bladder carcinoma: an updated experience with 404 patients.

BACKGROUND: The authors evaluated the experiences at their institution with radical cystectomy and urinary diversion performed on elderly bladder carcinoma patients to determine whether age had an impact on the clinical or functional results for this group of patients. METHODS: Between August 1971 and December 1996, 404 patients age 70 years or older (median age, 74 years) underwent radical cystectomy and urinary diversion for invasive bladder carcinoma: 352 (87%) were ages 70-79 years and 52 (13%) were age 80 years or older. Data analyzed included the following: perioperative mortality; early (within 90 days after surgery) and late (more than 90 days after surgery) postoperative complications, related and unrelated to the urinary diversion; length of hospital stay; pathologic staging; and clinical outcome. These data were then compared with those for 762 patients younger than 70 years (median age, 61 years) who underwent the same procedure during the same time period. RESULTS: The overall mortality rate for patients age 70 years or older was 2.8% (3.2% for those ages 70-79 years, 0% for those age 80 years or older), compared with 2% for patients younger than 70 years. The early complication rate for patients age 70 years or older was 32%, compared with 25% for patients younger than 70 years. Patients age 80 years or older had a similar early complication rate of 29%. Late postoperative complications occurred in 12.4% of patients age 70 years or older, compared with 22.8% of patients younger than 70 years. There was no significant difference between the two groups with regard to pathologic stage or length of hospital stay. The 3-year and 5-year overall survival rates for patients age 70 years or older were 60% and 53%, respectively, compared with 68% and 63%, respectively, for patients younger than 70 years (P=0.001). There was no statistical difference between the groups when rates of disease recurrence were compared (P=0.3627). The 5-year recurrence rate for patients age 70 years or older was 35%, compared with a 5-year recurrence rate of 31% for patients younger than 70 years. CONCLUSIONS: These data suggest that an aggressive, curative, radical surgical approach and urinary diversion may be a viable treatment strategy for properly selected elderly patients who are in generally good health and require definitive therapy for invasive bladder carcinoma.