Orthotopic neobladder reconstruction in elderly bladder cancer patients.

BACKGROUND: We compared the clinical results of orthotopic neobladder reconstruction in elderly patients and those in younger patients retrospectively in order to verify whether age is a critical factor in selecting a method of urinary diversion. METHODS: Following radical cystectomy for bladder cancer, 12 patients aged 75 or older and 17 patients under 75 who underwent orthotopic neobladder reconstruction between January 1992 and May 1999 were investigated in this study. The authors TS and BS were among the surgeons who performed operations for all cases. Of the 12 elderly patients, orthotopic neobladders were constructed according to Hautmann's method in nine cases, Studer's method in one case and Reddy's method in two cases. Of the 17 younger patients, these methods were employed in 12, one and four cases, respectively. Operative procedure, early and late complications, prognosis, continence and voiding pattern were investigated in these patients. RESULTS: The follow-up periods for elderly and younger groups ranged from 21.3 to 82.7 months and from 8.8 to 94.2 months, respectively. No difference in operation time, amount of bleeding or postoperative length of hospitalization was observed between elderly and younger patients. The rates of early complications in elderly and younger patients were 41.7% and 35.3%, respectively. Late complication rates were 33.3% and 47.1%, respectively. The difference in these complication rates was not statistically significant. One of the elderly and two of the younger patients had local recurrence and metastasis postoperatively. Those three patients had died of their bladder cancer. No statistically significant difference between groups was recognized in either cause-specific survival or overall survival, nor was there such a difference in relation to micturition/continence. CONCLUSION: Based on these results, we believe that because age is not a critical factor in the selection of urinary diversion method, neobladder reconstruction following cystectomy for bladder cancer is indicated in elderly patients. As stoma management is difficult for the patients, we consider orthotopic neobladder reconstruction to be the method of choice if the patients' general physical condition allows.

Treatment of androgen-independent prostate cancer with dexamethasone: a prospective study in stage D2 patients.

PURPOSE: In order to evaluate the efficacy of dexamethasone in the treatment of Japanese men with androgen-independent prostate cancer, a prospective study was conducted using prostate-specific antigen (PSA) as a primary end-point. METHODS: Nineteen Japanese men with stage D2 androgen-independent prostate cancer were registered and treatment was started. After ruling out anti-androgen withdrawal syndrome, they were treated with dexamethasone (1.5 mg daily). Patients were monitored for PSA, symptoms, radiologic response, survival rate, time to disease progression, time to treatment failure and complications. RESULTS: Prostate-specific antigen levels decreased in nine patients (50.0%); five (27.8%) showed a 50% or greater decrease and two (11.1%) showed an 80% or greater decrease. For the nine patients, the mean duration of PSA response was 7.3 months and the median duration was 2.1 months (range, 1.2-27.5+). Bone pain, which was noted in 13 patients at study entry, improved in seven patients (53.8%). Of nine patients who had serial radiographic examinations with bone scan, three (33%) showed partial response, two (22%) were stable and four (44%) showed disease progression. Treatment was well tolerated, except for one patient who suffered a severe pulmonary infection. CONCLUSION: Dexamethasone decreased PSA levels and produced subjective symptomatic improvement in the patients with stage D2 androgen-independent prostate cancer.

Optimal starting time for flutamide to prevent disease flare in prostate cancer patients treated with a gonadotropin-releasing hormone agonist.

OBJECTIVE: Flare-up phenomena, such as an increase in prostate-specific antigen (PSA) and/or deterioration of symptoms, are observed in some patients undergoing gonadotropin-releasing hormone (GnRH) agonist therapy. This study was carried out to determine the optimal time for starting the administration of flutamide to prevent flare-up phenomena. PATIENTS AND METHODS: Twenty-six patients with prostate cancer and elevated serum levels of PSA were randomly assigned to 5 groups. Group A patients (n = 6) were treated with a subcutaneous injection of 3.75 mg leuprorelin acetate depot alone. Group B, C, D and E patients (5 patients in each group) were treated with 375 mg/day of orally administered flutamide combined with leuprorelin. Flutamide was initiated on the day of leuprorelin injection in group B, and at 1, 2 and 4 weeks before leuprorelin injection in groups C, D and E, respectively. Serum PSA and testosterone levels were measured in each patient. RESULTS: Pretreatment with flutamide increased the serum testosterone level, but the testosterone surge after leuprorelin administration was almost the same in all 5 treatment groups. In patients who had been treated with flutamide in combination with leuprorelin, the mean PSA level did not exceed the pretreatment levels after leuprorelin administration. The rate of decrease in PSA in the group receiving simultaneous administration of flutamide with leuprorelin showed a decline comparable to that during the period before leuprorelin administration in the flutamide pretreatment groups. CONCLUSION: Simultaneous administration of flutamide with a GnRH agonist is sufficient to prevent flare-up phenomena.

[Clinical study of radical cystectomy and urinary reconstruction in elderly patients with bladder cancer].

We compared the clinical and functional results of radical cystectomy and urinary reconstructions performed on 19 elderly bladder cancer patients over 75 years old to those on 22 younger patients to determine whether age was one of the critical points for the application of this type of surgery. Between January 1992 and January 1998, bladder substitution was performed after cystectomy using either the Hautmann, Studer or Reddy procedure in 9 of the 19 elderly patients. Urinary diversion was performed after cystectomy using ileal conduit and ureterocutaneostomy procedures in the rest of the patients. On the other hand, bladder substitutions were performed in 11; urinary diversions with continent urinary reservoir in 6 and with ileal conduit in 4 of the 22 younger patients. Neither prolongation of the operation time, nor increase in the amount of bleeding or prolongation of the post-operative hospitalization period was observed in any procedure used for elderly patients in comparison with younger ones. In elderly patients, the average operation time of radical cystectomy with bladder substitution was slightly longer than that of total cystectomy with ileal conduit or ureterocutaneostomy. The post-operative hospitalization period in the case of bladder substitution was similar to that for ileal conduit and ureterocutaneostomy with the difference of only 5 days on average. There were no peri-operative deaths, and early post-operative complications were observed in 3 of 9 cases of the bladder substitution, in 4 of 10 cases of ileal conduit or ureterocutaneostomy. Five cases of bladder substitution maintained their comfortable voiding urine comfortably, while 4 had dysuria and/or urinary incontinence. Over all, late complications occurred in 10 of the elderly patients. The rate and types of complications in the elderly patients were not different from those in the younger patients. The cause-specific survival rate and overall survival rates of the elderly patients were similar to those of the younger patients. In conclusion, indication of cystectomy and selection of urinary reconstruction procedure are not dependent on patient's age, Orthotopic urinary reservoir was found to be useful for even an elderly patient.

[Clinical studies on renal trauma].

A total of 18 kidneys in 17 patients with renal trauma were treated at the Department of Urology, Mitoyo General Hospital between April 1991 and August 1997. Patients were between 10 and 88 years old (median; 52). Eleven of them were male and 6 were female. The main cause of injury was a traffic accident in 11 cases (64.7%), which was similar in tendency to previous reports in this country. According to the Classification of Renal Injury by the Japanese Association for the Surgery of Trauma in Japan, there were 8 cases (47.1%) of Type I (sub-capsular injury) and Type II (superficial injury) that was classified a minor injury, and there were 9 cases (52.9%) of Type III (deep injury), Type IV (pedicle injury) and open injury that was classified as a major injury. Surgical treatment was performed in 8 cases (47.1%), which were all classified as a major injury. Posttraumatic plasma lactate dehydrogenase (LDH) was elevated immediately in case of major injury in comparison with a case of minor injury. Serum LDH may be useful as a parameter of the degree of renal trauma.

ACTH-independent macronodular adrenocortical hyperplasia (AIMAH): report of two cases and the analysis of steroidogenic activity in adrenal nodules.

We report clinical findings and steroidogenic activities in adrenal tissues in 2 cases of AIMAH. Endocrine studies revealed an undetectable level of plasma ACTH and a diminished circadian rhythm of plasma cortisol. A significant increase in plasma cortisol levels in response to ACTH stimulation was observed in both cases. After the administration of metyrapone in one case, urinary excretion of 17-hydroxycorticosteroid (17-OHCS) significantly increased, although the plasma ACTH level did not respond. Computed tomography showed large masses in both adrenal glands, and bilateral uptake was identified on adrenal scintigraphy. The totals for the bilateral adrenal glands were 98 g and 105 g, respectively, and the left adrenal was larger than the right in both cases. Steroid content in the nodules measured by high performance liquid chromatography (HPLC) showed that the cortisol content was definitely lower than that in cortisol-producing adenoma (CPA) and even in normal adrenals. The activities of cytochrome P450c17, P450c21 and P450c11 were evaluated in one case, and all of them were reduced in the nodules. Especially that of P450c17 was remarkably reduced. These data suggest that cortisol production in AIMAH is inefficient, and that the cause of Cushing's syndrome may be related to the marked increase in the number of cells or bulk of the tumor.

[A case of normotensive primary aldosteronism in association with non-functioning adenoma and aldosterone producing adenoma in ipsilateral adrenal gland].

A case of normotensive primary aldosteronism in association with non-functioning adenoma and aldosterone producing adenoma in ipsilateral adrenal gland is reported. Fourteen cases of normotensive primary aldosteronism were previously reported and our case was considered as the fifteenth case. Furthermore, its association with non-functioning adenoma and aldosterone producing adenoma is very rare. Only four cases of such association were reported, and in these four cases non-functioning adenoma existed in contralateral side of aldosterone producing adenoma. In our case, its association with non-functioning adenoma and aldosterone producing adenoma was seen in the ipsilateral adrenal gland. The report of this kind of association has not been seen in the literature so far.

Urethral obstruction owing to retroperitoneal cystic lymphangioma.

We report a case of cystic lymphangioma arising from retroperitoneal tissues of the pelvis, which caused urethral obstruction and eventual urinary retention. Sonography and computerized tomography demonstrated a retroperitoneal cystic mass in the pelvis. A preoperative diagnosis of retroperitoneal cystic lymphangioma was suggested by typical computerized and sonographic features.

[Assessment of urinary ferritin, CEA and beta 2-MG determinations in patients with urinary tract malignancies].

Ferritin, carcinoembryonic antigen (CEA) and beta 2-microglobulin (beta 2-MG) levels in urine from 45 patients with cancer (4 with renal adenocarcinoma, 7 with renal pelvic and ureteral cancer and 34 with bladder cancer) at various stages were clinically evaluated for their significance as parameter of urinary tract malignancies as compared to urinary fibrin/fibrinogen degradation products (FDP) and urine cytology. Ferritin levels for the poorly-differentiated and advanced stage groups were higher than those for the well-differentiated and early stage groups, and were especially high in 5 of the 7 patients with renal pelvic and ureteral cancer and all of the 7 patients with bladder cancer involving the upper urinary tract. These data suggest that determination of urinary ferritin is useful in the detection of urinary tract cancer involving the upper urinary tract. The upper limits of CEA levels were determined respectively according to white blood cell counts in urine. Although, CEA levels were elevated in the poorly-differentiated group and the advanced stage group compared to the well-differentiated and early stage groups, the values were positive in only 12 out of 52 cases (23.1%). These values seemed to be low compared to other reports. beta 2-MG levels increased significantly in the poorly-differentiated and advanced stage groups. However, most cases in the above groups were complicated with pyelonephritis or renal impairment. It is suggested that the urinary beta 2-MG secretion from cancer itself is not so significant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Assessment of serum ferritin, CEA, beta 2-MG and PAP determinations in patients with urinary tract malignancies].

Ferritin, carcinoembryonic antigen (CEA), beta 2-microglobulin (beta 2-MG) and prostatic acid phosphatase (PAP) levels in serum from 77 patients with cancer (6 with renal adenocarcinoma, 9 with renal pelvic and ureteral cancer, 29 with bladder cancer and 33 with prostatic cancer) at various stages were clinically evaluated for their significance as a parameter of urinary tract malignancies. Although, ferritin, CEA and beta 2-MG levels in the poorly-differentiated and advanced stage groups of renal adenocarcinoma, renal pelvic and ureteral cancer, and bladder cancer were higher than those in the well-differentiated and early stage groups, those in most cases were within normal ranges. These proteins were not considered suitable for the screening test. Ferritin and beta 2-MG levels increased with advancement of the performance status (P.S.) proposed by Koyama and Saito; however, the latter was affected greatly by renal impairment. In prostatic cancer, PAP and ferritin levels were remarkably high in the poorly-differentiated group (PAP mean +/- S.E.: 57.6 +/- 22.5 ng/ml, ferritin 883 +/- 319 ng/ml) and the advanced stage group (27.2 +/- 10.5 ng/ml, 398 +/- 152 ng/ml) compared to the well-differentiated group (7.87 +/- 3.61 ng/ml, 88.5 +/- 25.8 ng/ml) and the early stage group (2.24 +/- 0.54 ng/ml, 186 +/- 91.7 ng/ml). PAP and ferritin levels of the untreated cases were positive in 10 out of 18 cases (55.6%) and 7 out of 18 cases (38.9%), respectively, and those of the relapsing cases were positive in 4 out of 7 cases (57.1%) and 6 out of 7 cases (85.7%), respectively. However, CEA and beta 2-MG levels were negative in most cases. Furthermore, increments of PAP and ferritin levels, especially that of the ferritin level, were significantly related to advancement of P.S., and high ferritin levels were obtained in all cases of P.S. 3 and 4. Therefore, determination of PAP and ferritin seems to be useful in monitoring prostatic cancer, and the latter to be useful in early detection of relapsing cases.