The role of exenterative surgery and urinary diversion in persistent or locally recurrent gynecological malignancy: complications and survival.

OBJECTIVE: Treatment options in patients with persistent or locally recurrent cervical cancer are limited. The aim of this study was to determine the chance of cure and associated morbidity following pelvic exenteration. PATIENTS AND METHODS: Consecutive patients who underwent pelvic exenteration between January 1992 and December 2006 at the University Hospital of Bern or the Karlsruhe Medical Center were evaluated. Time to recurrence, type of exenteration and urinary diversion, pathological stage, postoperative complications and survival were assessed. RESULTS: Initial therapy prior to diagnosis of persistent or locally recurrent disease included radiation therapy in 51%. Anterior exenteration was performed in 37 (86%) and total exenteration in 6 (14%). Half of the women underwent additional procedures. A continent urinary diversion was constructed in 16 and an ileal conduit in 27 patients. Early postoperative complications were generally minor and only 2 patients required surgical intervention. Four intestinal fistulas were successfully treated conservatively. Late complications were mainly tumor-related. Complication rates associated with the urinary diversion were low and there was no difference in complications between continent and incontinent diversions. The overall disease-specific 5-year survival rate after exenteration was 36.5%. Survival correlated significantly with surgical margin status. CONCLUSION: In patients with persistent or locally recurrent gynecological malignancy of the pelvis, exenteration is a viable option with long-term survival in over one third of patients. Continent urinary diversion did not show higher complication rates than an ileal conduit and should be considered even in irradiated patients. This may be of greater significance in younger patients in whom an intact body image can play an important role in quality of life.

[Noninvasive and invasive bladder cancer: diagnostics and treatment]. / Nichtinvasives und invasives Harnblasenkarzinom: Diagnostik und Therapie.

Therapy of superficial bladder tumors is transurethral resection (TUR), and in cases of pT1 or high-grade tumors a re-TUR is indicated. Patients with carcinoma in situ receive intravesical chemotherapy or BCG for at least 3 months. Persistent carcinoma in situ may be treated by radical cystectomy. With the provision of a functionally adequate urinary diversion, cystectomy represents an effective treatment for patients with muscle-invasive bladder cancer without metastatic spread. Regional lymph node metastases can be found in up to 15% of stage T1 disease and are present in 33% of stage T3/4 lesions. Thus, lymphadenectomy gains diagnostic and possibly also therapeutic importance. For selected patients, who cannot be treated by radical cystectomy, multimodal concepts aiming to preserve the bladder are discussed. After or prior to cystectomy systemic chemotherapy may become necessary for some patients to positively affect the course of the disease in cases of locally advanced or metastatic lesions.

What's new in urology?

Urology has undergone remarkable growth and a variety of clinical substantial therapeutic concepts have changed within the last few years. The following short summary incorporates the most actual advances in basic science and clinical medicine as well as surgical technique. Spectacular new concepts have been developed according to therapy of bladder substitution using bowel. Therapy of stone formation in the urinary tract is possible by using extracorporal shockwave therapy in more than 2/3 of the patients. Additionally, promising aspects in the treatment of hypernephroma with immune response modifiers are actually of great interest. The evaluation of prostatic specific antigen (PSA) as a specific marker in prostatic carcinoma and the conflict between indication for lymphadenectomy or surveillance therapy in testicular cancer stage I, as well as tumor regression under chemotherapy influences clinical trials (e.g. surgical debulking). The brief review of diagnostic and therapeutic approaches including some aspects of andrology hopefully may help to understand clinical problems and demonstrate the effectiveness of standard urologic diagnosis and therapy.

Angioma-like pseudometamorphosis in Wilms' tumors subjected to preoperative radio- and chemotherapy.

Six Wilms' tumors (stage III-V), which had undergone preoperative irradiation and chemotherapy, were examined histologically. While mesenchymal and differentiated epithelial tumor elements were preserved to a large extent, blastemic tumor structures were almost completely lacking. Instead, pseudoangioma-like structures similar to cavernous hemangioma prevailed. As demonstrated by transitional pictures, the pseudoangioma-like pattern is a result of the fact that blastemic tumor elements are replaced by blood after therapy-induced necrosis and lysis. The clinical advantages of preoperative treatment are briefly discussed, especially for patients with advanced tumors.

[An automatic histologic-cytologic image analysis procedure of organs of the urogenital tract. Technics and value in urology]. / Automatische histologisch-zytologische Bildanalyseverfahren an den Organen des Urogenitaltrakts. Techniken und Stellenwert in der Urologie.

The techniques and possible applications of automated image analyser systems with regard to the organs of the urogenital tract are shown and critically assessed. In contrast to fully automated image analysis, semi-automated systems have already become established as standard investigation procedures for scientific questions. It is hoped they will make a contribution towards objectivizing typical therapeutic or specific pathological changes in the target tissue. Fully automated systems are used mainly for the derivation of diagnostic-prognostic tumor criteria in cytological urine analyses. However, routine utilization is still unsatisfactory on account of inadequate diagnostic reliability, so that further development of hardware, software and preparative techniques is necessary. Nevertheless, there is already a striking level of agreement between the automated diagnoses and those made on assessment by an experienced investigator. Special aspects of measuring techniques as they relate to morphometry of the organs in the urogenital tract are discussed.

[Bilateral intrauterine testicular torsion]. / Die bilaterale intrauterine Hodentorsion.

Torsion of the testes is the most frequent urogenital emergency in childhood. Bilateral intrauterine torsion of the testes is a rare event. Only 15 cases have been reported up till now. We add two patients. Clinical findings, consequences and therapy of bilateral torsion of the testes are discussed. Etiology and symptomatology of testicular torsion in the newborn and the adult are different. Predisposing factors are lacking in the extravaginal torsion of the newborn but are present in the intravaginal torsion of the adult. The diagnosis is made by inspection, palpation, Doppler sonography and, if necessary, by immediate surgical exploration. Except for the local findings there are usually no symptoms in the newborn. Following bilateral torsion of the testes with consecutive bilateral orchiectomy the loss of exocrine function remains irreversible. Androgenic substitution therapy should begin at the age of 14. The full dose of hormone should not be given before the termination of bone growth. For psychological and cosmetic reasons a testicular prosthesis can be recommended.

[Practical experiences with antegrade local chemolysis of struvite/apatite, uric acid and cystine calculi in the kidney]. / Praktische Erfahrungen mit der antegraden lokalen Chemolyse von Struvit/Apatit-, Harnsäure- und Zystinsteinen in der Niere.

In 18 patients (20 kidneys) with struvite/apatite-, uric acid- and cystine stones antegrade local chemolysis was performed via percutaneous or operative nephrostomy. Complete stone dissolution was achieved in 11 kidneys, while in six kidneys partial dissolution of stones was performed. In these six cases added instrumental manipulations shortened the time of therapy. In three cases chemolysis was unsuccessful. Average irrigation time was 21 days per renal unit. Only minor complications like dysuria and skin rashes were seen. Due to long time of irrigation we recommend chemolitholysis mainly as an additional form of therapy in case of residual stones after operative or percutaneous nephrolithotomy.

[Conversion of supravesical urinary diversion to an ileal neobladder. Indications, results, problems]. / Umwandlung einer supravesikalen Harnableitung in Ileumneoblase. Indikation, Ergebnisse, Problematik.

The creation of an ileal neobladder or another continent bladder substitute can improve the psychological well-being of patients who need cystectomy. The excellent surgical outcome and continence that can be obtained with an ileal neobladder mean it can be constructed for reversal of diversion even in cystectomized male patients. Selection, indications and results in five patients with reversal of diversion are presented.

[Continent urinary diversion in the elderly patient. Results with an ileum neobladder]. / Kontinente Harnableitung beim älteren Patienten. Ergebnisse mit der Ileumneoblase.

From April 1986 to April 1989 an ileal neobladder was constructed in 101 male patients for complete bladder substitution following radical cystectomy. The patients were retrospectively stratified by age: 86 were over, 15 under the age of 70. No major differences were found in terms of early and late postoperative complications. However, the functional results differed markedly: whereas 89% of the younger patients achieved complete daytime and nighttime continence, only 50% of the older patients reached the same status. It is concluded that strict indications should be observed for complete continent bladder substitution in the elderly.

[The ileal neobladder]. / Die Ileum-Neoblase.

Currently we are witnessing an increase of interest in bladder substitution enterocystoplasty. The goal of this presentation is to describe operative technique and first clinical results of a ileal neobladder for total bladder replacement. Creation of a ileal neobladder for total bladder replacement is described in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressures lower than 30 cm water and no reflux. Eight of the 11 patients with the neobladder are completely dry day and night. Three are stress incontinent grade I. All 11 patients developed recognizable sensations of bladder distension closely simulating those of their earlier bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers a stoma free alternative to urinary diversion resulting in a highly compliant low pressure bladder. A urodynamic comparison between the most recent developments (Kock-pouch, Camey, Mainz-pouch, "Le Bag") is made and this clearly shows the ileal neobladder to have several distinct advantages: the ileocolonic junction and the terminal ileum are saved; the operative technique is safe, simple and reliable (no Kock valve, no 180 degree rotation of the reservoir, simple antireflux technique); development of recognizable sensations of bladder filling in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transurethral laser ablation of the prostate (TULAP). Initial results with 188 patients]. / Transurethrale Laserablation der Prostata (TULAP). Erste Ergebnisse bei 188 Patienten.

Laser therapy for benign prostatic hyperplasia (BPH) is now the most impressive alternative to transurethral resection of the prostate (TUR-P). Transurethral laser ablation of the prostate (TULAP) is a new technique that combines non-contact and contact laser treatment of BPH. From November 1992 to August 1994, 188 patients were treated by the TULAP technique. Their median age was 70.3 (58-87) years. The mean prostatic volume determined by transrectal ultrasound, was 49.2 ml. A 6-month follow up was possible for 102 patients. The AUA 7-Symptom Score decreased from 29 points preoperatively to 6 points after 6 months. Residual urine volume decreased from 205 ml to 27 ml after 6 months. Maximum flow rate increased from 7.2 ml/s to 19.3 ml/s after 6 months. No severe complications were observed, and in particular no major bleeding or TUR syndrome. We regard the TULAP procedure as an effective treatment alternative for obstructive symptoms caused by BPH.

[3 years' experience with the ileum neobladder--the first 108 patients]. / 3 Jahre Ileum-Neoblase--die ersten 108 Patienten.

Between April 1986 and April 1989, each of 108 patients received an ileum neobladder, 94 patients for total bladder substitution after radical cysto-prostatectomy and 14 for augmentation of a fibrotic and contracted bladder following tuberculosis, interstitial cystitis or radiotherapy of the pelvis. The operative technique is standardized, relatively simple and safe, and it prevents upper urinary tract deterioration and reflux. Continence is preserved in more than 80% of all patients by the function of the external urethral sphincter and by the high capacity and the low internal pressure of the intestinal reservoir. Follow-up of more than 3 months postoperatively was possible in 96 patients, the evaluation including micturition behavior at home and a urodynamic investigation. Stress incontinence requiring correction by an artificial sphincter was found in 3 and nocturnal incontinence necessitating some external device in 6 patients. There was no perioperative mortality. Local tumor recurrence and/or metastases occurred in 14 patients; 7 patients died postoperatively, 5 owing to tumor progression, 1 of pneumonia and serve metabolic acidosis, and 1 owing to septicemia of unknown cause. Re-operation was necessary in 13 patients, in 6 because of mechanical ileus or intra-abdominal abscess, in 3 because of stenosis of the uretero-ileal anastomosis, in 1 because of tumor progression, in 1 because of vesico-vaginal fistula, in 1 patient because of incisional hernia, and in 1 because of wound dehiscence. Urethrotomy or dilatation of urethral strictures was necessary in 8 patients. All other early and late complications were rare and could be managed by conservative means.(ABSTRACT TRUNCATED AT 250 WORDS)

[Birt-Hogg-Dubé syndrome : bilateral oncocytic kidney tumors in a patient]. / Birt-Hogg-Dubé-Syndrom : Bilateraler onkozytischer Hybridtumor der Niere.

We report on a rare case of bilateral oncocytic kidney tumors in a patient with Birt-Hogg-Dubé syndrome (BHD). BHD is an autosomal inherited cancer syndrome associated with multiple kidney tumors, benign cutaneous tumors, and pulmonary cysts with spontaneous pneumothorax. To date about 50 BHD families have been described. Patients are best treated with nephron-sparing surgery. Close follow-up is mandatory because recurrence in previously operated kidneys and metastatic tumor progression can occur. Family members at risk should also early be screened for BHD.

[Urinary diversions: which one one is right for which patient?]. / Harnableitungsformen: Welche für wen?

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.

Bladder carcinoma during pregnancy.

INTRODUCTION: We report 3 cases of bladder cancer during pregnancy and give a review of the literature in an attempt to evaluate tumor at presentation, characteristics, maternal and fetal outcome. MATERIALS AND METHODS: The case history of 3 pregnant women treated for bladder cancer in 2001 together with the results of a MEDLINE search from 1966 to 2003. RESULTS: Out of 27 cases of nonbilharzial bladder carcinoma, 74% presented with transitional cell carcinoma. Five patients had muscle-invasive tumors. Major symptom was hematuria in 81%, which was initially mistaken as vaginal bleeding in 22%. Only half of the tumors were identified by ultrasonography. Although superficial bladder carcinoma was transurethrally resected alone, outcome and prognosis are good. But the prognosis of locally advanced bladder carcinoma is poor. None of the fetuses delivered before 30 weeks of gestation survived. Two of the 5 patients died from the disease and follow-up is only short in the rest. CONCLUSION: Any doubtful genital bleeding during pregnancy without definite proof of vaginal/cervical origin should be investigated by both ultrasonography of the upper urinary tract and urethrocystoscopy. Superficial bladder tumors can be most effectively treated by transurethral resection followed by cystoscopy, whereas the prognosis of muscle-invasive bladder carcinoma is poor and demands more radical treatment, depending on the stage of pregnancy.

Diagnostic and prognostic relevance of morphometric structural analyses of the organs of the urogenital tract.

The significance of morphometric structural analyses in their clinical application to the organs of the urogenital tract is critically assessed. Morphometry is of prognostic relevance in examinations of carcinomas of the kidney, bladder and prostate, whereby the structural parameters and the DNA distribution patterns of the nuclei are crucial assessment criteria. For diagnostic purposes, morphometric structural analyses are mainly used in automated evaluations of cytological urine specimens. Especially in the diagnosis of highly differentiated tumors of the bladder, flow photocytometry and image analysis are certainly superior to the visual cytological urinalyses in use today.

[Double-J ureteral catheter: a method without complications?]. / La sonde urétérale double "J": méthode sans complication?

Since 1978, 90 patients with hydronephrosis due to ureteral obstruction have been treated with indwelling double-J ureteral stents (104 Renoureteral units). In cases of temporary treatment (e.g. infected hydronephrosis) splints were left in situ between 1 week and 19 months (mean 15 weeks). If permanent ureteral splinting was necessary as a palliative measure (e.g. progressive carcinoma of pelvic organs) stents were left in situ 6 months up to 5 years (mean 16 months). Replacement of the indwelling double-J stents was carried out in 4 to 12 weeks intervals. The all-over complication rate was near 11% including kidney stone formation in 6 cases and septicaemia due to a clogged stents and pyonephrosis in 3 cases. In two cases after pelvic radiotherapy severe hemorrhage occurred due to erosion of the commun iliac artery. The catheters had been left in situ for 28 and 30 months. Relief of obstruction by indwelling ureteral stents in the majority of the patients can simply be achieved usually without severe technical problems. Nevertheless, a 11% complication rate require restriction to indication especially in cases of long term treatment and after radiotherapy. Urinary diversion by percutaneous nephrostomy is the method of choice to avoid disadvantage of indwelling ureteral splinting.