Radiation therapy outcomes in muscle invasive urinary bladder cancer: A single institution experience.

INTRODUCTION: To audit the survival outcomes and loco-regional control in muscle invasive urinary bladder cancer patients treated with external beam radiation therapy (RT). MATERIALS AND METHODS: From November 2008 through December 2011, 50 consecutively diagnosed muscle invasive urinary bladder carcinoma (T2-4a N0-2, M0) patients were included in this retrospective study. All these patients received external beam RT to a median dose of 60 Gy (range 30-66 Gy), and were not suitable for radical surgery due to patients' preference or medical comorbidities. A stepwise procedure using proportional hazard regression was used to identify prognostic factors with respect to survival. RESULTS: Completion trans-urethral resection of bladder tumor was done in 38 (76%) patients of the cohort and 47 (94%) had transitional cell carcinoma on histopathology. Clinical stage T2 was diagnosed in 40 (80%) patients. The median follow-up for the entire cohort was 14 ± 8.9 months (range 1-36 months). In conclusion, 24 patients (48%) were free of disease, 5 patients (10%) had residual disease, and 13 patients (26%) had died of disease. Two-year and 3 year overall survival of intact bladder for the entire cohort was 58% and 43.6%, respectively. Cox regression modeling strongly suggested clinical stage (P = 0.01) and RT dose (P = 0.001) as being predictors for overall survival. CONCLUSION: RT shows reliable outcomes and excellent compliance in this advanced disease. Prescribing a higher RT dose could potentially correlate to better intact bladder control rates while maintaining good quality of life in selected patients.

Urodynamic Management of Neurogenic Bladder in Spinal Cord Injury.

BACKGROUND: A spinal cord injury is devastating and produces profound changes in the life style of the individual and his family. It is difficult to predict bladder and sphincter behaviour on the basis of clinical somatic neurological deficits. METHODS: A prospective study of 100 spinal cord injury patients was conducted to establish a bladder management protocol. The urodynamic variables were assessed frequently. Clean Intermittent Catheterization (CIC) along with antimuscarinic drugs was instituted and response monitored. Nonresponders were offered Intradetrusor Botulinum toxin. RESULT: Spinal shock lasted for upto six months and only 8% could be converted to CIC during the acute phase. A total of 82% patients underwent three to four urodynamic studies which revealed an increase in cystometric capacity and a decrease in the maximum detrusor pressures. This lowered the incidence of incontinence episodes and prevented upper urinary tract damage. Botulinum toxin provided only temporary relief. CONCLUSION: Aggressive management of neurogenic bladder (NB) dysfunction is a crucial component of the rehabilitation programme for spinal cord injury patients. Repeated urodynamic studies are an essential aid in managing the evolving nature of the bladder dysfunction. Meticulous bladder management protocol can prevent upper urinary tract complications.

Prostate Cancer - What's New?

Research has shown that prostate specific antigen (PSA) is a tumour marker for diagnosis of cancer prostate with significant prognostic value. Screening studies in North America and Europe have revealed that carcinoma prostate is common. Early detection and treatment improves the quality of life besides preventing deaths due to metastatic prostate cancer. Radical prostatectomy and laparoscopic radical prostatectomy has become the standard treatment for localized prostate cancer in all major uro-oncological centres resulting in reduced mortality. Magnetic resonance imaging and positron emission tomography have helped in detecting local and distant spread of cancer prostate. Revised approach to reduce occurrence of prostate cancer by the use of 5 alpha reductase inhibitors like finasteride and dietary supplements has been instituted. The World Health Organisation (WHO) has recommended lifestyle changes to promote men's health and reduce the incidence of prostate cancer.

Voided urinary cytology in bladder cancer: is it time to review the indications?

OBJECTIVES: The sensitivity of voided urinary cytology has been reported as very low. In this study, we investigated the sensitivity and clinical utility of voided urinary cytology in the detection of various grades and stages of transitional cell carcinoma (TCC) of the bladder compared with the urinary nuclear matrix protein-22 (NMP-22) qualitative assay. METHODS: From March 2004 to April 2006, all patients with TCC of the bladder receiving follow-up care and those presenting with gross hematuria were enrolled in this prospective study. These patients underwent urinary cytologic examination and NMP-22 qualitative assay. The diagnosis, determined from the cystoscopy findings and biopsy findings of the suspicious lesion, was accepted as the reference standard. RESULTS: A total of 196 patients were enrolled in this study, of whom 127 patients had previously been diagnosed with bladder TCC and 69 were presenting for investigation of gross hematuria. A total of 52 cases of bladder TCC were diagnosed. The overall sensitivity of voided urine cytology and NMP-22 assay was 21.1% and 67.3%, respectively (P <0.001). The sensitivity of urinary cytology and urinary NMP-22 for well-differentiated tumors was 9.5% and 52.4%, respectively, and was 18.1% and 77.3%, respectively (P <0.001), in moderately differentiated tumors. The overall specificity of urinary cytology for TCC of the bladder was 98.6% and was greater than the specificity of NMP-22 (80.5%). CONCLUSIONS: The results of our study suggest that urinary cytology has a very low sensitivity and can be omitted in favor of NMP-22 in the follow-up of low-grade superficial bladder TCC.

Symptomatic and complicated adult and adolescent primary obstructive megaureter--indications for surgery: analysis, outcome, and follow-up.

OBJECTIVES: Primary obstructive megaureter is an uncommon presentation in adult patients. Although not reported frequently in published studies, the anomaly exists and warrants aggressive surgical management in contrast to its presentation in children. METHODS: This study was composed of 55 patients (47 with unilateral and 8 with bilateral megaureters) with adult primary obstructive megaureter who were treated from January 1989 to December 2001. Their clinical presentation, renal function, radiologic data, treatment, complications, and follow-up were studied. RESULTS: Of the 55 patients, 36 were male and 19 were female (age range 13 to 52 years). All patients were symptomatic except two. Forty-four patients (50 renoureteral units) required ureteral reimplantation, with tailoring in 33. Five patients were treated with endoscopic techniques (ureteral meatotomy in 3 and ureteroscopic retrieval of ureteral calculi in 2). Four patients required nephroureterectomy for nonfunctioning kidneys. Associated renal calculi were managed by extracorporeal shock wave lithotripsy and pyelolithotomy and ureteral calculi by endoscopic methods or calculi removed at the time of ureteroneocystostomy. All but 4 patients showed improvement in hydroureter and hydronephrosis and developed no complications during the follow-up period of 1 to 12 years (mean 7). Five patients with bilateral megaureters had uremia. Only one improved after surgery with adequate drainage and 2 patients died despite reimplantation. CONCLUSIONS: Most adult patients with megaureter are symptomatic. Complications such as stone formation and deranged function of the affected kidney are common and almost all require surgical intervention. Surgery in those with bilateral megaureters with advanced renal failure is mostly unrewarding.

Mesonephroid adenocarcinoma of the bladder and urethra: a case report.

Mesonephric or mesonephroid adenocarcinoma of the bladder may be a malignant form of nephrogenic adenoma or nephroid metaplasia. The lesion is rare, and to the best of our knowledge only 9 cases have been reported in the world literature. We report another case of mesonephroid adenocarcinoma of the bladder and urethra which was treated with transurethral resection and subsequent chemotherapy.

Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc.

BACKGROUND AND PURPOSES: The morbidity of transurethral vesection of the prostate (TURP) necessitates constant attempts at modifications to the standard equipment and technique. Patients with larger prostates (>40 cc) need a longer time for the procedure, and the blood loss, requirement for irrigation fluid, and incidence of postoperative complications tend to be greater. We report on the safety and efficacy of TURP with the thick vapor resection loop compared with the standard wire loop in comparable groups of patients with prostates >40 cc. PATIENTS AND METHODS: We randomized 100 patients with benign prostatic hyperplasia (BPH) into two groups of 50 each which were similar in age. The inclusion criteria included an indication for prostatectomy and prostate size >40 cc. Patients who were on finasteride preoperatively (six) and those who had histopathologic adenocarcinoma of the prostate (three) were excluded. Preoperative evaluation included assessment of International Prostate Symptom Score (IPSS), prostate volume by abdominal ultrasonography, maximum flow rate (Q(max)), and residual urine volume. The two groups were similar in the signs and symptoms of BPH. Patients in Group 1 underwent transurethral vapor resection of the prostate (TUVRP) using the vapor resection loop (Wing trade mark; Richard Wolf, Germany), while patients in Group 2 underwent TURP using a standard wire loop. All procedures were performed by consultant urologists with equivalent experience. We used a Martin ME 401 (Gebruder Martin, Tuttlingen, Germany) electrosurgical generator with settings of 120 to 150 Watts and 50 to 70 W for cutting and coagulating, respectively, for the thick loop and 70 to 80 W and 40 to 50 W for the standard loop. Operating time, resected tissue weight, duration of catheterization, nursing contact time, hospital stay, hemoglobin change, serum sodium concentrations, and any complications were noted and analyzed using the Kruskal-Wallis paired variables test, and P values were calculated. P value <0.04 was considered significant. The IPSS, Q(max), and residual urine volume were reevaluated at 6 months and 1 year after the procedure and compared for the two groups. RESULTS: The median prostate volume was 63 cc and 54 cc in Groups 1 and 2, respectively, and the median resected weight was 20 and 19 g, respectively (P = NS). The differences in operating time (median 45 v 60 minutes; P < 0.0001), intraoperative irrigant use (15 v 21 L; P < 0.0001), and intraoperative blood loss (median 52.5 v 150 mL; P < 0.0001) in the two groups were statistically significant. Peroperative blood loss was estimated by the indicator dilution method of Freedman et al in three 5-mL samples of the irrigant fluid and arriving at the average of the three values and adjusted for the volume of irrigant fluid used. The differences in postoperative irrigant (P < 0.01) and catheter duration (P = 0.04) were also significant. Two patients received blood transfusion in Group 2 and none in Group 1. The difference in the change in hemoglobin and serum sodium postoperatively in the two groups was not statistically significant. The complications were dysuria in six patients lasting for a month and one capsular perforation in Group and incontinence lasting for 6 months in two patients and stricture in one patient in Group 2. The efficacy, assessed with IPSS, Q(max), and residual urine volume, was comparable at 6 months and at 1 year. CONCLUSION: The use of a thick vapor resection loop for TURP coupled with higher generator settings as recommended for them, especially for prostates >40 cc, is beneficial, as it significantly reduces operating time, blood loss, irrigant requirement, nursing contact time, and duration of catheterization, besides providing clear vision during surgery and ease of resection. There was no reduction in efficacy or increase in complications.

Ureteral stent--help or hindrance? In healing of post traumatic nephrocutaneous fistula.

Nephrocutaneous fistulas are rare complications of blunt or penetrating renal trauma. The majority are managed conservatively, some may require percutaneous drainage or ureteral stenting and some require operative intervention. Diversion of the urine by a ureteral stent usually aids in the healing of the fistula. We present an unusual case of nephrocutaneous fistula following blunt renal trauma which persisted as long as a stent was in place but healed immediately after the stent was removed.