Functional Outcome and Complications following Ileal Neobladder Reconstruction in Male Patients without Tumor Recurrence. More than 35 Years of Experience from a Single Center.

PURPOSE: There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. MATERIALS AND METHODS: Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. RESULTS: Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). CONCLUSIONS: The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.

Chemotherapy is of limited efficacy in the control of contralateral testicular intraepithelial neoplasia in patients with testicular germ cell cancer.

INTRODUCTION: Testicular intraepithelial neoplasia (TIN, also called carcinoma in situ of the testis), the precursor of testicular germ cell tumors, will progress to invasive cancer unless appropriate treatment is instituted. Orchiectomy and local radiotherapy have been shown to eradicate TIN safely. The efficacy of chemotherapy is equivocal to date. PATIENTS AND METHODS: Eleven patients with unilateral testicular cancer (5 pure seminoma, 6 nonseminoma) and biopsy-proven contralateral TIN underwent chemotherapy. Four patients received 2 courses of carboplatin single agent, 4 had 2 courses of platin, etoposide, bleomycin (PEB) treatment and 3 had a full 3-cycle treatment with PEB. Rebiopsy to look for persistent TIN was performed after a mean interval of 8.8 months (range 2-31). The patients were then followed clinically. RESULTS: Five patients had persistent TIN upon rebiopsy. Each of the patients failing to chemotherapy had undergone 2 or 3 cycles of the PEB regimen, while 3 had received carboplatin treatment. Two of the patients with no TIN upon rebiopsy developed invasive testis cancer subsequently. In summary, 7 of 11 patients thus failed to chemotherapy (64%; exact 95% confidence interval 30.8-89.1%). Three of the patients had complete absence of spermatogenesis upon rebiopsy histologically, while the remaining cases showed various forms of spermatogenetic arrest. Three of the failing patients were rescued by local radiotherapy, 4 patients underwent partial orchidectomy followed by local radiotherapy. No relapse occurred thereafter. CONCLUSIONS: Chemotherapy was shown to be of only littleeffect in eradicating TIN. The failure rate of 64% is much higher than reported previously. As the majority of failing cases had received carboplatin single-agent therapy or adjuvant PEB therapy with 2 cycles, it may be speculated that the efficacy of chemotherapy regarding TIN clearance is dose dependent. Multidrug regimens appear to be more efficacious than single-agent therapy. As spermatogenesis is only incompletely eliminated by chemotherapy, it is postulated that chemotherapy does no more than temporarily suppress TIN, while only selected cases are cleared of the lesion. Practically, rebiopsy to look for retained TIN about 2 years after completion of chemotherapy is valuable.

Nosocomial bacteriuria in patients with indwelling catheter after radical retropubic prostatectomy for prostate cancer.

INTRODUCTION: Patients with prolonged catheter drainage following pelvic surgery are at increased risk for bacteriuria that may have an impact on the clinical course. MATERIALS AND METHODS: We retrieved all urine analyses from 148 consecutive patients that underwent open retropubic radical prostatectomy at our institution in 2002. The following data were generated: number of bacteriuria with day of onset, used antibiotics, microbiological analysis, resistogram, day of catheter removal and clinical postoperative course. RESULTS: 44.6% of the investigated patients presented with bacteriuria. The highest incidence of bacteriuria was between day 13-15 (40.4%). The most common bacteria detected over the hospital stay were Staphylococcus spp. (24.3%). The most common used antibiotic was trimethoprim/sulfamethoxazole (44.6%). The highest susceptibility was found for levofloxacin (62.4%). No difference in time period of catheter drainage was noticeable in patients with bacteriuria compared to patients without bacteriuria. CONCLUSIONS: Bacteriuria is common after radical prostatectomy. To minor the risk of complications related to bacterial infection, the catheter should be removed 7-10 days after surgery. In case of the necessity of longer catheter drainage, an empiric antibiotic therapy seems rational.

Prognostic significance of disseminated tumor cells in the bone marrow of prostate cancer patients treated with neoadjuvant hormone treatment.

PURPOSE: To explore whether the presence of occult disseminated tumor cells (DTCs) in the bone marrow before neoadjuvant hormone therapy influences the prognosis of patients with organ confined prostate cancer treated by radical prostatectomy. PATIENTS AND METHODS: Pretreatment bone marrow aspirates from 193 cT (1-4) pN0M0 prostate cancer patients submitted to neoadjuvant hormone therapy (mean, 8 months) followed by radical prostatectomy were immunohistochemically evaluated by anticytokeratin antibody A45-B/B3 previously validated for the detection of DTCs. Bone marrow status was compared with established clinical and histopathologic risk parameters. Patients' outcome was evaluated using prostate-specific antigen (PSA) blood serum measurements as surrogate marker for recurrence over a median follow-up of 44 months. RESULTS: DTCs were detected in 44.6% of patients. Bone marrow status neither correlated with tumor grade and stage, nor with the pretreatment PSA risk category (all P values > .05). In the univariate Kaplan-Meier analysis, the presence of DTCs was a significant prognostic factor with respect to poor PSA progression-free survival (log-rank test P = .0035). Using a multivariable piecewise Cox regression model, the presence of DTCs was an independent predictor of PSA relapse (relative risk 1.82; P = .014). CONCLUSION: The presence of DTCs in the bone marrow of patients with prostate cancer before neoadjuvant hormone therapy and subsequent surgery represents an independent prognostic parameter, suggesting that DTCs may contribute to the failure of current neoadjuvant hormone therapy regimens.

Cyclophosphamide is contraindicated in patients with a history of transitional cell carcinoma.

Cyclophosphamide is a urotoxic agent that increases the incidence of malignant neoplasms of the urinary tract. The aim of this study was to evaluate the long-term impact of cyclophosphamide on patients with a history of superficial bladder cancer. Between July 1986 and January 1988, 58 consecutive patients with primary superficial transitional cell carcinoma of the bladder were included in this study. All patients had a transurethral R0 resection. Then 6 weekly intravesical instillations of 120 mg bacillus Calmette-Guérin (BCG) were performed. Until June 1987, 22 consecutive patients (group A) received an additional intravenous application of 700 mg/m(2) cyclophosphamide prior to the BCG immunotherapy, while from July 1987 36 patients were treated without cyclophosphamide. Survival was calculated using the Kaplan-Meier method and comparison of survival using the log rank test. Tumor staging, grading, and size were equally distributed in both groups. No significant difference could be observed regarding the 10-year overall survival rate (group A: 59%, group B: 58%), the 10-year tumor-specific survival rate (89 vs 94%), and the 10-year progression-free survival rate (85 vs 97%). There was a statistically significant deterioration of the 10-year recurrence-free survival rate in the cyclophosphamide group (44 vs 70%, log rank test: p < 0.05). Whereas there were no recurrences in the upper urinary tract among the patients of group B, 2 of the 22 patients from group A developed cancer of the renal pelvis. In patients with a history of superficial bladder cancer, a single dose of cyclophosphamide poses a significantly increased risk of tumor recurrence in the lower and in the upper urinary tract as well.

Pregnancy in women with ureterosigmoidostomy.

OBJECTIVES: To review our experience with four pregnancies during the past 5 years with special attention to the diagnostic and therapeutic aspects of ureterosigmoidostomy. Pregnancy in women with ureterosigmoidostomy is a rare condition that differs in many ways from pregnancies in women with other forms of urinary diversion. METHODS: From 1995 to 2000, we observed four pregnancies in 3 women with ureterosigmoidostomy. Two women had had bladder exstrophy, and one had had interstitial cystitis. During pregnancy, we performed urologic examinations every 4 weeks with renal ultrasonography, calculation of the resistive index, and tests of serum electrolytes, urea, creatinine, and blood gas analysis. In all pregnancies, antibiotic prophylaxis was performed. RESULTS: All women had recurring urinary tract infections before pregnancy. In all cases, reversible dilation of the upper urinary tract was observed during pregnancy. The resistive index never increased to a pathologic range (greater than 0.7). With administration of sodium-potassium-hydrogen citrate, no acidosis was observed. With antibiotic prophylaxis, the women only had one episode each of urinary tract infection during pregnancy. One patient developed preeclampsia that led to a cesarean section at week 36 of gestation. Delivery was achieved by cesarean section in two more cases and vaginally in 1 case. We did not observe any postpartum or neonatal complications related to pregnancy. CONCLUSIONS: Under regular urologic and gynecologic control, there is no contraindication to pregnancy in patients with ureterosigmoidostomy. Antibiotic prophylaxis seems to be recommended.