Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center.

BACKGROUND: The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients. METHODS: We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS. RESULTS: Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20-101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11-235) vs. 50 ivMEQ (7-277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14-2.45; p = 0.009) and CSS (HR = 1.53, 1.04-2.25; p = 0.030) on multivariable analyses. CONCLUSIONS: Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

Robotic Assisted Laparoscopic Partial Cystectomy as Treatment for Pseudosarcomatous Fibromyxoid Tumor of the Bladder.

This case is of a 26 year old female evaluated for gross hematuria and suprapubic pain found to have a large bladder tumor. She subsequently underwent successful robotic assisted laparoscopic partial cystectomy. Pathology revealed pseudosarcomatous fibromyxoid tumor, an uncommon lesion that occurs most frequently among young females and must be distinguished from other malignant lesions, as treatment may differ. Partial cystectomy via robotic approach has never been described in the literature as a treatment option for this type of bladder lesion. In this case, the patient did exceptionally well upon follow-up. As such, robotic assisted laparoscopic partial cystectomy is presented a viable option for treatment of select patients with pseudosarcomatous fibromyxoid tumor.

Change in Management Based on Pathologic Second Opinion Among Bladder Cancer Patients Presenting to a Comprehensive Cancer Center: Implications for Clinical Practice.

OBJECTIVE: To evaluate the incidence and degree of change from a pathologic second opinion of bladder biopsies at a Comprehensive Cancer Center that were initially performed at referring community hospitals. The secondary objective was to determine the impact the potential changes would have on a patient's treatment. MATERIALS AND METHODS: Dedicated genitourinary pathologists reviewed 1191 transurethral biopsies of the bladder and/or prostatic urethra from 2008 to 2013. Major and minor treatment changes were defined as altering recommendations for cystectomy, systemic chemotherapy, or primary cancer diagnosis, and alterations in intravesical regimens, respectively. RESULTS: There were 326/1191 patients (27.4%) with a pathologic change on second opinion: grade (62/1191, 5.2%), stage (115/1191, 9.7%), muscle in the specimen (29/1191, 2.4%), presence or absence of carcinoma in situ (34/1191, 2.9%). Outside pathology did not address the presence or absence of lymphovascular invasion in 620/759 (81.7%) of invasive cases (≥cT1), of which 35/620 (5.6%) had lymphovascular invasion. There were 212 mixed, variant, or nonurothelial histologies detected in 199/1191 (16.7%) patients, with 114/212 (53.7%) resulting in reclassification by our pathologists. Potential treatment alterations accounted for 182/1191 (15.3%) of cases, with 141/1191 (11.8%) imparting major changes. There were 82/1191 (6.8%) changes in recommendation for a radical cystectomy, 38/1191 (3.2%) had a complete change in primary tumor type, and 21/1191 (1.8%) for change in chemotherapy regimen. CONCLUSION: The amount and degree of pathologic changes and its potential impact on treatment emphasize the importance of bladder cancer patients having their histology reviewed by genitourinary-dedicated pathologists. In our cohort, 15.3% of patients could see a treatment alteration, with 11.8% being a major change.

Patient and disease-specific factors and their influence on urinary reconstruction choice at a referral center.

PURPOSE: To evaluate potential socioeconomic and demographic factors that may influence or be associated with various types of urinary reconstruction (UR) following a radical cystectomy (RC) accounting for existing clinical variables. METHODS: There were 828 patients that underwent a RC and UR between 2000 and 2013. After excluding patients that did not meet medical or surgical criteria for a continent urinary reconstruction (CUR-orthotopic neobladder or continent catheterizable pouch), there were 714 patients available for analysis. Socioeconomic and demographic data along with disease-specific variables were recorded preoperatively and analyzed to determine a correlation with a particular type of UR. RESULTS: Non-continent urinary reconstruction (ileal conduit or cutaneous ureterostomies) and CUR accounted for 78.3 % (559/714) and 21.7 % (155/714) of UR following RC, respectively. On univariate analysis, younger age, marital status, employment status, type of insurance, ASA score, and preoperative glomerular filtration rate were significantly associated with CUR (p < 0.01). Travel distance, race, and education level were not factors for UR type. Additionally, there was no significant difference between males and females receiving a CUR. On multivariate analysis, older age [odds ratio (OR) 0.85, p < 0.01], marital status (OR 0.28, p < 0.01), insurance status (OR 0.22, p = 0.04), and higher ASA score (OR 0.50, p < 0.01) remained independent predictors of those less likely to receive a CUR. CONCLUSION: Predictable socioeconomic and demographic influences exist between the choice of UR after RC. Increasing age corresponds to a decreasing likelihood of receiving a CUR. No significant difference was seen between men and women in undergoing a CUR.

A single-institution experience with metallic ureteral stents: a cost-effective method of managing deficiencies in ureteral drainage.

INTRODUCTION: The limitations of traditional ureteral stents in patients with deficiencies in ureteral drainage have resulted in frequent stent exchanges. The implementation of metallic stents was introduced to improve the patency rates of patients with chronic upper urinary tract obstruction, obviating the need for frequent stent exchanges. We report our clinical experiences with the use of metallic ureteral stents in the management of poor ureteral drainage. MATERIALS AND METHODS: Fifty patients underwent metallic ureteral stent placement from 2009 to 2012. Stent failure was defined as an unplanned stent exchange, need for nephrostomy tube placement, increasing hydronephrosis with stent in place, or an elevation in serum creatinine. Stent life was analyzed using the Kaplan-Meier methodology, as this was a time dependent continuous variable. A cost analysis was similarly conducted. RESULTS: A total of 97 metallic stents were placed among our cohort of patients: 63 in cases of malignant obstruction, 33 in the setting of cutaneous ureterostomies, and 1 in an ileal conduit urinary diversion. Overall, stent failure occurred in 8.2% of the stents placed. Median stent life was 288.4 days (95% CI: 277.4-321.2 days). The estimated annual cost for traditional polymer stents (exchanged every 90 days) was $9,648-$13,128, while the estimated cost for metallic stents was $4,211-$5,313. CONCLUSION: Our results indicate that metallic ureteral stent placement is a technically feasible procedure with minimal complications and is well tolerated among patients. Metallic stents can be left in situ for longer durations and provide a significant financial benefit when compared to traditional polymer stents.

A Single-Institution Experience with Metallic Ureteral Stents: A Cost-Effective Method of Managing Deficiencies in Ureteral Drainage

IntroductionThe limitations of traditional ureteral stents in patients with deficiencies in ureteral drainage have resulted in frequent stent exchanges. The implementation of metallic stents was introduced to improve the patency rates of patients with chronic upper urinary tract obstruction, obviating the need for frequent stent exchanges. We report our clinical experiences with the use of metallic ureteral stents in the management of poor ureteral drainage.Materials and MethodsFifty patients underwent metallic ureteral stent placement from 2009 to 2012. Stent failure was defined as an unplanned stent exchange, need for nephrostomy tube placement, increasing hydronephrosis with stent in place, or an elevation in serum creatinine. Stent life was analyzed using the Kaplan-Meier methodology, as this was a time dependent continuous variable. A cost analysis was similarly conducted.ResultsA total of 97 metallic stents were placed among our cohort of patients: 63 in cases of malignant obstruction, 33 in the setting of cutaneous ureterostomies, and 1 in an ileal conduit urinary diversion. Overall, stent failure occurred in 8.2% of the stents placed. Median stent life was 288.4 days (95% CI: 277.4-321.2 days). The estimated annual cost for traditional polymer stents (exchanged every 90 days) was $9,648-$13,128, while the estimated cost for metallic stents was $4,211-$5,313.ConclusionOur results indicate that metallic ureteral stent placement is a technically feasible procedure with minimal complications and is well tolerated among patients. Metallic stents can be left in situ for longer durations and provide a significant financial benefit when compared to traditional polymer stents.

Salvage surgical resection for isolated locally recurrent inguinal lymph node metastasis of penile cancer: international study collaboration.

PURPOSE: We assessed the merit of performing salvage inguinal lymph node dissection in those infrequent cases of penile cancer with locally recurrent inguinal lymph node metastases in the absence of other suspected sites of disease. MATERIALS AND METHODS: A total of 20 patients were retrospectively identified as having undergone salvage inguinal lymph node dissection for locally recurrent penile cancer. Patients were previously treated with primary inguinal lymph node dissection with curative intent. At the time of salvage inguinal lymph node dissection, superficial and deep inguinal lymph node dissection was performed with resection outside of the standardized surgical template if there was inguinal recurrence outside of this region. RESULTS: All cases were primary penile squamous cell carcinomas. Median time to recurrence from initial inguinal lymph node dissection was 7.7 months (range 3.1 to 35.0). At salvage inguinal lymph node dissection a median of 3 lymph nodes (range 1 to 17) was resected with a median of 2 (range 1 to 7) nodes positive for malignancy. Median overall survival after salvage inguinal lymph node dissection was 10.1 months (95% CI 1.9-18.3) and median disease specific survival after salvage inguinal lymph node dissection was 16.4 months (95% CI 5.1-27.8). Of the initial 20 patients 9 have no evidence of disease (median followup 12.0 months, range 7.1 to 70.1). Postoperative complications developed in 11 patients, including wound infections in 6, postoperative severe (debilitating) lymphedema in 4 and seroma in 1. CONCLUSIONS: Salvage inguinal lymph node dissection is a potentially curative treatment in patients with penile cancer with locally recurrent inguinal lymph node metastases in the absence of occult disease. Patients undergoing such salvage surgery should be informed of the high likelihood of postoperative complications.

Ureteral replacement and onlay repair with reconfigured intestinal segments.

PURPOSE: Ureteral loss represents a surgical challenge to provide low pressure drainage while avoiding urinary stasis and reflux. The ideal replacement should optimize drainage while minimizing absorption, allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract. We reviewed our experience with ureteral repair, focusing on the use of reconfigured intestine. We report what is to our knowledge the novel use of reconfigured intestine as an onlay flap on the preserved ureteral segment and as a circumferential interpositioned segment. MATERIALS AND METHODS: A total of 16 ureters were repaired in 4 men and 9 women using reconfigured ileum, colon or appendix. Mean patient age was 45 years (range 26 to 66). The etiology of the ureteral defect was iatrogenic in 8 patients, retroperitoneal fibrosis in 3, trauma in 3 and ureteritis cystica in 1. Mean defect length was 10 cm (range 5 to 20) in the 10 right and 6 left ureters, and the defect was proximal in 3, mid in 4, distal in 7 and panureteral in 2. Ureteral replacement was performed using a segment of ileum in 13 cases or colon in 1. The segment was detubularized and reconfigured according to the Yang-Monti principle and used as a complete retubularized interposed segment in 7 cases or as an onlay flap on the opened ureter without resection in 7. Also, 2 ureters were reconstructed with an incised appendiceal flap onlayed over the preserved ureteral plate. At a mean followup of 44 months (range 12 to 78) all patients underwent antegrade nephrostogram, followed by renal scan and upper tract imaging. RESULTS: All patients tolerated the procedure without initial bowel or urinary tract complications. In 1 patient who had received radiation a ureteral fistula developed to a blind Hartmann pouch at 9 months, requiring repair. Ultimately, cystectomy was done for irradiation cystitis (onlay group). Another patient with bilateral obstruction at presentation lost unilateral renal function during 5 years. Urinary drainage was achieved in all 14 remaining renal units with preservation of function, as shown on renal scan. Patients reported minor mucous production without renal colic or stone formation. CONCLUSIONS: Long ureteral defects require tissue replacement when bladder flaps do not suffice. Ureteral replacement can be achieved by reconfigured intestinal segments, which are readily mobilized and secured as interposed segments or as an onlay flap on the preserved ureter. A relatively short segment can be used to repair a lengthy defect along any segment of ureter, also allowing for nonrefluxing reimplantation.

A large cellular angiofibroma of the male pelvis presenting with obstructive voiding: A case report and review of the literature.

Cellular angiofibromas (CAF) are rare, benign soft-tissue tumours. The diagnosis of CAF is important given the heavy resemblance to other tumours. Herein, we describe a case of a rapidly growing, very large (13.5 cm) CAF located in the deep pelvis of a middle-aged male who presented with difficulty voiding.

Primary Ewing sarcoma of the kidney: a symptomatic presentation and review of the literature.

The objective of this review is to discuss the unique nature of primary renal Ewing sarcoma, including incidence, presentation and management. We also report on a common pattern of presentation, consisting of acute flank pain mimicking a renal stone colic, with or without hydronephrosis, and a renal mass discovered during imaging studies of renal Ewing sarcoma. We present our case of renal Ewing sarcoma along with imaging and pathological analysis. We also performed a retrospective review of all cases of renal Ewing sarcoma using PubMed. A total of 48 cases of renal EWS sarcoma have been reported and analyzed in this review. A mean age of 30.4 years was found along with a 61% male predominance. The mean survival was 26.14 months with a lower median survival in patients with advanced metastatic disease. Primary Ewing sarcoma of the kidney is rare. The diagnosis of primary renal EWS can be difficult and is based on a combination of electron microscopy, immunohistochemistry, chromosomal analysis, fluorescence in situ hybridization (FISH) and light microscopy.

A preliminary report on the usage of an intracorporal antibiotic cast with synthetic high purity CaSO4 for the treatment of infected penile implant.

INTRODUCTION: Currently, the surgical treatment of infected penile prostheses is complete removal and either immediate salvage procedure, which carries a significant infection risk, or delayed implantation. With delayed implantation the risk of infection is lower, but the patient loses penile length and width due to corporal fibrosis. AIM: We present our experience with the use of a novel temporary synthetic high purity calcium sulfate (SHPCaSO4) component that acts as a "spacer" at the time of removal of an infected prosthesis while providing constant delivery of local antibiotic elution to the infected area. MAIN OUTCOME MEASURES: Demonstrate that the use of a novel material, SHPCaSO4, can be an innovative way to bridge the gap between removal of an infected penile implant and delayed reimplantation. METHODS: Two patients (Patient A and B) presented with pain and erythema and were found to have infected malleable penile prosthesis. Both underwent removal of all infected components, and sent for tissue culture. The SHPCaSO4 was mixed with vancomycin and tobramycin, allowed to set up for 5 minutes, and then injected into the corporal space followed by closure with 2-0 Vicryl sutures. The injected SHPCaSO4 was palpable in the penile shaft both proximally and distally, as an "intracorporal casts." RESULTS: Patients denied pain postoperatively. Delayed implantation occurred at 6 weeks for patient A. This went uneventful and a new three-piece inflatable implant was inserted. Patient B underwent salvage placement of right malleable implant at 15 weeks, and here significant corporal fibrosis was encountered. Patients have had no infection since their delayed implantation (mean follow-up 4 months). CONCLUSIONS: Data in reference to SHPCaSO4 shows that this product dissolves in approximately 4-6 weeks. This may account for the difference in the ease of delayed implantation between the two patients. Further investigation is warranted.

Ventral phalloplasty.

PURPOSE: To present the surgical technique of ventral phalloplasty as an adjunct procedure to the classic prosthetic surgery. MATERIALS AND METHODS: In this video we demonstrate how to perform a ventral phalloplasty in a patient that has undergone a penile prosthesis implantation. Our technique consists of: delineation of the penile scrotal web, excision of this redundant skin, and re-approximation of the wound to mimic the natural median raphe. RESULTS: The ventral phalloplasty improves the perception of phallic length, as well as patients' satisfaction after prosthetic surgery. CONCLUSION: Penile length perception is the main concern of patients that have undergone penile prosthesis implantation. In this video we demonstrate that the ventral phalloplasty can improve perception of phallic length, and can be an important adjunct to the classic prosthetic surgery.

Morbidity associated with nonemergent hysterectomy for placenta accreta.

OBJECTIVE: The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta. STUDY DESIGN: This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009. RESULTS: Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation. CONCLUSION: Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

Subarachnoid hemorrhage as complication of phenylephrine injection for the treatment of ischemic priapism in a sickle cell disease patient.

INTRODUCTION: Ischemic priapism (IP) is a urologic condition, which necessitates prompt management. Intracavernosal injection of phenylephrine is a usual treatment modality utilized for the management of these patients. Aim. We present a case of subarachnoid hemorrhage following intracavernosal injection of phenylephrine for IP in a patient with sickle cell disease. METHODS: We analyzed the degree of subarachnoid hemorrhage in our patient after intracavernosal injection of phenylephrine. The patient had an acute rise in blood pressure during corporal irrigation. This was followed by the onset of severe headache. Computed tomography (CT) scan confirmed the diagnosis of a subarachnoid hemorrhage. MAIN OUTCOME MEASURE: Subarachnoid hemorrhage associated with intracavernosal injection of phenylephrine. Result. A 23-year-old African American male with a history of sickle cell disease presented with a painful penile erection. The patient was started on intravenous fluids, oxygen by nasal canula, and analgesic medication. After this, a blood gas was obtained from his left corpora cavernosa. This was followed by normal saline irrigation and injection of phenylephrine. The patient complained of a sudden, severe "terrible headache" immediately following the last injection, and noncontrast CT scan of the head was obtained and a subarachnoid hemorrhage was noted. The patient was admitted for observation and no significant changes were noted. CONCLUSIONS: Intracavernosal injection of phenylephrine for the management of IP can be associated with several possible complications. We present our single case complicated with the formation of a subarachnoid hemorrhage. The patient was treated conservatively and had no long-term neurologic sequelae. Davila HH, Parker J, Webster JC, Lockhart JL, and Carrion RE. Subarachnoid hemorrhage as complication of phenylephrine injection for the treatment of ischemic priapism in a sickle cell disease patient.

Total or partial prostate sparing cystectomy for invasive bladder cancer: long-term implications on erectile function.

OBJECTIVE: To review the long-term results in patients treated with either total or partial prostate-sparing cystectomy, focusing on erectile function (EF), as en-bloc radical cystectomy (RC) with or without urethrectomy has been the method of choice for managing invasive bladder carcinoma, but has inherent risks of subsequent urinary incontinence and erectile dysfunction, with a marked effect on quality of life, especially in younger patients. PATIENTS AND METHODS: Between 2003 and 2005 we assessed 21 men (mean age 56 years) who had either a prostate apex-sparing cystectomy (PASC, 15) or total prostate-sparing cystectomy (TPSC, six). The mean follow-up was 30 months for PASC and 24 months for TPSC. The evaluation before surgery included standard bladder cancer staging, prostate specific antigen level, a digital rectal examination and a complete medical history, with attention to self-reported EF before surgery and the EF domain of the International Index of EF (IIEF) after surgery. RESULTS: The EF domain score was 20 after PASC and 30 after TPSC; this correlates with mild to moderate ED in the PASC group vs normal erectile function in the TPSC group. After transurethral resection of the bladder tumours (TURBT) 10 of 14 in the PASC group were T1 or T2a, and in the TPSC group, five of six were T2a and one patient was T2b. From the cystectomy specimen, in the PASC group eight were understaged compared with the TURBT specimen (T2b/T4a vs T1/T2a), while in the TPSC group there was understaging two (T3a vs T2a/T2b); this was significantly different (P < 0.05). There was recurrence of urothelial carcinoma in one of 15 and one of six after PASC and TPSC, respectively. CONCLUSION: The EF domain score after PASC was 10 points lower than after TPSC, representing a 30% increase in EF by preserving the entire prostate. We conclude that in patients with invasive bladder cancer, EF can be significantly preserved by prostate-sparing cystectomy. If adequate selection criteria are applied, EF can be preserved without compromising cancer control.

Sexual function after surgery for prostate or bladder cancer.

BACKGROUND: Compromised sexual function is often a side effect for patients following radical surgical procedures for bladder or prostate cancer. METHODS: The authors review the classification and physiology of sexual function and dysfunction. Moreover, they explain the possible pathophysiology directly resulting from surgery, and they discuss several approaches available to address these problems. RESULTS: Options for male sexual dysfunction, primarily erectile dysfunction resulting from radical prostatectomy or surgery for bladder cancer, range from patient education to penile prosthesis implantation. Female sexual dysfunction caused by surgical intervention for bladder cancer includes problems with libido, arousal, orgasm, and dyspareunia. Treatment options for women can include sex therapy, hormonal therapy, and preventive strategies. However, no consensus has been established on the most effective agents and time points to treat male or female sexual dysfunction following radical cystectomies or prostatectomies. The chronic intermittent treatment of erectile dysfunction following radical prostatectomy has been commonly referred to as penile rehabilitation. CONCLUSIONS: Additional research is needed to obtain further data concerning sexual dysfunction in both men and women following radical pelvic surgeries. Modification of surgical techniques, the use of various treatment modalities for sexual dysfunction, and the development of new agents will help to successfully minimize or prevent damage and restore normal sexual function after local surgical therapy for prostate or bladder cancer in the future.

Sites of bowel resected to achieve optimal ovarian cancer cytoreduction: implications regarding surgical management.

OBJECTIVE: The purpose of this study was to 1) report on the distribution of bowel segments resected in a population of patients who underwent primary optimal cytoreductive surgery for epithelial ovarian cancer, and 2) discuss implications for surgical management regarding resection of these bowel segments. STUDY DESIGN: This was a retrospective study from 1995 to 2003 of 144 ovarian cancer patients who underwent primary optimal cytoreductive operations that included bowel resection. RESULTS: Bowel segments removed and major complications are presented in tabulated form. Eighty-one out of 144 resections were rectosigmoid only. Thirty-six percent had extensive involvement of colon segments separate from the rectosigmoid. Excluding hemorrhage, 9 patients (6%) experienced a major complication. CONCLUSION: The present study does suggest the necessity for a highly individualized approach to the surgical management of epithelial ovarian cancer patients who can be optimally cyto-reduced by resection of multifocal colonic involvement. Further study is needed to better assess the complications, function, and oncologic outcome of the different surgical approaches to these patients.

Investigation of the safety and accuracy of intraoperative gamma probe directed biopsy of bone scan detected rib abnormalities in prostatic adenocarcinoma.

PURPOSE: We evaluated the technique of intraoperative gamma probe directed rib biopsy in patients with suspected metastatic prostate adenocarcinoma. This technique can be used to identify accurately the rib in question, reliably obtain sufficient tissue for diagnosis, be performed with minimal patient morbidity and potentially alter the course of therapy. MATERIALS AND METHODS: From 1996 to 2001, 8 patients with biopsy proved adenocarcinoma of the prostate and suspicious rib lesions on radionuclide bone scanning underwent open rib biopsy as part of the evaluation for metastatic disease. Mean prostate specific antigen in the patient population was 17.1 ng/ml (range 6.1 to 36.5) and clinical stage was T1c to T3c. A new technique of intraoperative gamma probe directed biopsy was used to localize and resect the rib in question. At 6 to 12 hours before the operation each patient received an intravenous injection of 28 mCi. (99m)technetium-oxidronate. The hand held, pencil sized gamma probe in a sterile sleeve was used to localize the area of greatest activity in the target bone and 3 cm. of bone were resected. RESULTS: Of the 8 patients who underwent the procedure 2 had metastatic prostate cancer on final rib pathological findings. Four of the remaining 5 patients had benign rib lesions (an old rib fracture) and 1 had metastatic lung cancer. The hot spot on bone scan was localized with 100% accuracy using our technique and a pathological diagnosis was made in all cases. Mean operative time was 61 minutes and estimated blood loss was less than 20 ml. in all cases. Seven of the 8 patients were discharged home the same day, while 1 required overnight hospitalization. There was 1 intraoperative complication of inadvertent entry into the pleural cavity, resulting in a small pneumothorax, which was treated with small chest catheter drainage and observation. CONCLUSIONS: Intraoperative gamma probe directed rib biopsy of suspected metastatic lesions in patients with prostate cancer can be safely and accurately performed with minimal patient morbidity. The information obtained using this technique can be used to tailor treatment decisions for this subset of patients with prostate cancer.

Urinary incontinence after continent urinary diversion using cecal wrap or plicated ileum: a patient questionnaire review.

OBJECTIVES: To evaluate the clinical and urodynamic results of a tapered-cecal wrap (TCW) versus a tapered-plicated ileal (TPI) anti-incontinence mechanism. METHODS: Of 54 consecutive patients who had undergone continent urinary diversions, 33 (17 with TCW and 16 with TPI) were evaluated. The primary disease that prompted diversion included bladder cancer (84%), neurogenic bladder (12%), and interstitial cystitis (3%). All patients were evaluated using a telephone questionnaire regarding ease of catheterization, degree of continence, occurrence of postoperative complications, and overall satisfaction in relation to their stoma. In addition, 6 patients in the TPI group and 5 in the TCW group underwent enterocystometry and outlet pressure recording. The mean follow-up was 30 months for the TCW group and 48 months for the TPI group. RESULTS: The overall functional continence rate was 100% for the TCW group and 81.3% for the TPI group. Transient difficulty with catheterization occurred in 35.3% of the TCW group and 18.7% of the TPI group. No differences were observed in the occurrence of postoperative complications. Urodynamics demonstrated a statistically significant increase in maximal outlet pressure with the reservoir full in the TCW group that was not noted in the TPI group. CONCLUSIONS: The addition of a cecal wrap to the efferent limb results in significantly improved continence. This was supported urodynamically with demonstration of an increase in maximal outlet pressure with the reservoir full in the TCW group. No difference in the surgical complication rate or long-term difficulty with catheterization was observed.