Pneumovesicum approach to en-bloc laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial cancer: midterm oncological results.

INTRODUCTION: We reported the pneumovesicum (PV) approach to lower ureter and bladder cuff excision and closure. We believe that this approach bears the closest resemblance to the laparoscopic skill set of intravesical dissection and suturing. Herein, we report the midterm oncological results of the approach's use in a series of patients with upper tract urothelial cancer. MATERIALS AND METHODS: From July 2004 to May 2010, 10 patients with upper tract urothelial cancer who underwent PV-assisted laparoscopic nephroureterectomy (LNU) were reviewed. Laparoscopic ports were inserted into the bladder via a suprapubic route, and carbon dioxide PV was induced. Laparoscopic dissection of the lower ureter and excision of the bladder cuff were then performed. The bladder defect was securely closed using laparoscopic suturing, and standard LNU followed. RESULTS: Nine men and one woman with a mean age of 71.6 years (47-82) underwent the procedure. Six of the patients had renal pelvic tumor, two had upper ureter tumor, one had midureter tumor, and one had synchronous renal pelvis and upper ureter tumor. In terms of final pathology, there were three, two, and five patients with T1, T2, and T3 diseases, respectively. All of the patients had grade 2 (G2) disease, except for two with grade 3 (G3) disease. Over a median follow-up of 46 months (22-67 months), four patients developed superficial bladder tumor recurrence. The bladder and systemic recurrence rates were 40% and 10%, respectively. There was no port site recurrence. CONCLUSION: Based on our midterm follow-up information, it can be concluded that the PV approach to en-bloc bladder cuff excision and LNU for upper tract urothelial cancer provides intermediate oncological results comparable to those of other approaches to en-bloc excision of the bladder cuff.

Pneumovesicum method in en-Bloc laparoscopic nephroureterectomy with bladder cuff resection for upper-tract urothelial cancer.

BACKGROUND AND PURPOSE: A novel technique for managing the distal ureter and bladder cuff during laparoscopic nephroureterectomy is introduced. TECHNIQUE: The procedure consists of three steps: (1) cystoscopy and PediPort (Tyco) insertion; (2) establishment of pneumovesicum and intramural ureter mobilization; and (3) laparoscopic nephroureterectomy. The use of PediPorts, a 5-mm lens, and Ski needles greatly facilitates the pneumovesicum. The ureteral orifice is closed, and the intramural ureter is dissected out with the patient in the lithotomy position. Laparoscopic nephroureterectomy is then accomplished with the patient in the lateral position. RESULTS: The postoperative course was uneventful, and the pathology examination showed clear margins. CONCLUSION: Pneumovesicum is a minimally invasive approach that provides an excellent endoscopic view. It is an oncologically sound method, as the ureteral orifice is closed early, and the chance of cancer-cell spillage is minimized by the use of gas instead of liquid in the bladder. Moreover, the procedure is not technically demanding.

Twelve-year follow up of a randomized prospective trial comparing bacillus Calmette-Guerin and epirubicin as adjuvant therapy in superficial bladder cancer.

AIM: To compare bacillus Calmette-Guerin (BCG) with epirubicin in adjuvant therapy of superficial bladder transitional cell carcinoma, with respect to recurrence, progression and survival. Prognostic factors are also evaluated. METHODS: Between October 1991 and September 1999, all patients harboring superficial bladder cancers (Ta or T1) with any of the relevant criteria (stage>a, grade>1, size>1 cm, multiple or recurrent tumors), after complete transurethral resection were randomized to receive either 81 mg Connaught strain BCG or 50 mg epirubicin. Patients with recurrences were eligible to crossover, even repeatedly, until progression. Recurrence, progression and survival were analyzed in relation to initial treatment, patient characteristics and tumor characteristics. RESULTS: There were 209 patients included in the study, 149 men and 60 women. The mean age was 69.9 years (range, 24-92). The BCG group consisted of 102 patients and the epirubicin group contained 107 patients. Final analysis was made at a median follow up of 23, 47 and 61 months for recurrence, progression and survival, respectively. The 10-year Kaplan-Meier estimates for recurrence-free, progression-free and disease-specific survival were 61%, 78% and 80%, respectively, for the BCG group. The corresponding figures were 32%, 74% and 92%, respectively, for the epirubicin group. Time to recurrence differed significantly between two treatment groups (P=0.0004). Multiplicity increased the risk of recurrence, while grading influenced recurrence, progression and disease specific survival. CONCLUSIONS: Bacillus Calmette-Guerin prolonged time to recurrence when compared with epirubicin. Grading was shown to be a universal prognostic factor for recurrence, progression and disease specific survival.

Is surveillance necessary for inverted papilloma in the urinary bladder and urethra?

BACKGROUND: A case series of inverted papilloma of the urinary bladder and urethra is presented, together with a review of the literature with respect to multiplicity, recurrence rate and association with transitional cell carcinoma, and a discussion on surveillance of the lesion. METHODS: Cases of inverted papilloma of the lower urinary tract in a single centre were reviewed. Patient and tumour characteristics, recurrence and associated transitional cell carcinoma are reported. RESULTS: Twenty patients were included (18 male, two female). The mean age was 60.8 years (range 35-78 years). All had solitary tumours ranging from 3 mm to 30 mm in size. Median cystoscopic follow up was 30 months (range 2-140 months). There was no recurrence. One patient was associated with subsequent transitional cell carcinoma 44 and 76 months later. Together with the present 20 cases, review of the English literature with respect to inverted papilloma of the lower urinary tract identified a total of 322 cases reported, with a recurrence rate of 3.85%. Moreover, 1.55%, 5.90% and 1.54% were associated with previous, simultaneous and subsequent transitional cell carcinoma, respectively. CONCLUSIONS: Recurrence is not uncommon and risk of subsequent transitional cell carcinoma is not rare, such that non-invasive surveillance with flexible cystoscopy is recommended for inverted papilloma of the lower urinary tract.

A rare cause of acute urinary retention: urethral metastasis from renal cell carcinoma.

Metastatic renal cell carcinoma in the urethra is exceedingly rare, with only three cases of metachronous metastases previously reported. We report a 78-year-old man with acute urinary retention secondary to urethral metastasis presented as the first clinical manifestation. Subsequent investigation confirmed a primary in the right kidney. Radical nephrectomy and total penectomy were performed aiming for cure, though the patient died with brain metastases 22 months after the surgery. The incidence and route of spread of the disease are discussed. The presentation, treatment and outcome of the reported cases are reviewed.

15-year experience on intravesical therapy of T1G3 urinary bladder cancer: a conservative approach.

OBJECTIVE: To report the recurrence, progression and survival in patients with T1G3 transitional cell carcinoma (TCC) of the urinary bladder treated with sequential intravesical bacillus Calmette-Guérin (BCG) and chemotherapeutic agents (doxorubicin or epirubicin) on long-term follow up. METHODS: Between July 1988 and September 1999, all patients in a single center with T1G3 bladder TCC, after complete transurethral resection (TURBT), received either 81 mg of Connaught strain BCG or 50 mg of doxorubicin or epirubicin as adjuvant therapy. A conservative approach was adopted whereby those with superficial recurrences were eligible to crossover, even repeatedly, until progression to muscle invasion. Recurrence, progression and disease-specific survival were analyzed. RESULTS: There were 36 patients included, with 26 males and 10 females. The mean age was 71.6 years (range 53-85 years). Final analysis was made at a median follow-up of 23.5 months (range 0-125 months) for recurrence, 33 months (range 0-125 months) for progression and 45.5 months (range 3-125 months) for survival. Sixteen (44.4%) patients showed recurrence. Nine (25%) of these 16 patients progressed. Five (13.9%) of those who progressed died of TCC. The 10 year Kaplan-Meier estimates for recurrence-free survival, progression-free survival and disease-specific survival were 48, 68 and 81%, respectively. Figures with this conservative approach were comparable to those with more aggressive approaches reported in the literature. CONCLUSIONS: Adjuvant intravesical therapy with either BCG or a chemotherapeutic agent (doxorubicin or epirubicin) and crossover on recurrence was an effective conservative treatment for T1G3 bladder TCC.

Carcinosarcoma of the bladder diverticulum and a review of the literature.

We report a carcinosarcoma within a bladder diverticulum together with a review of 18 previously reported cases of intradiverticular sarcomas and carcinosarcomas with respect to their clinical features, treatments and outcomes. Frequent deaths with intra-abdominal recurrences suggest the need for total cystectomy, rather than diverticulectomy.