Is Tumor Budding a New Predictor for Early Cystectomy in pT1 High-Grade Bladder Cancer?

Background & Objectives: We aimed to evaluate the risk of progression in high-grade T1 (HGT1) tumors using tumor budding (TB) and other standard clinical and histological features. TB is defined as an isolated cancer cell or a cluster composed of fewer than 5 cells scattered in the stroma and is usually used as a strong predictor of lymph node metastasis in T1 colorectal cancer. METHODS: This is an observational longitudinal cohort study involving 168 consecutive patients with HGT1 between 2013 and 2016. Cox regression was performed to analyze the relationship between the clinical and histological features and progression. All slides were blindly assessed by 2 genitourinary pathologists. Budding was determined to be positive when the number of buds was equal to or greater than 6. RESULTS: The median age was 75 years; 152 (90.5%) patients were men, and 49 (29.2%) were positive for TB. At a median follow-up time of 35 months, 33 patients (19.6%) showed progression. Progression was observed in 32.7% of the patients positive for TB and in only 14.3% of those who were negative (p = 0.006). TB was significantly associated with the endoscopic tumor pattern (TP) (papillary/solid) and lymphovascular invasion (LVI). Univariate analysis showed that TB, carcinoma in situ (CIS), TP, LVI, sub-staging, and BCG induction predict progression. The multivariate analysis showed that TB (p = 0.032, hazard ratio 2.1), CIS, TP, and lack of BCG induction were significant for progression. CONCLUSIONS: TB is a new and significant pathological variable for predicting progression in HGT1 tumors and can be easily introduced in clinical practice. Its inclusion in the TNM system should be carefully considered, as it may aid early cystectomy decisions.

[Closure of a neobladder-vaginal fistula in a patient with Studer's type neobladder using a transvaginal approach with interposition of a Martius' flap]. / Cierre de fístula neovésico-vaginal en paciente con neovejiga tipo Studer mediante abordaje transvaginal con interposición de colgajo de Martius.

OBJECTIVE: We report a case of neobladder-vaginal fistula in a patient, and its closure using a Martius flap interposition. METHODS: A 51-year-old patient required cystectomy and Studer's neobladder for invasive bladder adenocarcinoma. After urethral catheter removal she presented constant leakage and was diagnosed by cystoscopy of neobladder-vaginal fistula. RESULTS: This complication was successfully treated using a vaginal approach with closure in two layers and interposition of a Martius flap. CONCLUSIONS: Neobladder is a rare indication in women, as it is the eventuality of presenting this type of fistula. The adequate approach to treat it is still controversial. In our experience and after reviewing literature we think vaginal closure using a Martius flap interposition is a good technique to treat a neobladder-vaginal fistula.

Cierre de fístula neovésical-vaginal en paciente con neovejiga tipo Studer mediante abordaje transvaginal con interposición de colgajo de Martius / Closure of a neobladder-vaginal fistula in a patient with Studer’s type neobladder using a transvaginal approach with interposition of a Martius’ flap

OBJETIVO: Presentamos el caso de una fístula neovésico-vaginal en una paciente, así como su cierre mediante interposición de colgajo de Martius. Se realiza una revisión bibliográfica de este tipo de complicaciones.MÉTODOS: Paciente de 51 años que requirió de una cistectomía y neovejiga tipo Studer por adenocarcinoma vesical infiltrante. Tras la retirada de la sonda uretral presentó incontinencia urinaria y fue diagnosticada mediante cistoscopia de una fístula neovésico-vaginal RESULTADOS: Dicha complicación se resolvió de forma exitosa por abordaje vaginal mediante el cierre en dos planos y la interposición de un colgajo de Martius.CONCLUSIONES: La creación de una neovejiga es una indicación poco frecuente en mujeres, como también lo es la eventualidad de presentar este tipo de fístulas, y la mejor vía de abordaje para tratarlas es aún tema de discusión. En nuestra experiencia y tras revisar la literatura pensamos que el cierre vaginal con interposición de colgajo de Martius es una buena técnica para tratar la fístula neovésico-vaginal(AU)

OBJECTIVE: We report a case of neobladder-vaginal fistula in a patient, and its closure using a Martius flap interposition.METHODS: A 51 year old patient required cystectomy and Studer’s neobladder for invasive bladder adenocarcinoma. After urethral catheter removal she presented constant leakage and was diagnosed by cystoscopy of neobladder-vaginal fistula.RESULTS: This complication was successfully treated using a vaginal approach with closure in two layers and interposition of a Martius flap .CONCLUSIONS: Neobladder is a rare indication in women, as it is the eventuality of presenting this type of fistula. The adequate approach to treat it is still controversial. In our experience and after reviewing literature we think vaginal closure using a Martius flap interposition is a good technique to treat a neobladder-vaginal fistula(AU)

[Laparoscopic radical cystectomy in clinically localized (T2) bladder tumors]. / Cistectomía radical laparoscópica en los tumores vesicales clínicamente localizados (T2).

OBJECTIVES: Laparoscopic radical cystectomy has been developed after the expansion of laparoscopic radical prostatectomy. This technique makes possible a minimally invasive approach to muscle-invasive bladder cancer with less blood loss and faster postoperative recovery. METHODS: From September 2004 to January 2007, 54 laparoscopic radical cystectomies were performed, 48 of them in stage T2, from which 43 (90%) were male and 5 (10%) female patients. Mean age was 64 years (27-881. Lymphadenectomy was carried out by laparoscopic approach in all cases, with a mean of 13 nodes obtained (4-24). Urinary diversion was done through the incision needed to extract the specimen in all cases but one that was completed completely intracorporeally; constructing a Bricker-type ureteroileostomy in 30 (62%) cases, orthotopic neobladder (Vesica Ileale Padovana) in 17 cases (35%), and cutaneous ureterostomy in 1 case (2%). RESULTS: Mean surgical time for the whole procedure was 287 minutes (180-480), 270 minutes for Bricker-type derivation cases and 316 minutes for neobladder cases. Blood transfusion rate was 25%. Mean ileal paralysis was 5 days (2-10) with a mean hospital stay of 13 days (6-34) for Bricker cases and 16 days (8-30) for neobladder cases. Oncological control, after a mean follow-up of 10,8 months (0,4-30), showed a cancer-specific survival of 90% with a mean survival time of 28 months (95% CI 26-30). Global mean survival was 79% with a mean survival of 26 months (95% CI 23-29). CONCLUSIONS: Laparoscopic radical cystectomy is a feasible technique that offers some advantages. It allows excision with less blood loss and an easier postoperative period. Randomized studies should demonstrate these advantages to confirm this approach as the technique of choice. Urinary diversion performed through the laparotomy incision, necessary to extract the specimen, optimizes derivation results and whole surgical time without reducing the beneficial effects of the laparoscopic exeresis.