The role of squamous differentiation in patients with transitional cell carcinoma of the bladder treated with radical cystectomy

OBJECTIVE: We aim at determining the prognostic value of squamous differentiation in patients with transitional cell carcinoma (TCC) of the bladder that were treated with radical cystectomy. MATERIALS AND METHODS: From January 1993 to January 2005, we retrospectively selected 113 patients. Correlations among squamous differentiation with other clinical and pathological features were assessed by both chi-square and Fisher tests. The Kaplan-Meier method was used to evaluate survival curves and statistical significance was determined by the log-rank test. Multivariate analysis was performed through a Cox proportional hazards regression model. RESULTS: Squamous differentiation was observed in 25 (22.1 percent) of the 113 patients. This finding was significantly related only to the pathological stage. Mean follow-up after cystectomy was 31.7 ± 28.5 months. Disease recurrence occurred in 16 (64 percent) and 30 (34 percent) patients with and without squamous differentiation (log-rank test, p = 0.001), and mortality occurred in 10 (40 percent) and 14 (16 percent) of the patients with and without squamous differentiation respectively. Univariate analysis revealed that pathological stage, squamous differentiation, tumor size and lymph node involvement were significant predictors of cancer-specific survival. However, only squamous differentiation and tumor size were independent prognostic variables on multivariate analysis. CONCLUSIONS: Squamous differentiation was an independent prognostic factor for cancer specific survival in patients with bladder cancer treated with radical cystectomy. Further studies with a larger number of patients are necessary to confirm these results.

Perineural invasion by transitional cell carcinoma of the bladder in patients submitted to radical cystectomy: what is the prognostic value?

OBJECTIVE: Determine the prognostic value of perineural invasion (PNI) in patients with transitional cell carcinoma (TCC) of the bladder treated with radical cystectomy. MATERIALS AND METHODS: From January 1993 to January 2005, 113 people were selected from 153 patients with TCC of the bladder treated with radical cystectomy. The association between the presence of PNI and other pathologic characteristics were analyzed through Fisher exact test. The Kaplan-Meier method was utilized to assess the survival curve and the statistical significance was determined by the Breslow test. The multivariate analysis was performed through the Cox regression model. RESULTS: The PNI was identified in 10 (8.8 percent) of the 113 patients. This variable significantly related to the microvascular invasion and to tumor staging. The mean segment after surgery was 31.7 ± 28.5 months. Recurrence occurred in 5 (50 percent) and in 41 (39.8 percent) patients (p = 0.363) and mortality occurred in 2 (20 percent) and 22 (21.9 percent) patients (p = 0.606) with or without PNI respectively. In Cox regression analysis, patients with PNI presented with 1.53 times (IC 95 percent 0.60 to 3.91; p = 0.371) and 1.60 times (IC 95 percent 0.37 to 6.95; p = 0.532) the risk of recurrence and mortality when compared to patients without PNI. CONCLUSIONS: The PNI does not constitute an independent variable of disease-free and cancer specific survival in patients with TCC of the bladder treated with radical cystectomy.

The York-Mason technique for recto-urethral fistulas

OBJECTIVE: Recto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. There is no consensus in the literature regarding the treatment of these fistulas. We present here our experiences treating recto-urethral fistulas. MATERIAL AND METHODS: We analyzed 8 cases of rectourethral fistula treated at our institution in the last seven years. Seven of the patients underwent repair of the fistula using the modified York-Mason procedure. RESULTS: The causes of the fistula were radical retropubic prostatectomy in five patients, perineal debridement of Fournier's gangrene in one, transvesical prostatectomy in one and transurethral resection of the prostate in the other patient. The most common clinical manifestation was fecaluria, present in 87.5 percent of the cases. The mean time elapsed between diagnosis and correction of the fistula was 29.6 (7-63) months. One spontaneous closure occurred after five months of delayed catheterization. Urinary and retrograde urethrocystography indicated the site of the fistula in 71.4 percent of the cases. No patient presented recurrence of the fistula after its correction with the modified York-Mason procedure. CONCLUSION: The performance of routine colostomy and cystostomy is unnecessary. The technique described by York-Mason permits easy access, reduces surgical and hospitalization times and presents low complication and morbidity rates when surgically correcting recto-urethral fistulas.

OBJETIVO: As fístulas reto-uretrais são de acesso difícil e por vezes complexo, sendo seu fechamento espontâneo raro. Com o diagnóstico precoce e aumento do número de intervenções, principalmente a cirurgia por adenocarcinoma da próstata localizado, sua incidência apesar de rara vem crescendo. Nós demonstramos a nossa experiência dos casos de fístulas reto-uretrais entre 2000 a 2006 com uma serie de oito pacientes, sendo que sete realizaram correção da fístula pela Técnica de York Mason modificada. MATERIAL E MÉTODO: Nos retrospectivamente analisamos os prontuários de todos os casos de fístulas reto-uretrais tratados no nosso serviço no período de 2000 a 2006. Sete de oito pacientes realizaram reparo da fístula através do procedimento de York Mason modificado. RESULTADOS: Cinco pacientes tiveram a fístula como conseqüência da Prostatectomia Radical Retropúbica, sendo os outros três após debridamento devido a Fasceíte de Fournier, Prostatectomia Transvesical e Ressecção Transuretral da Próstata. A fecalúria foi o quadro clínico prevalente em 87,5 por cento dos casos, o tempo médio entre o diagnóstico e a correção da fístula foi de 29,6 (7-63 meses) ocorreu um fechamento espontâneo após cinco meses de sondagem vesical de demora, a Uretrocistografia Retrograda e Miccional demonstrou a localização da fístula em 71,4 por cento. Nenhum paciente apresentou recidiva da fístula após correção pela técnica de York Mason modificada. A colostomia foi realizada em 50 por cento dos casos e não ocorreram casos de incontinência fecal ou estenose anal. CONCLUÇÃO: Após identificação de fístula reto-uretral, não é necessário à realização de colostomia e cistostomia de rotina. Sua correção pela técnica descrita por York Mason modificada nos propicia fácil acesso a sua localização, diminui o tempo cirúrgico e de internação, com baixos índices de complicações e morbidade.

Analysis of prognostic factors in patients with transitional cell carcinoma of the bladder treated with radical cystectomy

OBJECTIVE: To analyze the results of the treatment of transitional cell carcinoma (TCC) of the bladder with radical cystectomy and determine which prognostic factors can be utilized as disease-free survival and cancer-specific survival independent variables. MATERIALS AND METHODS: Medical records of 113 patients submitted to radical cystectomy and bilateral iliac lymphadenectomy between 1993 and 2005 were reviewed. The risk factors analyzed were age, sex, pathological stage, tumor grade, presence of carcinoma in situ and the presence of lymph nodes involvement. RESULTS: After a mean follow-up of 31.7 ± 28.5 months, 46 patients (40.7 percent) presented recurrence and 24 patients (21.2 percent) died due to cancer. Only pathological stage and the lymph nodes involvement became independent variables for recurrence and survival. Patients with T4 stage presented 9.6 times the risk of recurrence of the disease when compared with stage T0 patients (p = 0.010) and the patients with lymph node involvement presented 2.5 times the risk of recurrence (p = 0.047) and 3.1 times the risk of death (p = 0.022) when compared to patients without lymph nodes involvement. CONCLUSIONS: Pathological stage and the involvement of lymph nodes represented more important prognostic variables, and in the presence of advanced stage tumors (T3/T4) and involvement of lymph nodes, the institution of adjuvant treatment should be considered.

Survival of patients with prostate cancer and normal PSA levels treated by radical prostatectomy

INTRODUCTION: The unpredictability of prostate cancer has become a daily challenge for the urologist, with different strategies being required to manage these cases. In this study, we report on the perspectives for curing prostate cancer in males undergoing radical prostatectomy with Gleason score of 2-6 on prostate biopsy in relation to pre-operative PSA levels. MATERIALS AND METHODS: From 1991 - 2000, we selected 440 individuals whose pathological diagnosis revealed a Gleason score of 2-6 upon prostate biopsy and who subsequently underwent retro-pubic radical prostatectomy due to localized prostate cancer. The clinical stage identified in the group under study was T1c: 206 (46.8 percent); T2a: 122 (27.7 percent); T2b: 93 (21.1 percent); T2c: 17 (3.9 percent); T3a: 2 (0.5 percent). Following surgery, we constructed a biochemical recurrence-free survival curve according to pre-operative PSA levels between 0-4; 4.1-10; 10.1-20 and > 20 ng/mL, with a median follow-up of 5 years. RESULTS: Following radical prostatectomy, the pathological stage was confirmed as pT2a: 137 (31.1 percent); T2b: 118 (26.8 percent); T2c: 85 (19.3 percent); T3a: 67 (15.2 percent); T3b: 6 (1.4 percent); T3c: 22 (5 percent). The biochemical recurrence-free survival, according to PSA values between 0-4; 4.1-10; 10.1-20 and > 20 ng/mL, was 86.6 percent, 62.7 percent, 39.8 percent and 24.8 percent respectively. CONCLUSION: Better chances for curing low-grade prostate cancer occur in individuals with normal PSA for whom a biopsy is not usually recommended.

Analysis of risk factors of involvement of seminal vesicles in patients with prostate cancer undergoing radical prostatectomy

OBJECTIVE: To determine through preoperative serum PSA level, Gleason score on biopsy and percentage of fragments affected by tumor on biopsy, the probability of involvement of the seminal vesicles. MATERIALS AND METHODS: During the period between March 1991 to December 2002, we selected 899 patients undergoing radical prostatectomy for treatment of localized prostate adenocarcinoma. The analyzed preoperative variables were PSA, percentage of positive fragments and Gleason score on the biopsy. Pre-operative PSA was divided in scales from 0 to 4.0 ng/mL, 4.1 to 10 ng/mL, 10.1 to 20 ng/mL and > 20 ng/mL, Gleason score was categorized in scales from 2 to 6. 7 and 8 to 10, and the percentage of affected fragments was divided in 0 to 25 percent, 25.1 percent to 50 percent, 50.1 percent to 75 percent, and 75.1 percent to 100 percent. All these variables were correlated with the involvement of seminal vesicles in the surgical specimen. RESULTS: Of the 899 patients under study, approximately 11 percent (95 percent CI, [9 percent - 13 percent]) had involvement of seminal vesicles. On the multivariate analysis, when PSA was < 4, the Gleason score was 2 to 6, and less than 25 percent of fragments were involved on the biopsy, only 3.6 percent, 7.6 percent and 6.2 percent of patients respectively, had involvement of seminal vesicles. On the multivariate analysis, we observed that PSA, Gleason score and the percentage of involved fragments were independent prognostic factors for invasion of seminal vesicles. CONCLUSION: The preoperative variables used in the present study allow the identification of men with minimal risk (lower than 5 percent) if involvement of seminal vesicles.