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.

Urothelial carcinoma in a child.

OBJECTIVES: Urothelial carcinoma of the bladder occurs rarely in the first 2 decades of life. We report a case of a 12 year-old child that presented with a Ta grade II/III urothelial carcinoma of the bladder. METHODS: We describe its clinical presentation and diagnostic procedures as well as treatment and follow-up. Finally, we review the literature to analyze the etiology, treatment, and surveillance of urothelial carcinoma in the pediatric population. RESULTS: Since 1950, there are less than 100 cases of urothelial carcinoma reported in patients less than 30 years, and even less in children and adolescents. Most of the small series describe these tumors as being characteristically superficial and low grade (I-ll). This child presented with silent macroscopic hematuria and an MRI revealed a solid and papillary mass measuring 2.7 cm. A cystoscopy and resection of the tumor confirmed the diagnosis. A re-resection at two months confirmed no residual tumor in the bladder. CONCLUSIONS: There is no established criteria for the etiology, treatment, and surveillance of urothelial carcinoma in the pediatric population. Children with gross hematuria as the presenting complaint should undergo a complete evaluation to rule out the presence of urothelial carcinoma.

Utility of oral dissolution therapy in the management of referred patients with secondarily treated uric acid stones.

OBJECTIVES: Uric acid stones are best managed by chemolysis. Some patients with acutely symptomatic stones opt for endourologic therapies. The radiolucent nature of these stones makes secondary interventions difficult to plan. Computed tomography becomes the modality of choice to identify stone locations and size in these patients. We analyzed patients with uric acid stones referred to our stone center after primary treatment had failed to establish the efficacy of oral alkalinization therapy. METHODS: Eleven patients presented after one or more failed attempts to intervene for uric acid stones. Charts were reviewed for age, sex, time with stone before referral, medical therapies undertaken, number of antecedent urologic interventions, number of radiographic studies performed, subsequent procedures performed, and outcomes with a minimal follow-up of 6 months. RESULTS: Eight patients were men and four presented with bilateral stone disease (overall, 15 involved upper tracts). Sixty-seven percent of patients had right-sided solitary calculi. All patients at presentation filled out urinary pH diaries. Of the 11 patients, 4 stated they had been prescribed oral alkaline therapy but were found to be noncompliant, 4 were never prescribed this therapy, and 3 took the medication sporadically. All patients were counseled on self-dosing to maintain their urinary pH between 6.0 and 6.5 and to continue the diaries. Computed tomography scans were done in 9 patients, and intravenous urography and ultrasonography in the other 2 patients confirmed the stone burden. Only 3 patients (27%) required subsequent interventions (ureteroscopic laser lithotripsy). CONCLUSIONS: Secondarily referred patients with uric acid stones are best treated with medical therapy. These findings suggest that the initial medical regimens had failed because of noncompliance or lack of effective follow-up by the primary urologist. Seventy-three percent of these patients had dissolution of the stones, requiring no further endourologic intervention.

Carcinoma urotelial infantil / Urothelial carcinoma in a child

OBJETIVO: El carcinoma urotelial de vejigaocurre raramente en las primeras 2 décadas de lavida. Presentamos el caso de un niño de 12 años quepresentó un carcinoma urotelial Ta grado II/III.MÉTODOS: Describimos la presentación clínica y elproceso de diagnóstico, asi como el tratamiento yseguimiento. Finalmente, revisamos la literatura paraanalizar la etiología, tratamiento, y seguimiento del carcinomaurotelial en la población pediátrica.RESULTADOS: Desde 1950, existen menos de 100casos de carcinoma urotelial reportados en pacientesmenores de 30 años, y mucho menos en niños y adolecentes.La mayoría de las pequeñas series describenestos tumors como de caracteristicas superficiales y debajo grado (I-II). Este niño presentó una hematuria asintomática y una resonancia magnética descubrió unamasa sólida y papilar que medía 2.7 cm. La cistoscopíay resección del tumor confirmó el diagnóstico. Unasegunda resección 2 meses después confirmó que noexistía tumor residual.CONCLUSIONES: No existen normas establecidasacerca de la etiología, tratamiento, y seguimiento delcarcinoma urotelial en pacientes pediátricos. Niñoscon hematuria macroscópica como síntoma principaldeberían ser sometidos a una evaluación completapara descartar la presencia de un carcinoma urotelial

OBJECTIVES: Urothelial carcinoma of ;;the bladder occurs rarely in the first 2 decades of life. ;;We report a case of a 12 year-old child that presented ;;with a Ta grade II/III urothelial carcinoma of the bladder. ;;METHODS: We describe its clinical presentation and ;;diagnostic procedures as well as treatment and followup. ;;Finally, we review the literature to analyze the etiology, ;;treatment, and surveillance of urothelial carcinoma in ;;the pediatric population. ;;RESULTS: Since 1950, there are less than 100 cases ;;of urothelial carcinoma reported in patients less than 30 ;;years, and even less in children and adolescents. Most ;;of the small series describe these tumors as being ;;characteristically superficial and low grade (I-II). This ;;child presented with silent macroscopic hematuria and ;;an MRI revealed a solid and papillary mass measuring ;;2.7 cm. A cystoscopy and resection of the tumor ;;confirmed the diagnosis. A re-resection at two months ;;confirmed no residual tumor in the bladder. ;;CONCLUSIONS: There is no established criteria for the ;;etiology, treatment, and surveillance of urothelial ;;carcinoma in the pediatric population. Children with ;;gross hematuria as the presenting complaint should ;;undergo a complete evaluation to rule out the presence ;;of urothelial carcinoma