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Biomedical subjects

D G Skinner

Publications and source records attributed to D G Skinner.

At least 91 records · Page 5Linked to original sources
PubMed1995

Orthotopic urinary diversion.

Internal reservoirs constructed from segments of stomach, ileum, the ileocecal region, and the sigmoid colon provide a reliable form of continent diversion.

Carcinoma, Transitional Cell↗
PubMed1995

Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens.

PURPOSE: In an attempt to identify women who may be appropriate candidates for orthotopic lower urinary tract reconstruction, archival cystectomy specimens from female patients undergoing cystectomy for primary bladder cancer were reviewed. These pathological findings should provide a better understanding of tumor involvement at the bladder neck (vesicourethral junction) and urethra in women with transitional cell carcinoma of the bladder. MATERIALS AND METHODS: Cystectomy specimens of 67 consecutive women undergoing surgery for biopsy proved transitional cell carcinoma of the bladder between July 1982 and July 1990 were pathologically reviewed. RESULTS: Histological evidence of tumor (carcinoma in situ or gross carcinoma) involving the urethra was present in 9 patients (13%). Tumor was confined to the proximal and mid urethra, and the distal urethra was not involved. All patients with carcinoma involving the urethra had concomitant evidence of carcinoma involving the bladder neck. A total of 17 patients (25%) had tumor involvement of the bladder neck and those with an uninvolved bladder neck also had an uninvolved urethra. The association between the presence of tumor in the bladder neck and urethra was highly significant (p < or = 0.00012). Tumor involving the bladder neck and urethra tended to be more commonly associated with high grade and stage tumors, and node-positive disease. CONCLUSIONS: Although the fate of the retained urethra following cystectomy for bladder cancer in women is unknown, these results show that women with transitional cell carcinoma of the bladder without evidence of tumor involving the bladder neck are at low risk for urethral malignancy. These patients may be offered lower urinary tract reconstruction that includes preservation of and diversion through the urethra (orthotopic diversion). Urethral surveillance will be necessary, as it is in men after orthotopic urinary diversion.

Carcinoma in Situ↗
PubMed1995

Treatment of renal cell carcinoma in von Hippel-Lindau disease: a multicenter study.

A total of 65 patients with von Hippel-Lindau disease underwent surgery for renal cell carcinoma (54 bilaterally and 11 unilaterally) at 8 medical centers. Only 1 patient presented with metastatic disease. Radical nephrectomy and nephron sparing surgery were performed in 16 and 49 patients, respectively. Mean posttreatment followup was 68 months. The 5 and 10-year cancer-specific survival rates for all patients were 95% and 77%, respectively. The corresponding rates for patients treated with nephron sparing surgery were 100% and 81%, respectively. Of the latter patients 25 (51%) had postoperative local tumor recurrence but only 2 had concomitant metastatic disease. Survival free of local recurrence was 71% at 5 years but only 15% at 10 years. End stage renal failure occurred in 15 patients (23%): 6 underwent renal transplantation (5 are alive with satisfactory renal function and no evidence of malignancy) and 9 were treated with chronic dialysis (6 are free of tumor). Our results indicate that nephron sparing surgery can provide effective initial treatment for patients with renal cell carcinoma and von Hippel-Lindau disease. These patients must be followed closely, since most will eventually have locally recurrent renal cell carcinoma. When removal of all renal tissue is necessary to achieve control of malignancy, renal transplantation can provide satisfactory replacement therapy for end stage renal disease.

Adolescent↗
PubMed1995

Continent and orthotopic urinary diversion following radical cystectomy. Should these reconstructive procedures now be considered standard of care?

Our extensive operative experience with various forms of the continent ileal reservoir in more than 1000 patients over the past 12 years has demonstrated clearly the extreme reliability and durability of this diversion system. Reflux reliably can be prevented and the upper urinary tracts protected. Patients can void or catheterize with confidence. Orthotopic diversions should now be available to most patients, both male and female. Patients should be able to live a more normal life style with a positive self image. We believe that because our modifications of the ileal reservoir systems have decreased the need for reoperation, these forms of continent urinary diversion have emerged as optimal operations and even as the standard of care in cystectomy patients. Ileal conduits should be reserved for poor-risk candidates with short-term life expectancy or for those patients not motivated for continent diversion. The most vocal advocates of the procedures remain those continent diversion patients who have had urinary diversion by another method. Patients still must be aware that complications can occur. Appropriate patient motivation and a thorough understanding of the continent diversion technique and its potential problems continue to be essential prerequisites of the operation. Although minor refinements to these systems will continue to be made, we feel that continent diversion, most often in the form of orthotopic reconstruction, can be offered safely and wisely most to patients.

Cystectomy↗
PubMed1994

Accumulation of nuclear p53 and tumor progression in bladder cancer.

BACKGROUND: We have previously demonstrated a strong association between nuclear accumulation of p53 protein, as determined by immunohistochemical analysis, and mutations in the p53 gene. The purpose of this study was to determine the relation between nuclear accumulation of p53 and tumor progression in transitional-cell carcinoma of the bladder. METHODS: Histologic specimens of transitional-cell carcinoma of the bladder (stages Pa, noninvasive disease, to P4, disease with direct extension into adjacent organs or structures) from 243 patients who were treated by radical cystectomy were examined for the immunohistochemical detection of p53 protein. Nuclear p53 reactivity was then analyzed in relation to time to recurrence and overall survival. RESULTS: The detection of nuclear p53 was significantly associated with an increased risk of recurrence of bladder cancer (P < 0.001) and with decreased overall survival (P < 0.001). In patients with cancer confined to the bladder, the rates of recurrence for stage P1, P2, and P3a tumors that had no detectable nuclear p53 reactivity at five years were 7, 12, and 11 percent, respectively, as compared with 62, 56, and 80 percent, respectively, for tumors that had p53 immunoreactivity. Similar results were obtained when the presence or absence of p53 in the nuclei of the tumor cells was studied in relation to overall survival. In a multivariable analysis stratified according to grade, pathological stage, and lymph-node status, nuclear p53 status was an independent predictor (and in cancer confined to the bladder, the only independent predictor) of recurrence and overall survival (P < 0.001). CONCLUSIONS: In patients with transitional-cell carcinoma confined to the bladder, an accumulation of p53 in the tumor-cell nuclei detected by immunohistochemical methods predicts a significantly increased risk of recurrence and death, independently of tumor grade, stage, and lymph-node status. Patients with transitional-cell carcinoma confirmed to the bladder that demonstrates nuclear p53 reactivity should be considered for protocols of adjuvant treatment.

Aged↗
PubMed1994

Recurrent lymphoma resulting in Kock pouch incontinence.

Incontinence following the Kock pouch continent cutaneous urinary diversion currently occurs in < 20 percent of patients undergoing the operation. Various causes of cutaneous incontinence have been identified, including efferent nipple prolapse, incompetent valve, pinhole fistula, parastomal herniation, and Marlex mesh erosion into the efferent nipple mechanism. We report the first case of a patient with recurrent lymphoma involving the small bowel utilized for the efferent continence nipple valve mechanism resulting in incontinence.

Carcinoma, Transitional Cell↗
PubMed1994

Undiversion in men following prior cystoprostatectomy and cutaneous diversion. Is it practical?

This report discusses the feasibility and functional outcome of conversion to an orthotopic Kock neobladder in 11 men (average age 58 years) who underwent cystoprostatectomy and cutaneous urinary diversion an average of 7.3 years previously are discussed. Cystectomy had been performed for bladder cancer in 9 men and for multiple failed bladder reconstructions in 2. No patient had any evidence of recurrent cancer. The reasons for conversion to a Kock neobladder included complications with the current form of diversion (stomal stenosis, leakage and so forth) and dislike of a cutaneous stoma. Average followup since neobladder conversion was 36 months. The exactness of the anastomosis to the urethra and the presence of a retained apex of the prostate were major factors in the technical success of the operation, degree of continence and satisfaction of the patients. All 4 patients who had some portion of retained prostate enjoy excellent continence without anastomotic stricture. In 2 of the early undiversion patients with direct membranous urethral anastomoses anastomotic strictures occurred and they subsequently chose to resume continent cutaneous diversion. The other 5 patients with anastomoses to the membranous urethral stump did well but 2 required an artificial urinary sphincter for continence. These latter 5 patients had more extensive pelvic mobilization of the urethra for more exact anastomoses. The satisfaction level of all 9 continuing neobladder patients, even if an artificial urinary sphincter was necessary, has been exceptional.

Adult↗
PubMed1994

Stenosis of the afferent antireflux valve in the Kock pouch continent urinary diversion: diagnosis and management.

Between August 1982 and May 1988, 503 patients underwent construction of a continent ileal reservoir (Kock pouch) for cutaneous urinary diversion at our university. Stenosis of the afferent antireflux valve resulted in upper urinary tract obstruction in 11 patients (2%). In addition, 2 patients underwent Kock pouch diversion elsewhere and upon referral to our institution they had afferent valve stenosis. To date 13 patients have been identified with this problem. Hydronephrosis was present in 100% of the functional kidneys in these patients. Radiographs of the Kock pouch were uniformly normal without evidence of reflux or other pathological condition. The most common presenting symptom was flank pain in 7 patients (54%) and the most common presenting sign was creatinine elevation above baseline in 7 (54%). Infections recurred with or without sepsis in 5 patients (38%). Ureteroileal anastomotic strictures were not present in any patient. The interval from creation of the Kock pouch to the diagnosis of stenosis ranged from 2 to 75 months (mean 39). All patients underwent endoscopic evaluation of the Kock pouch confirming stenosis of the afferent antireflux valve, and subsequent mechanical dilation of the stenotic valve. Dilation procedures were repeated in 6 patients (46%), 4 of whom subsequently required open surgical revision of the afferent valve. Of these patients 3 are clinically stable and 1 died of the primary malignancy. The remaining 2 patients are clinically and radiographically stable after multiple dilations. Of the 7 patients (54%) requiring only a single dilation 6 are clinically stable and 1 died of the primary malignancy. Stenosis of the afferent antireflux valve of the Kock pouch, previously unreported to our knowledge, is a rare late complication leading to flank pain, hydronephrosis, recurrent infection and elevation of serum creatinine levels. Approximately 50% of the patients respond to a single dilation of the nipple valve. However, most patients who require repeat dilation will need open surgical revision.

Adult↗
PubMed1994

Papillary adenocarcinoma of the rete testis: a case report and review of the literature.

Adenocarcinoma of the rete testis is a rare neoplasm with 40 reported cases in the world literature to our knowledge. Although the natural history of this tumor is not well known, it appears highly malignant even in localized forms. Adenocarcinoma of the rete testis is highly resistant to adjuvant radiotherapy and any known chemotherapeutic regimen. We recommend radical orchiectomy followed by a retroperitoneal lymphadenectomy as the treatment for clinically localized Stage A tumors and minimal or microscopic Stage B disease. We report a case of adenocarcinoma of the rete testis and review the world literature.

Adenocarcinoma, Papillary↗
PubMed1994

Metastatic malignant melanoma: an unusual case presentation.

Secondary involvement of the genitourinary tract with malignant melanoma is a common autopsy finding, but rarely evident clinically. We report a rare case involving a previously asymptomatic patient presenting with gross hematuria and a large renal mass, which was found to be metastatic melanoma. We propose that metastatic melanoma to the kidney, although rare, be considered in the differential diagnosis of disease processes causing hematuria.

Adult↗
PubMed1994

Adjuvant radiation, chemotherapy, and androgen deprivation therapy for pathologic stage D1 adenocarcinoma of the prostate.

OBJECTIVES: A retrospective analysis of the results of an aggressive multimodal approach combining radical prostatectomy with adjuvant radiation, chemotherapy, or androgen deprivation therapy for patients with pathologic Stage D1 prostate carcinoma was performed to assess the impact of these therapies on survival, recurrence, local control, and morbidity. METHODS: Case records of 76 patients with pathologic Stage D1 tumors were reviewed. All had radical retropubic prostatectomy and were recommended adjuvant therapy based on the pathologic extent of the primary tumor and the number of involved lymph nodes. RESULTS: With a median follow-up of 7 years, overall survival was estimated to be 88% and 66% at 5 and 10 years, respectively, and equaled age- and race-matched controls. Prostate cancer-specific survival at 5 and 10 years was 88% and 74%, respectively. The probability of developing a clinically detectable recurrence (excluding prostate-specific antigen [PSA]) was 29% and 62% at 5 and 10 years, respectively. When PSA was added to the detection data, the probability of developing a recurrence increased to 58% and 78% at 5 and 10 years, respectively. Recurrence and cause-specific survival correlated with Gleason sum. Univariate analysis of the adjuvant therapies demonstrated no effect on survival, but adjuvant radiation alone and in combination with androgen deprivation increased the time to recurrence. Local control was excellent, surgical morbidity was equivalent to that of all patients undergoing prostatectomy during the same time period, and the morbidity of adjuvant therapy was minimal. CONCLUSIONS: Survival equivalent to age- and race-matched controls, with excellent control of the extensive primary tumor, can be achieved in patients with Stage D1 prostate carcinoma by a combination of radical prostatectomy and radiation therapy without the need for routine androgen deprivation therapy.

Acid Phosphatase↗
PubMed1994

Surgical resection in patients with nonseminomatous germ cell tumor who fail to normalize serum tumor markers after chemotherapy.

OBJECTIVE: Patients with high-stage nonseminomatous germ cell tumors treated with platinum-based chemotherapy who have residual radiographic evidence of disease and fail to normalize tumor markers present a difficult clinical dilemma. Some authors feel that these patients are not appropriate surgical candidates. Our practice has been to offer certain patients salvage surgery in an attempt for cure. This report is designed to review that experience and critically analyze the results. METHOD: We report a series of 16 such patients with advanced-stage nonseminomatous germ cell tumors who had persistently elevated alpha fetoprotein and/or human chorionic gonadotropin. All underwent resection of all radiographically evident sites of residual disease following induction or salvage chemotherapy. RESULTS: Ten patients had only retroperitoneal (RP) metastasis. Six patients had more than one site of residual disease--4 RP and lung, 2 RP and liver. There were no postoperative deaths. The mean postoperative stay was eleven days (range 7 to 36 days). Six patients (37%) are alive and free of disease at a mean of seventy-four months following surgery (range 20 to 145 months). Five had RP disease only. Ten patients died of disease at a mean of eight months postoperatively (range 5 to 21 months). CONCLUSIONS: Patients with advanced nonseminomatous germ cell tumor who fail to normalize their serum tumor markers after adequate platinum-based chemotherapy should be considered for surgical resection of all radiographically evident residual disease. In select cases this practice offers the only viable chance for cure.

Biomarkers, Tumor↗
PubMed1994

Results of radical prostatectomy and adjuvant therapy in the management of locally advanced, clinical stage TC, prostate cancer.

Fifty-seven patients with locally advanced, clinical stage TC, adenocarcinoma of the prostate underwent treatment consisting of surgery, external beam radiation therapy and, in selected patients, early hormonal ablation and/or systemic chemotherapy. Surgical morbidity from radical retropubic prostatectomy and limited pelvic lymph node dissection was acceptable with an early complication rate of 11%. Followup ranged from 3.5 to 19.9 years (median 5.4 years). Actuarial 5 and 7.5 years survival rates for all patients was 91.2% and 77.6%, respectively. Of the 57 study patients 19 (33%) were alive with no evidence of disease, including a prostate specific antigen (PSA) less than 0.4 ng/ml at all times during follow-up. The estimated 5 year probability of clinical recurrence was 18.6% and the 5 year probability of clinical and PSA recurrence (> 0.4 ng/ml) was 54.5%. Local recurrence occurred in only 3 patients. This included 2 (4%) patients who received adjuvant radiotherapy. Our results suggest that patients with locally advanced prostate cancer can be successfully treated with low morbidity using a combination of radical prostatectomy and planned adjuvant radiotherapy.

Adenocarcinoma↗
PubMed1994

Management of the patient with bladder cancer. Urethral recurrence.

Urethral recurrence develops in roughly 10% of patients following cystectomy for bladder cancer and appears to be another manifestation of the multicentric nature of TCC. By far the greatest risk factor for recurrence is tumor involvement of the prostate in the radical cystectomy specimen, with prostatic stromal invasion more ominous than either ductal or mucosal involvement. For patients in whom orthotopic diversion is contemplated, precystectomy screening of the prostate is recommended by means of deep transurethral biopsy. Surveillance of the urethra following cystectomy should be done by urethral wash cytology at 6-month to yearly intervals and must be continued for life. Management of documented urethral recurrence should be by total urethrectomy, including the meatus.

Carcinoma, Transitional Cell↗