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Biomedical subjects

G Lieskovsky

Publications and source records attributed to G Lieskovsky.

At least 19 recordsLinked to original sources
PubMed1992

Salvage surgery plus androgen deprivation for radioresistant prostatic adenocarcinoma.

We report on 34 patients with persistent local radiation resistant prostate cancer who underwent salvage surgical resection and hormonal deprivation. Initially, salvage prostatectomy was done in 11 patients but in 1 disease recurred locally and cystectomy was performed, for a total of 24 patients undergoing cystoprostatectomy. There were no postoperative complications in the prostatectomy group and the average postoperative stay was 7.6 days (range 6 to 12 days). Of 11 patients 4 (36%) are completely continent. There were 2 complications in the cystoprostatectomy group (1 small bowel obstruction and 1 prolonged ileus). The average postoperative stay without complication was 11 days (range 7 to 16 days). Of the 34 patients 24 (71%) are alive without radiographic evidence of disease, including 2 with detectable prostate specific antigen values at a mean of 53 months after surgery (range 25 to 93 months). Of the patients 3 (9%) are alive with radiographically evident recurrent disease (mean 53 months, range 49 to 77 months) and 7 (21%) are dead of disease (mean 52 months, range 20 to 120 months).

Adenocarcinoma↗
PubMed1992

Experience with fossa recurrence of renal cell carcinoma.

We describe the surgical management and followup of 11 patients with local recurrence of renal cell carcinoma in the renal fossa, 10 of whom demonstrated no evidence of distant metastatic disease at the time of recurrence. Average interval to recurrence was 31 months from nephrectomy, with the majority of patients presenting with symptoms of weight loss, fatigue and lumbar discomfort. A total of 13 resections of recurrent carcinoma was performed with 3 immediate postoperative complications, including a retroperitoneal abscess, jejunal necrosis requiring resection and a duodenal obstruction requiring duodenojejunostomy. There were 2 postoperative deaths, 2 patients died of disseminated disease at 8 and 22 months, and 3 died of causes unrelated to cancer recurrence at 4 months, 6 months and 10 years. Four patients were without disease at a followup of 35, 46, 48 and 211 months. We include in this review a report on 1 patient who maintains a disease-free survival of 17 years after resection of a recurrent spindle cell carcinoma. We conclude that an aggressive surgical approach to recurrent renal cell carcinoma within the renal fossa can produce long-term disease-free survival and is justified when compared to the results reported for chemotherapy.

Adult↗
PubMed1991

Study of antireflux nipple valves of Kock ileal urinary reservoir. Experimental investigation in dogs.

To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir with its continent antirefluxing nipple valves, laboratory investigations in dogs were done simultaneously with clinical trials in humans in 1983. Fifteen dogs underwent creation of hemi-Kock ileal reservoirs (without the efferent valve and limb) that were anastomosed to their bladders as enterocystoplasties. The afferent antirefluxing nipple valves were intussuscepted after 7 cm of underlying mesentery had been removed. The nipples were further stabilized with metal and absorbable (Polysorb) staples and Marlex collars. The right ureters were anastomosed to the afferent limb of the reservoirs with the contralateral systems left intact as controls. Ten dogs were able to be followed at the vivaria for twelve to thirty-six months and then studied. All nipple valves remained intact, viable, and nonrefluxing without revision. All kidneys remained histologically normal except those in dogs with dilated ureters secondary to ureteroileal stenosis with concurrent calculi formation. Calculi formed on exposed metal staples and Marlex. The absorbable staples were found to promote appropriate healing and were never the nidus for stone formation. It appears that the intussuscepted nipple valve (with its mesentery removed) is reproducible and functionally reliable in preventing reflux. It also appears these valves can histologically preserve diverted kidneys if the upper urinary tract drainage is normal and calculi are minimized. The proper placement of staples and the elimination of Marlex-anchoring collars are indicated to minimize calculi.

Anastomosis, Surgical↗
PubMed1991

Radiotherapy following radical prostatectomy in patients with adenocarcinoma of the prostate.

From 1973 to 1986, 160 patients with adenocarcinoma localized to the prostate were treated with radical prostatectomy and pelvic lymphadenectomy. In 78 (49%) patients more advanced stage of disease was found at surgery and they received local pelvic irradiation (RT). This consisted of 45 Gy for microscopic and 55 Gy for macroscopic residual disease. RT was given at 1.8 Gy a day, using the four-field "box" technique with the 23 MV X ray beam. Pelvic lymph node metastases were found in 28 (36%) patients who, in addition to RT, received systemic therapy: 20 with cyclophosphamide alone, 4 combined with 5-Fluorouracil, and 4 patients received DES. The 5- and 10-year overall actuarial survival was 95 and 77%, respectively, and the 5- and 10-year disease-free survival was 58 and 43%, respectively. Recurrent tumor was found in 34 (44%) patients. Of these 34 patients, 32 (94%) had distant metastatic tumor and 2 (6%) had local recurrence in the pelvis. The presence of metastatic disease in pelvic lymph nodes had clinical significance since it influenced disease-free survival and the incidence of tumor recurrence. The 10-year disease-free survival for the 50 patients with no lymph node metastases was 51%, as compared to 28% for the 28 patients with such metastases, p = 0.001. Similarly, recurrent tumor was found in 28% of the former and 68% of the latter patients, p = 0.002. Other important parameters predicting recurrence were: clinical stage, p = 0.018, histological grade, p = 0.013, and Gleason's grade, p = 0.002. This treatment program was very well tolerated and of low toxicity. There was no surgical mortality. Surgical complications were seen in 10 (13%) patients including: minor in 5 and major in 5. At 1 year, 77% of the patients remained continent, while 10% had mild stress incontinence. Of the remaining 13% only 3 (4%) patients had severe incontinence (greater than 5 pads daily). RT toxicity was mild with 38% experiencing diarrhea. Severe toxicity was seen in 2 (3%) patients who, early in the study, developed scrotal and lower extremity edema. Severe chemotherapy complications were seen in 1 (4%) patient who had severe neutropenic sepsis. Postoperative radiotherapy is a well tolerated, safe and effective treatment in patients who have microscopic or macroscopic residual tumor following radical prostatectomy.

Adenocarcinoma↗
PubMed1991

Lower urinary tract reconstruction following cystectomy: experience and results in 126 patients using the Kock ileal reservoir with bilateral ureteroileal urethrostomy.

Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patient acceptance with few late complications or need for reoperation.

Adult↗
PubMed1991

The role of adjuvant chemotherapy following cystectomy for invasive bladder cancer: a prospective comparative trial.

We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional cell carcinoma of the bladder (with or without squamous or glandular differentiation) to adjuvant chemotherapy or to observation after radical cystectomy and pelvic lymph node dissection. For most patients chemotherapy was planned as 4 courses at 28-day intervals of 100 mg./M.2 cisplatin, 60 mg./M.2 doxorubicin and 600 mg./M.2 cyclophosphamide. A significant delay was shown in the time to progression (p = 0.0010) with 70% of the patients assigned to chemotherapy free of disease at 3 years compared to 46% in the observation group. Median survival time for patients in the chemotherapy group was 4.3 years compared to 2.4 years in the observation group (p = 0.0062). In addition to treatment groups, important prognostic factors included age, gender and lymph node status. The number of involved lymph nodes was the single most important variable. We recommend adjuvant chemotherapy for patients with invasive transitional cell carcinoma after definitive surgical resection.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1991

Urinary tract stones: a complication of the Kock pouch continent urinary diversion.

Urinary tract stone disease has been found to be a later complication associated with the construction of the Kock pouch continent urinary diversion. Of 383 patients who underwent Kock pouch diversion between August 1982 and December 1986 stones developed in the pouch in 64 (16.7%), usually on exposed staples or eroded Marlex used to construct the nipple valves. Stones have recurred in 13 of the 64 patients (22%). Most stones were removed endoscopically with techniques similar to those used for percutaneous stone removal. Risk factors for stone formation include Marlex collar erosion and acute pyelonephritis. Changes in surgical techniques with elimination of the Marlex collar and a reduction in the number of staples have reduced the incidence of this later complication to 10%.

Female↗
PubMed1991

Primary adenocarcinoma of bladder.

Between April 1983 and December 1987, we have treated and followed 16 patients at the University of Southern California for adenocarcinoma of the bladder. In 10 patients, the cancer originated from a nonurachal source; all underwent radical cystectomy, bilateral pelvic lymph node dissection, and urinary diversion. The other 6 patients had an apparent urachal origin of their cancer. Half of these patients were treated with radical cystectomy and urinary diversion and half were treated initially with segmental cystectomy. Presenting characteristics (age, sex ratio, and symptoms) were similar for both groups. Three-year adjusted acturial tumor-free survival rates for the two groups were 48 percent and 31 percent, respectively. We advocate an aggressive approach of radical cystectomy, bilateral pelvic lymph node dissection, and urinary diversion for all invasive adenocarcinoma of the bladder, regardless of location.

Actuarial Analysis↗
PubMed1991

Regional hyperthermia in patients with recurrent genitourinary cancer.

During a 6-year period, 53 patients with advanced tumors of the genitourinary tract were treated in Phase I protocols with deep regional hyperthermia in combination with irradiation (83%) or in combination with chemotherapy (11%). Primary tumors included those of bladder in 22 patients (41%), prostate in 20 patients (37%), kidney in 9 patients (17%), and ureter testicle or adrenal in 3 patients (5%). The majority (77%) had prior definitive therapy and had experienced treatment failure, and 11% had clinically important distant metastases. Treatment consisted of deep regional hyperthermia (mean of 4 sessions). In addition, 44 patients (83%) received irradiation (mean dose 39.2 Gy). The 1- and 3-year actuarial survival was 60% and 56%, respectively. Patients with carcinoma of the prostate had a 1- and 3-year survival of 82%. Complete response was observed in 7 patients (13%), partial response in 8 (15%), and nominal response in 13 (25%). Complete and partial response correlated well with histology of the tumor (adenocarcinoma), radiation dose (greater than 50 Gy), primary site (prostate, kidney), and treatment (hyperthermia-radiotherapy combination), (p = 0.02). There was no such correlation between response and thermal dose (p = 0.13). The treatment tolerance was good in 79% of patients. Treatment toxicity was limited to acute side effects, including pain during hyperthermia (47%), tachycardia greater than 140/min (7%), and blister formation in the treated area (4%). Phase II studies in previously untreated patients with locally advanced tumors of bladder, prostate, and kidney are needed for evaluation of the role of deep regional hyperthermia in the management of these cancers.

Actuarial Analysis↗
PubMed1991

Kock pouch bladder replacement.

Between May 1986 and February 1990, 126 consecutive male patients have undergone lower urinary-tract reconstruction by means of Kock bladder replacement at our institution. The early and late complication rates have been minimal. Good continence has been achieved in 94% of patients during the day and in 84% at night. Our experience with bladder replacement has yielded extraordinary results in terms of patients acceptance. It is anticipated that our experience as well as the experience of others with this surgery will encourage patients afflicted with high-grade bladder cancer and their physicians toward an earlier decision for aggressive therapy by cystectomy while cure is still possible.

Adult↗
PubMed1990

The role of radical cystectomy in the management of high grade superficial bladder cancer (PA, P1, PIS and P2)

Between January 1979 and 1987, 411 consecutive patients were considered candidates for bilateral pelvic iliac lymph node dissection and radical cystectomy for the management of bladder cancer. From this group 160 were identified as having pathological stage P2 or less disease, including 11 who also had positive nodes. The 5-year actuarial survival rate for the respective stages at 95% confidence limits was 100% for stage P0/A, 80% for stage P1, 78% for stage P1 with stage PIS, 85% for pure stage PIS, 76% for stage P2 and 87% for stage P2 with stage PIS. Additionally, we identified a group of patients with stage P2 transitional cell carcinoma who were at significant risk for development of metastatic disease. Of 46 patients with stage P2 transitional cell carcinoma 18 had vascular space invasion resulting in 6 of 18 cancer-related deaths (33%). Our study demonstrates that radical cystectomy has been highly effective in curing patients with high grade superficial disease, including those with superficially invasive disease associated with nodal metastases.

Carcinoma, Transitional Cell↗
PubMed1989

Prospective study of metabolic abnormalities in patient with continent Kock pouch urinary diversion.

Metabolic alterations as a result of bowel being employed in the urinary tract are well documented. To investigate this phenomenon in the continent ileal reservoir urinary diversion, 106 patients who had undergone Kock pouch surgery were followed in a prospective study at the University of Southern California between 1985 and 1987. Serum chemistries and urine osmolality determinations were performed approximately every three months for a year. Mean patient values for each time period were then compiled and compared with the norms and with the preoperative values. The mean serum electrolyte values were found to be within normal limits during all follow-up periods. Fourteen patients were identified, however, as having values falling intermittently outside of the normal range. These patients were investigated and found to be abnormal during episodes of acute renal failure usually secondary to dehydration or obstruction at which time they usually became acidotic and occasionally hyperchloremic. These problems disappeared when the renal failure was corrected. This study corroborated our previously reported findings that hyperchloremic acidosis or other metabolic alterations requiring replacement therapy do not routinely occur in this population.

Acute Kidney Injury↗
PubMed1989

Results of local and/or systemic adjuvant therapy in the management of pathological stage C or D1 prostate cancer following radical prostatectomy.

Between 1976 and 1984, 47 of 108 patients (44%) who underwent radical retropubic prostatectomy and pelvic lymphadenectomy for clinical stage A2 or B adenocarcinoma of the prostate were found to have pathological stage C or D1 disease. A total of 31 consecutive patients with pathological stage C disease received 45 to 55 Gy. adjuvant external beam radiation postoperatively. Actuarial 5 and 10-year survival rates free of disease were 92%, with a local recurrence rate of 3% and a distant recurrence rate of 6% at a mean followup of 5 years. Sixteen consecutive pathological stage D1 cancer patients received 45 to 60 Gy. adjuvant external beam radiation alone (4), adjuvant cytotoxic chemotherapy alone with cyclophosphamide (5) or combined adjuvant radiation and chemotherapy (7). Actuarial 5 and 10-year survival rates free of disease were 86% with no local recurrences and a distant recurrence rate of 12% at a mean followup of 5 years. These results provide further evidence to support the use of adjuvant external beam radiation therapy in the management of pathological stage C disease. Our preliminary results suggest that an aggressive, multidisciplinary approach is warranted in pathological stage D1 disease and that adjuvant chemotherapy, with or without adjuvant radiation, may have a role in prolonging survival free of disease in this high risk group.

Combined Modality Therapy↗
PubMed1989

Continent urinary diversion.

From August 1982 through March 1988, 531 patients have undergone continent urinary diversion using an ileal reservoir constructed according to the method of Kock. For the last 18 months we have used the principle of Kock reservoir construction for primary lower urinary tract reconstruction after cystectomy in 39 highly selected male patients by means of a ureteroileal urethrostomy. Early complications occurred in 86 of 531 patients (16.2 per cent), resulting in an operative mortality rate of 1.9 per cent (10 of 531). The early complication rate was 16.5 per cent among patients undergoing 1-stage cystectomy and Kock pouch construction, and 15.2 per cent among patients undergoing Kock pouch conversion. Late complications have been analyzed in 489 patients who have undergone Kock cutaneous diversion. The complications unique to continent urinary diversion, their incidence and the effect of technical modifications in reducing the number of late complications are shown. Note that since the last modification in July 1985 the over-all incidence of late complication has decreased to 22 per cent. Based on this ongoing experience we conclude that the continent ileal reservoir, as conceived by Kock, remains the ideal internal reservoir for bladder replacement in terms of volume accommodation with the lowest internal pressures, and the intussuscepted ileal nipple valve mechanism is a reproducible, highly effective mechanism that prevents reflux and pyelonephritis in greater than 95 per cent of the patients and produces excellent continence. Our enthusiasm remains tempered by the need for reoperation in approximately 10 to 15 per cent of the patients, usually due to a pinhole fistula or false passage at the base of the efferent nipple valve mechanism. Electrolyte abnormalities rarely occur and in the absence of radiation gastrointestinal dysfunction is unusual. Continent urinary diversion is a viable concept that provides a real alternative in terms of quality of life and self-image for the patient who requires urinary diversion for any reason.

Adolescent↗
PubMed1989

Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival.

In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.

Actuarial Analysis↗
PubMed1989

[The Kock continent urinary diversion].

The continent ileal reservoir as conceived by Kock produces a low-pressure, high-capacity reservoir with continent and nonrefluxing valves constructed from ileum. From August 1982 through March 1988, 531 patients underwent continent urinary diversion via a Kock reservoir at our institution. Of these, 39 males had a Kock bladder substitution, while the rest underwent cutaneous Kock diversion. Early complications occurred in 16% of all patients, and there was an operative mortality rate of 1.9%. Surgical modifications of nipple fixation, which are discussed in detail in this paper, help to reduce late complications to less than 10%. Patient satisfaction with both procedures remains excellent.

Adolescent↗
PubMed1988

The hemi-Kock augmentation ileocystoplasty: a low pressure anti-refluxing system.

Experiences with various methods of using intestinal segments for bladder augmentation and urinary undiversion, as well as with clinical applications of the Kock continent ileostomy for urinary diversion have led us to develop the hemi-Kock augmentation ileocystoplasty for selected patients requiring a nonrefluxing bladder augmentation. In 6 of 7 patients this bladder augmentation technique fulfilled the requirement for a low pressure nonrefluxing reservoir. Renal function has been preserved and electrolyte problems have not occurred. Nocturnal incontinence has been eliminated. Although 2 of 7 patients required surgical revision patient acceptance has been excellent. Prerequisites to implementing this approach are appropriate patient selection and familiarity with the surgical principles of the continent ileal reservoir.

Adult↗