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The obturator reflex is a frequent complication of the transurethral resection of bladder tumors, specially those localized at the side of bladder. The transurethral operation often must be interrupted, or changed into a transabdominal one, because of danger of bladder perforation or severe bleeding. In addition to spinal analgesia two techniques of obturator block are presented and their use is discussed.
The patient was a 71-year-old woman. Two years ago right nephrectomy was performed by a general surgeon at the diagnosis of right renal cell carcinoma. However, the pathological report was transitional cell carcinoma (TCC) of the right renal pelvis, Grade II. She developed chronic renal failure and received hemodialysis once a week. The recurrence of bladder tumor was recognized and she was transferred to our hospital. Transurethral resection of bladder tumor (TUR-Bt) and right ureterectomy with a bladder cuff were performed. Also intravesical instillation of pirarubicin was done after the operation. No side effects or elevation of serum pirarubicin level were observed.
BACKGROUND: The objective of this study was to retrospectively investigate the effectiveness of transurethral resection of bladder tumor (TURBT) and intravesical instillation therapy for stage T1, grade 3 (T1G3) transitional cell carcinoma (TCC) of the urinary bladder. METHODS: Between January 1995 and December 1997, 97 patients with T1G3 TCC of the urinary bladder were treated by TURBT and adjuvant intravesical instillation with bacillus Calmette-Guérin (BCG) or other anticancer agents. The recurrence-free survival rates were evaluated according to several clinicopathological factors. The cases that progressed to muscle invasive disease were also analysed. RESULTS: In this series, the median follow-up period was 25 months (range, 5- 41) after the initial TURBT. Intravesical recurrence was noted in 44 patients (45%), and the 1, 2, and 3 year recurrence-free survival rates were 72%, 58%, and 42%, respectively. Multivariate analyses revealed that the risk of intravesical recurrence was significantly higher for patients who did not receive BCG therapy, irrespective of age, gender, tumor size, multiplicity, pathological stage, concomitant carcinoma in situ, and lymphovascular involvement. Moreover, after a median of 10 months, disease progression occurred in seven patients (7%), of which only one patient was treated by BCG therapy after initial TURBT. CONCLUSION: These findings suggest that intravesical instillation with BCG combined with TURBT is an effective conservative treatment for T1G3 TCC of the bladder. Patients with negative prognostic factors should be treated by BCG rather than other anticancer agents after TURBT.
We report 2 patients who absorbed large amounts of irrigating fluid during transurethral resection of bladder tumours (TURB). Ethanol indication facilitated diagnosis of this complication and showed that absorption had occurred by the extravascular route. Symptoms occurred in one case but they resolved when hypertonic saline and furosemide were given.
Intravesical instillation of Tokyo 172 strain bacillus Calmette-Guerin (BCG) after transurethral resection of bladder tumor (TUR-Bt) was applied to 35 patients with superficial bladder cancer. The patients received 80 mg of BCG in 40 ml saline infused into the bladder once a week for 6 weeks. Actuarial non-recurrence rates for all 35 patients were 81.7% and 58.4% at one and two years after the BCG therapy, respectively. The recurrence of the bladder cancer after the BCG therapy was observed in 12 patients 3-27 months later. Seven patients received an additional course of BCG instillation, and 6 (86%) showed no further recurrence. Thus, the overall success rate of 2 cycles of BCG instillation was 83% (29 of 35 patients). Moreover, in some cases intravesical BCG instillation was effective for recurrent superficial bladder cancer after intravesical instillation of anti-cancer agents and prolonged the period until recurrence. The progression rate was only 5% (2 of 35 patients). These results suggest that intravesical BCG therapy for superficial bladder cancer helps prevent disease progression.
We investigated the safety, technique, and effectiveness of holmium laser resection of bladder tumors (HoLRBT). Data are presented on 23 patients who were treated with the HoLRBT technique. Holmium:YAG laser has a wavelength of 2,140 nm, which is delivered in a pulsed fashion via an end-firing quartz fiber placed through a modified resectoscope. Twenty-three patients with newly diagnosed transitional cell carcinoma underwent HoLRBT. Cold cup biopsies of the bladder tumor base were taken and compared to the HoLRBT specimens. Twenty-two of 23 patients were discharged catheter-free within 24 hours. One patient required a catheter for 3 days. The mean total energy used was 13.14 kJ with a maximum of 34.31 kJ. Mean resection time was 18.6 minutes. Cold cup biopsy of the tumor base did not alter the stage of the bladder tumor. The HoLRBT technique can be used to safely and effectively treat bladder tumors. This laser technique did not alter the stage or the diagnosis of bladder tumors. Holmium resection of bladder tumors usually can be performed as an outpatient catheter-free procedure and is a viable alternative to the standard electrocautery transurethral resection of bladder tumors.
A total of 84 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to three treatment groups: I. Control group-transurethral resection (TUR-BT) discontinued within the study. II. Oral BCG group-TUR-BT plus BCG (Moreau). III. Intravesical BCG group-TUR-BT plus BCG. Of 9 patients in the control group, 8 (89%) experienced tumor recurrence during a mean follow-up of 20 months. Of the 33 patients in the oral BCG group, 13 patients (39.3%) had recurrence during a mean follow-up of 39 months. Of the 42 patients in the intravesical group, 8 patients (19%) had recurrence in a 30-month mean follow-up. The incidence of complications was higher in the intravesical (33.4%) than in the oral BCG group (24.2%). These results showed that intravesical BCG is a more effective immunotherapy; however, oral BCG can be utilized in patients who do not accept intravesical BCG administration.
PURPOSE: We assess the results of bladder preservation for infiltrating bladder cancer. The potential for neoadjuvant chemotherapy followed by extensive transurethral resection and radiotherapy was evaluated in 40 patients with T2-T4a G2-G3 bladder carcinoma. MATERIALS AND METHODS: From 1983 to 1995, 40 patients with bladder cancer underwent bladder sparing treatment, consisting of neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy. Most patients had T3G3 cancer. A deep transurethral resection biopsy was performed before and after chemotherapy, and an extensive transurethral resection was repeated at the end of radiotherapy. Of the patients 30 received cisplatin and methotrexate and 10 also received vinblastine. Total dose of radiotherapy was 60 to 65 Gy. Recurrent superficial tumors were treated transurethrally. Radical cystectomy was considered for persistent or recurrent invasive disease. RESULTS: Complete response occurred in 19 patients (47.5%) after chemotherapy, and in 8 patients after transurethral resection and radiotherapy (67.5%). Within 10 years 8 responding patients (30%) had local recurrences and 3 underwent cystectomy. Of the patients 14 (35%) are alive, including 13 with no evidence of disease (mean survival 65 months), 5 died of unrelated disease and 21 (52.5%) died of distant metastases (mean survival 28 months). Of the 21 patients 14 had residual tumor after radiotherapy, 3 presented with distant metastases after vesical infiltrating recurrence and 4 had distant metastases in the absence of locoregional recurrence. In 22 patients (55%) the bladder was salvaged. Patients with complete response to chemotherapy had a low risk for recurrent infiltrating tumors and metastases. CONCLUSIONS: Complete tumor control was maintained at 5 years in more than 50% of the patients treated conservatively. Bladder salvage is feasible in select patients.
OBJECTIVE: To investigate the clinical features, pathology, diagnosis and treatment of inverted urothelial papilloma. METHODS: A total of 151 cases of urothelial inverted papilloma were analysed retrospectively. Of the cases, 134 were male and 17 were female, with a mean age of 54 years old. Most patients complained of painless gross hematuria. The diagnosis could be established mainly by ultrasonic, intravenous urography, retrograde pyelography, cystoscope and pathology. Among them, 7 cases who had the papilloma at upper urinary tract underwent nephroureterectomy except one. One hundred and forty-four cases had the papilloma at low urinary tract, with 124 treated by transurethral bladder tumor resection (TURBT), among which 11 cases accompanying benign prostatic hyperplasia were treated by transurethral prostatic resection, 3 by transurethral resection of prostatic urethral tumor, 15 by partial cystectomy, 2 by total cystectomy. RESULTS: One hundred and eighteen cases were followed up 1 year to 12.5 years (mean 6.3 years). Intravesical recurrence was found in 5 cases. Of them 2 cases developed malignance in 8 and 30 months postoperatively, and 1 case underwent total cystectomy. CONCLUSIONS: Inverted urothelial papilloma is a benign tumor, which appears male predominant. Most of the lesions are found in the bladder. TURBT is the preferred treatment choice for inverted papilloma of the bladder. Although this disease has a good prognosis, regular follow-up observations are necessary.
We report a case of 2 large calculi encased within a 15 gm. tumor of cystitis cystica and cystitis glandularis. The patient presented with acute right epididymitis. An excretory urogram showed 2 bladder calculi. Cystoscopy revealed a mass around the stones resembling adenocarcinoma of the bladder base. Transurethral resection of the tumor and cystolitholapaxy were performed. The final diagnosis was bladder calculi within a mass of cystitis cystica and cystitis glandularis. A review of the literature failed to reveal a similar case.
After transurethral resection or biopsy, patients with recurrent bladder cancer or in situ carcinoma were given topical immunotherapy with low-dose Calmette-Guérin bacillus (BCG). In the recurrence-free interval they were treated with BCG monthly for 1 year and then every 3 months for the next year. Cytological analysis was always performed concomitant with the administration of immunotherapy. In order to evaluate the therapeutic success, cystoscopy and biopsy were performed after the first cycle of BCG and then every 3 months. At the start of topical therapy with BCG, a great increase in the number of inflammatory cells was seen. In urothelial cells the nuclei were enlarged; they were hyperchromatic with sometimes increased and prominent nucleoli, anisocaryosis and a distorted nucleus-plasma ratio. These cytological findings were also made 1 year after initial therapy and slowly diminished in the 2nd year during immunotherapy at 3-month intervals. The accuracy of urine cytology for carcinoma in situ is 80%. Interpretation of cytology in the recurrence-free interval was impaired. When doubtful, the recurrence of a carcinoma in situ under maintenance therapy with BCG must be proved by biopsy.
OBJECTIVES: The authors present the results of two parallel phase II trials, instituted by the EORTC Genito-Urinary Group in 1986, whose aims were to assess the tolerability and ablative capacity of mitomycin C (study 30864) and epirubicin (study 30869) in patients with multiple primary or recurrent Ta-T1 bladder cancer. METHODS: A well-defined tumour (marker lesion) was left in the bladder after transurethral resection (TUR). All patients received 8 weekly instillations, after which cystoscopy with bladder biopsies +/- TUR was performed. Responses were rated as follows: (1) complete-no visible or microscopic bladder cancer; (2) no change-persistence of the marker lesion; (3) progression-increased marker lesion size, new tumour(s) or presence of muscle-invasive disease at any site. RESULTS: Ninety-six evaluable patients were treated with mitomycin and 36 with epirubicin. The overall bladder response in the former group was complete in 50%, no change in 30% and progression in 20% of patients, while the marker lesion response was complete in 57%, no change in 39% and progression in 4%. In the epirubicin group, 56% of the patients achieved a complete overall response, while there was no change in 22% and progression in 22%. The marker lesion response in this group was complete in 67%, no change in 31% and progression in 3%. Only 2 cases of progression were due to the presence of muscle-invasive disease. Both of these were in the mitomycin group; 1 was at the marker lesion site, and 1 was at a remote site. CONCLUSIONS: The present studies confirm the feasibility and safety of the marker lesion model for the objective evaluation of the antitumoural activity of intravesically administered drugs.
We report a case of small cell carcinoma of the urinary bladder. A 60-year-old man with microscopic hematuria was referred to our hospital. Cystoscopy revealed a sessile tumor on the left lateral wall of the urinary bladder. The patient underwent transurethral resection of the bladder tumor (TUR-Bt). Because of muscle invasion (pT2), total cystectomy was recommended, but was not performed because the patient would not give consent for the operation. Six months after TUR-Bt, invasive bladder tumor recurred and total cystectomy was performed. Pathological examination of the operative specimen revealed small cell carcinoma. Adjuvant combined therapy of irradiation and chemotherapy (nedaplatin and etoposide) was ineffective. Metastases to retroperitoneal lymph nodes, lung and liver were detected soon after the adjuvant therapy. The patient died 15 months after his first visit to our hospital.
A clinical statistical survey of the operations was performed at our urology department during a 10-year period from 1993 to 2002. The total number of operations was 2,909 including 806 sessions of extracorporeal shock-wave lithotripsy (ESWL) that started in 1999. Since a combination unit of ESWL, fluoroscopic apparatus and digital video-urodynamics system was built next to the outpatient department in 1999, the number of operations and examinations has dramatically increased. Operations for bladders made up the greatest portion of all the surgeries and especially transurethral resection of bladder tumor and hydrodistention have been increasing.
We report two men with inverted papilloma of urinary bladder with urination difficulty as initial symptom. One was 51 years old and the other was 60 years old. Ultrasound revealed a tumor in the bladder and cystoscopy revealed a smooth-surfaced tumor with a stalk at the bladder trigon. They underwent transurethral resection of the bladder tumor and histopathological findings were consistent with inverted papilloma. Postoperatively, they are free of urination difficulty and have had no recurrence for 3 and 1 years, respectively.
A case of primary adenocarcinoma of the bladder is reported. The patient was a 83-year-old man admitted to our hospital in February, 1988 with the complaint of gross hematuria that had lasted for about 1 month. Cystoscopic examination showed a solid tumor in the lateral wall of the bladder with a bladder stone. Papillary adenocarcinoma was found in the biopsy specimen from the bladder tumor. The gastrointestinal, respiratory and genitourinary tracts were examined but no other tumor lesions could be found. Therefore, primary adenocarcinoma of the bladder with a bladder stone was suspected. Transurethral resection of the bladder tumor and cystolithotripsy were performed; histological study showed that the tumor was limited to submucosa, that is to pTlb. The literature is reviewed.
In urology, endoscopic surgery and laparoscopic surgery are generally named as endourology. Transurethral endoscopic surgery was originated in mid 19th century, and established by 1950s. At present, transurethral resection of the prostate, transurethral resection of the bladder tumor, transurethral incision of the urethral stricture, transurethral vesicolithotripsy, and transurethral ureterolithotripsy, were commonly performed in many urological clinics. Percutaneous nephrolithotripsy and extracorporeal shock wave lithotripsy were introduced in 1980s, and now, open operation for urolithiasis are rarely performed. In 1990s, as a new endourologic procedure, laparoscopic operations are being increasingly applied to the treatment of urological diseases; for example, laparoscopic pelvic lymphadenectomy, laparoscopic varicocelectomy, laparoscopic exploration of non-palpable testis, laparoscopic nephrectomy, and laparoscopic adrenalectomy etc. Of the variety of treatment modalities available, the most effective and least invasive method should be selected appropriately. So, we anticipate the further advancement in minimally invasive therapy, interdependently with our sufficient experience and skills.
A case of unusual tumor of renal pelvis and ureter is reported. A 82-year-old man was admitted with the chief complaint of gross hematuria. He was diagnosed with bladder tumor and right renal pelvic and ureter tumor by bladder biopsy (TCC G2) and radiological examinations. Right nephroureterectomy was performed after transurethral resection of bladder tumor (TUR-Bt). Histological findings of renal pelvic and ureteral tumor were squamous carcinoma with pseudosarcomatous stroma (so-called carcinosarcoma). Tumor cells showed mostly a sarcomatoid spindle pattern and partly apparent SCC. He was discharged without adjuvant therapy and no recurrence was found for 7 months after operation. In our case, CA19-9 was useful as a tumor marker. Such disease has been confused with true carcinosarcoma or sarcomatoid carcinoma and should be distinguished from them. We reviewed 18 case reports of true carcinosarcoma or sarcomatoid carcinoma of the renal pelvis.