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PubMed2004

Laparoscopic radical nephroureterectomy: dilemma of the distal ureter.

PURPOSE OF REVIEW: Laparoscopic nephroureterectomy has recently emerged as a safe, minimally invasive approach to upper tract urothelial cancers. The most controversial and challenging feature of laparoscopic nephroureterectomy is the management of the distal ureter. We review the most common methods of managing the distal ureter, with emphasis on contemporary oncologic outcomes, indications, advantages, and disadvantages. RECENT FINDINGS: There are currently in excess of five different approaches to the lower ureter. These techniques often combine features of endoscopic, laparoscopic, or open management. They include open excision, a transvesical laparoscopic detachment and ligation technique, laparoscopic stapling of the distal ureter and bladder cuff, the "pluck" technique, and ureteral intussusception. Each technique has distinct advantages and disadvantages, differing not only in technical approach, but oncological principles as well. While the existing published data do not overwhelmingly support one approach over the others, the open approach remains one of the most reliable and oncologically sound procedures. SUMMARY: The principles of surgical oncology dictate that a complete, en-bloc resection, with avoidance of tumor seeding, remains the preferred treatment of all urothelial cancers. The classical open technique of securing the distal ureter and bladder cuff achieves this principle and has withstood the test of time. Transvesical laparoscopic detachment and ligation is an oncologically valid approach in patients without bladder tumors, but is limited by technical considerations. The laparoscopic stapling technique maintains a closed system but risks leaving behind ureteral and bladder cuff segments. Both transurethral resection of the ureteral orifice (pluck) and intussusception techniques should be approached with caution, as the potential for tumor seeding exists. Additional long-term comparative outcomes are needed to solve the dilemma of the distal ureter.

Humans↗

PubMed1984

Transurethral treatment of bladder diverticula. Alternative to open diverticulectomy.

Since October, 1980, we have used transurethral fulguration of the diverticular mucosa and incision of the diverticular neck in combination with electrohydraulic lithotripsy of bladder stones and transurethral prostatic resection to treat all aspects of diverticula in 11 patients. In comparing the results with those of open diverticulectomy, we found the transurethral procedure to be equally effective while being safer, faster, and less expensive.

Aged↗

PubMed1996

Management of vesical calculi: comparison of lithotripsy devices.

Although endoscopic lithotripsy of bladder stones has been well described and is widely practiced, comparison of the main modalities of mechanical, electrohydraulic, and ultrasonic lithotripsy is lacking. The exact role of these and other modalities such as the Swiss Lithoclast and extracorporeal shockwave lithotripsy is not clearly defined. The safety and efficacy of the various lithotripsy modalities available to treat bladder calculi were reviewed retrospectively over an 18-year period. A total of 106 patients were treated with some form of intracorporeal lithotripsy. In general, all devices proved to be effective with a low rate of complications. The addition of transurethral resection of the prostate to bladder stone management under the same anesthetic was also found to be a safe procedure for moderate benign prostatic hyperplasia. In summary, transurethral endoscopic lithotripsy is a safe and effective method of bladder stone management both alone and in combination with transurethral prostatectomy. All modalities of intracorporeal lithotripsy are effective; however, devices such as ultrasound lithotripters or the Swiss Lithoclast that utilize larger, rigid probes may be more efficient for patients with large or particularly hard vesical calculi.

Adolescent↗

PubMed1998

[A case of synchronous triple primary cancers of prostate, kidney and bladder].

A case of synchronous triple primary cancer occurring in the prostate, kidney and urinary bladder is reported. A 74-year-old man had been complaining of macroscopic hematuria, dysuria and residual sensation of urine since January 1994. Pathological analysis of prostate revealed poorly differentiated adenocarcinoma in March, 1994. Bone and Ga scintigraphy gave no evidence of metastasis. Computerized tomography (CT) revealed irregularity of a part of the margin of prostate (T2N0M0) and enhanced mass with a diameter of 3 cm localized at the hilus of the right kidney. Excretory urography showed a shadow defect in the right pelvis and elevation of the bladder base. In spite of the appearance of class 5 in urine cytology, no tumor was detected in the bladder by cystoscopy. Angiography confirmed the presence of a hypervascular tumor in the right kidney. He underwent right-sided nephroureterectomy in April, 1994, because not only right pelvic tumor but also right renal tumor was suspected. Histological examination of the renal tumor revealed clear cell carcinoma (T2N0M0). Then, he did not visit our hospital for 8 months. In January, 1995 a papillary broadbase tumor was found near the bladder neck by cystoscopy. Transurethral resection of the tumor (TUR-Bt) was performed in February, 1995. Pathological analysis of the tumor revealed TCC G1 pT1 (T1N0M0).

Adenocarcinoma↗

PubMed1993

Follow-up of the effect of BCG vaccine treatment in bladder tumour patients.

The effect of intravesical BCG vaccine treatment in 38 patients with superficial bladder tumour after TUR (Transurethral Resection) was followed by the lymphocyte transformation test (LTT) and the staphylococcus phagocytosis test of in vitro washed leukocytes. The results have confirmed the immunostimulating and hence anti-tumour effect of intravesical BCG vaccine. Monitoring of the cellular immune response is suitable for the continuous follow-up of the BCG effect. Comparing the tolerable side-effects with their favourable therapeutic results, BCG vaccine is considered to be effective for the prevention of recurrences in treating superficial bladder tumours.

BCG Vaccine↗

PubMed1989

[Triple malignancy including bladder carcinoma, prostate carcinoma and malignant lymphoma: a case report].

A 70-year-old man was admitted to our hospital with the complaint of lower abdominal mass. Previously, he had received partial cystectomy and radiation of 38 Gy for bladder transitional cell carcinoma and transurethral resection of prostate and diethylstilbestrol administration for prostatic adenocarcinoma. The third tumor was located between the bladder and lower abdominal wall with inguinal lymph node swelling. Biopsy specimen revealed malignant lymphoma. After 2 courses of combination chemotherapy consisting of vincristine, prednisolone and procarbazine, complete remission was achieved. We discuss about multiple malignancies including urological organs.

Adenocarcinoma↗

PubMed1988

Long-term follow-up of unilateral bladder neck incision.

Sixty-four patients who underwent unilateral bladder neck incision (BNI) between 1980 and 1983 were reviewed. In 53 cases the flow rates showed no significant change from immediate post-operative values. All patients were interviewed or completed a questionnaire which demonstrated that 87% were satisfied with the long-term outcome of surgery. The incidence of repeat bladder neck incision or transurethral resection of prostate (TURP) compared well with the incidence reported in other studies, as did the recorded incidence of retrograde ejaculation at 16%, although 52.5% of patients noted a reduction in the volume of ejaculate.

Adult↗

PubMed2001

A practical approach to bladder sampling and diagnostic reporting of pathological findings.

The most common bladder specimens are obtained from endoscopic biopsies and transurethral resections (TURB), both of which sample subepithelial tissue of varying depth. Other specimens can be obtained from cystectomy, cystoprostatectomy, pelvic exenteration ("en bloc" resection), and partial cystectomy including resection of diverticulae and surgical excision of a urachal carcinoma. The correct assessment of bladder specimens may provide clinically relevant diagnostic and prognostic data. This protocol is intended to assist pathologists in providing clinically useful information as a result of examination of surgical specimens.

Biopsy↗

PubMed1991

Metastasising carcinoma of the urinary bladder presenting as a retro-orbital mass. Case report.

A 61-year-old man presented with macroscopic haematuria. Infiltrating transitional cell carcinoma of the urinary bladder was diagnosed after transurethral resection, and he was treated first with three doses of cisplatinum (100 mg/m2 at three week intervals) and then by radical cystectomy. Eleven months later he complained of progressive diplopia, which was found on computed tomography to be caused by a retro-orbital metastatic mass. There was no evidence of a space occupying lesion in the brain or of other metastases. The patient died four weeks later and permission for necropsy was refused. Despite the fact that carcinoma of the urinary bladder rarely metastasis in this way, urologists should be aware that it can happen.

Carcinoma, Transitional Cell↗

PubMed1995

Bladder-sparing multimodality treatment of muscle-invasive bladder cancer: a five-year follow-up.

OBJECTIVES: To determine the long-term results of a bladder-sparing approach in the treatment of muscle-invasive bladder cancer. METHODS: Ninety-four patients with invasive transitional cell carcinoma of the bladder were treated by transurethral resection followed by 2 or 3 cycles of cisplatin-based chemotherapy. Patients were then treated with 6480 cGy of radiation in 49 patients, segmental cystectomy in 8, or surveillance only in 7. Patients who failed to respond to chemotherapy or radiation therapy, or who developed recurrent muscle-invasive disease in follow-up, underwent salvage cystectomy. Patients were then carefully followed for a median follow-up of more than 5 years. RESULTS: After initial therapy, 53 patients (56%) were alive with their bladder preserved. Thirty of those 53 (57%) developed a local recurrence in follow-up. After a median follow-up of more than 5 years, the ultimate relapse-free survival is 49% (Stage T2, 84%; T3, 53%; and T4, 11%; P < 0.01). Of all patients enrolled, 53% had bladder preservation; however, of the currently surviving patients, 16 of 39 (41%) have their bladders intact (T2, 50%; T3, 37%; T4, 0%). Only 18% of the initially enrolled population is alive with a preserved bladder. The 5-year survival of patients who had cystectomy at some point during the study, compared with those who have had their bladders preserved, was 65% versus 40%, respectively (P < 0.01). CONCLUSIONS: Our long-term results with multimodality therapy with attempted bladder preservation showed no definitive improvement in survival compared with modern series of cystectomy alone, and a disappointingly low rate of disease-free bladder preservation. We found a high rate of locally recurrent disease in the preserved bladders. We also noted a decrease in survival in our patients with bladder preservation compared with those without preservation. Bladder preservation, although possible, should be limited to a very select group of patients.

Aged↗

PubMed1992

[Organ-preserving therapy in invasive bladder carcinoma].

With the aim of organ preservation, transurethral resection with subsequent radiotherapy (until 1985) or combined radio- and chemotherapy (since 1986) was undertaken as part of a prospective trial in 175 consecutive patients (137 men, 38 women; mean age 65 [31-90] years) with invasive bladder carcinoma, tumour stage T1-4 N0-3 M0. All patients had a transurethral resection, followed 2-6 weeks later by definitive radiotherapy at a dose of 50.4 Gy to the bladder in 28 fractions. 85 patients simultaneously with the radiotherapy received chemotherapy with cisplatin (25 mg/m2 daily) or carboplatin (65-75 mg/m2 daily) in the first and fifth weeks of radiotherapy. The 5-year survival rate for the whole group (including inoperable cases) was 50%. The survival rate as related to the T category was 53% for T1 (n = 26), 68% for T2 (n = 34), 45% for T3 (n = 94) and 22% for T4 (n = 17). 139 patients (79%) were left with a normally functioning bladder. Cystectomy was performed in 36 patients because of remaining tumour or recurrence after radiotherapy. Combined radio- and chemotherapy improved the histological remission rate, compared with an earlier control group with radiotherapy only, but it did not affect the survival rate. These data indicate that in advanced bladder carcinoma organ-preserving treatment with transurethral resection and definitive radiotherapy or combined radio- and chemotherapy can be successful.

Adult↗

PubMed2001

Molecular followup of newly diagnosed bladder cancer using urine samples.

PURPOSE: Patients with superficial bladder cancer can be treated with transurethral resection. However, 50% to 70% of them have intravesical recurrence after transurethral resection and muscle invasive disease develops in 10% to 20%, which is eventually indicated for radical cystectomy. Therefore, reliable predictors of intravesical recurrence are required for management of superficial bladder cancer. We investigated whether detection of the loss of heterozygosity in urine samples would be available as a sensitive diagnostic modality for recurrence of bladder cancer. MATERIALS AND METHODS: Urine samples, cancer tissue and peripheral blood lymphocytes were obtained from 37 patients with newly diagnosed bladder cancer, and analyzed for the loss of heterozygosity on chromosomes 9 and 17p by single strand DNA conformation polymorphism analysis. RESULTS: Chromosomal loss was detected on 24 (65%) cancer tissues and 26 (70%) urine samples. The loss of heterozygosity on chromosome 17p was detected in 19 (51%) urine samples, mostly in cancers with higher grades and/or stages. During postoperative followup of 24 patients with superficial bladder cancer who had undergone transurethral resection, intravesical recurrence did not develop in 9 of 10 without chromosomal aberrations in urine samples. In contrast, intravesical recurrence developed in 11 of 14 patients who had a loss of heterozygosity in urine samples. This loss showed a significant correlation with the intravesical disease-free period (p = 0.004). Multivariate analysis revealed that the loss of heterozygosity in urine samples was a significant predictor of intravesical recurrence. CONCLUSIONS: Detection of the loss of heterozygosity in urine samples is available as a sensitive marker for predicting intravesical recurrence of superficial bladder cancer.

Adult↗

PubMedDate not supplied

Microscopic changes of the urinary bladder in patients with primary tumors locally treated with Corynebacterium parvum.

The study covered 34 patients with tumors of the urinary bladder treated surgically by transurethral resection and, as an adjuvant therapy, with Corynebacterium parvum intravesically administered. Microscopic observations were performed on smears stained with blue polychrome-tannin and the histologic study used preparata stained with hematoxylin-eosin and van Gieson. After the second series of instillations, many biopsies from the same patient were taken. The investigation revealed the negativity for malignant cells on the cytologically studied smears, and histologically a chronic infiltrate formed of lymphocytes and plasma cells along the basement membrane could be observed; sometimes the infiltrate was follicularly organized. The morphologic changes of the urinary bladder mucosa were correlated with the immunostimulation potential of Corynebacterium parvum.

Bacterial Vaccines↗

PubMed2000

Outcomes after intravesical bacillus Calmette-Guerin are not affected by substaging of high grade T1 transitional cell carcinoma.

PURPOSE: Substaging of T1 bladder tumors into T1a and T1b based on invasion of the tumor superficial to and beyond the muscularis mucosa has been assigned prognostic significance. We determined whether outcomes after intravesical bacillus Calmette-Guerin (BCG) differ between stage T1a and T1b subcategories. MATERIALS AND METHODS: Retrospective pathological evaluation of the initial transurethral resection specimens of stage T1 bladder tumors was performed by 2 pathologists. Grade 1, 2 or 3 and stage T1a or T1b were assigned to each case. Followup was from the date of transurethral resection to date of death or the last visit. Kaplan-Meier probability and log rank test were used to evaluate recurrence and progression. RESULTS: Substaging was performed in 49 of the 55 patients (89%) with stage T1 disease. Disease was stage T1a in 32 (65%), stage T1b in 17 (35%), grade 3 in 45 (92%) and grade 2 in 4 (8%) cases. Maximum followup was 147 months (median 71) and 28 cases had a minimum of 5 years of followup. Recurrence was noted in 33 cases (67.3%), including 22 stage T1a (69%) and 11 stage T1b (65%), at a median followup of 11.3 and 8.6 months, respectively. Progression to a higher stage of disease was recorded in 12 cases (24.4%), including 7 (22%) stage T1a and 5 (29%) stage T1b, at a median followup of 108 and 120 months, respectively. The difference between T1a and T1b subcategories was not statistically significant in regard to recurrence-free (p = 0.7203) and progression-free (p = 0.574) outcomes. CONCLUSIONS: Substaging of T1 tumors did not affect response to BCG in regard to recurrence or progression. Therefore, intravesical BCG is effective for stages T1a and T1b disease.

Adjuvants, Immunologic↗

PubMed1990

[Granulomatous prostatitis after intravesical BCG immunotherapy of superficial bladder cancer: a case report].

We report a case of granulomatous prostatitis after intravesical BCG immunotherapy for superficial bladder cancer. A 58-year-old man presented with gross hematuria. Cystoscopic examination revealed multiple tumors at the posterior wall of the bladder. The patient underwent transurethral resection of the tumor. Intravesical BCG immunotherapy was postoperatively followed and it eradicated the disease. Digital examination revealed that the prostate became stony-hard and larger 10 weeks after the initial BCG immunotherapy. A needle aspiration cytology and biopsy of the prostate revealed the granulomatous prostatitis due to BCG immunotherapy.

Administration, Intravesical↗

PubMed1993

[Transurethral resection of papillary tumor in the lower end of the ureter: report of two cases].

Two cases of papillary ureteral end tumors, treated by transurethral resection are presented. Case 1: A 71-year-old female visited us for asymptomatic macroscopic hematuria. Cystoscopy revealed a papillary pedunculated tumor in the bladder protruding from the right ureteral orifice. Under a diagnosis of superficial tumor at the right ureteral end, transurethral resection was performed using a rigid ureteral resectoscope. Pathological examination revealed transitional cell carcinoma, grade 2 without muscular invasion. There is no evidence of recurrence after 25 months of follow up postoperatively. Case 2: On a routine cystoscopy after transurethral resection of bladder tumor in a 68-year-old male, papillary pedunculated tumors protruding from the right ureteral orifice were found. Under a diagnosis of superficial tumor at the right lower ureter, transurethral resection was performed using cold cup forceps and loop electrocoagulation. The tumor was transitional cell carcinoma, grade 1 without invasion. No evidence of recurrence was detected 15 months postoperatively. Transurethral resection of the ureteral tumor at the lower end appeared to be useful for the selected cases. The indications, complications and follow up for this procedure were discussed.

Aged↗

PubMed1994

Prognostic factors in pTa-pT1 superficial bladder tumours treated with intravesical instillations. The Dutch South-Eastern Urological Collaborative Group.

OBJECTIVE: To identify prognostic factors that enable patients with superficial bladder cancer to be divided into groups who will probably respond to therapy and those who will not. PATIENTS AND METHODS: In a prospective randomized study 387 patients with pTa-pT1 superficial bladder carcinoma received, after transurethral resection, intravesical instillations with immuno- or chemotherapy. A simultaneous computerized analysis of factors predicting the recurrence-free interval was performed. All these patients had negative random biopsies. Pretreatment factors analysed for recurrence were gender, age, history (primary or recurrent disease), location of tumour, number of tumours, pT-stage and grade. RESULTS MEDIAN: Follow-up was 27 months (range 12-56). During the follow-up period 37.2% of the patients had recurrence and eight patients (2.2%) had progression into muscle invasive disease. After a univariate analysis the number of tumours and location of the tumour in the bladder appeared to be a significant influence on the recurrence-free interval. Location of at least one of the tumours in the prostatic urethra, bladder neck, posterior wall, and trigone area was significantly related to a shorter recurrence-free interval; these areas were defined as high risk. Tumour stage showed borderline significance. By using multivariate methods to assess the relative importance of these factors, location of tumour in the high risk region was related especially to a short recurrence-free interval. The factor found to be of significance for the prognosis for recurrence was tumour multiplicity. Gender, age, history of recurrent disease, size of the largest tumour, tumour stage or grade gave no additional information about the risk of recurrence. CONCLUSION: Prognostic factor analysis, as an auxiliary study of trials of patients treated for superficial bladder tumours, is mandatory. The prognostic factors related to recurrence-free interval found in this study, location of the tumour and multiplicity, may be of use in the stratification necessary for current protocol design.

Administration, Intravesical↗

PubMed2002

Leiomyosarcoma in urinary bladder after cyclophosphamide therapy for retinoblastoma and review of bladder sarcomas.

We report an unusual case of a leiomyosarcoma of the urinary bladder after chemotherapy for retinoblastoma and the results of a review of the published reports of bladder sarcomas. A 22-year-old man presented with hematuria and was found to have a mass in his urinary bladder on computed tomography. Transurethral resection of the mass revealed a leiomyosarcoma. The patient underwent radical cystectomy and an ileal conduit was created. The final pathologic examination confirmed high-grade leiomyosarcoma. Prospective randomized combination trials similar to the Intergroup Rhabdomyosarcoma Study in the pediatric population are necessary to better understand and manage these potentially curable sarcomas.

Adult↗