Urethral tumor recurrences after radical cystoprostatectomy: the case for primary cystoprostatourethrectomy?

Of 273 male patients who underwent radical cystoprostatectomy between 1967 and 1987, 22 were regarded as at risk for urethral recurrence. These patients underwent simultaneous primary urethrectomy or urethrectomy shortly after cystectomy because of the histology of the cystectomy specimen. Of the remaining 251 patients a urethral recurrence was observed in 23 (9.2%). A patient with a urethral recurrence originally had undergone an operation at another hospital. The first urethral tumor recurrence was observed in 1977 but between October 1987 and May 1988, 7 patients were treated for an initial or secondary urethral recurrence. This finding suggests that the rate of urethral recurrence increases with improved survival rates after cystoprostatectomy and longer followup of these patients. Of the 24 patients who had urethral recurrence 21 showed multifocal tumor growth in the primary cystectomy specimen and 2 had unifocal tumors. The original histological status in the patient treated elsewhere is not known. The data suggest that primary simultaneous urethrectomy should be performed in all patients undergoing cystoprostatectomy for multifocal bladder tumors. Patients who retain the urethra require regular and life-long washout cytology studies of the urethra for early diagnosis of recurrent urethral tumor.

Computerized tomography: an unreliable method for accurate staging of bladder tumors in patients who are candidates for radical cystectomy

A total of 164 patients with bladder tumors underwent preoperative staging by computerized tomography. All patients were previously untreated, or had undergone only transurethral biopsy or resection of the tumor before computerized tomography. The post-cystectomy histological stage was compared to the preoperative computerized tomography stage. Computerized tomography accuracy according to the tumor, nodes and metastasis classification was only 32.3%, whereas overstaging was found in 39.6% and understaging in 28.1% of the cases. In untouched tumors or after transurethral resection computerized tomography accuracy demonstrated no significant difference. Only 2 of 19 true positive lymph nodes were staged correctly. Of 10 suspicious nodes results of computerized tomography were false positive in 8. Computerized tomography is an unreliable method for accurate preoperative staging of bladder carcinoma. The indication for either an operation, chemotherapy or radiotherapy for the treatment of bladder neoplasms should not be based on computerized tomography findings.

[Urethral tumor recurrence following radical cystoprostatectomy--an indication for primary cystoprostato-urethrectomy?]

A total of 273 male patients underwent radical cystoprostatectomy between 1967 and 1987, 22 of them being regarded as at risk for urethral tumor recurrence. In these 22 primary simultaneous urethrectomy was performed or urethrectomy followed shortly after cystectomy because of the histology of the cystectomy specimen. Of the remaining 251 patients, a urethral tumor recurrence was observed in 23 (9.2%). Another patient with a urethral recurrence had originally been operated on in another hospital. The first urethral tumor recurrence was observed in 1977, but between October 1987 and May 1988, 7 patients were treated for urethral recurrence or rerecurrence, suggesting that this problem will be recorded increasingly often with improved survival rates from the original bladder tumor and longer follow-up of these patients. In 21 of the 24 patients with recurrence, multifocal tumor growth (multiple primary tumors, multifocal carcinoma in situ, unifocal primary tumor with concomitant carcinoma in situ or severe dysplasia) was found in their primary cystectomy specimen. Two had unifocal tumors. The original histology of the patient operated on elsewhere is not known. The data suggest that primary simultaneous urethrectomy should be performed in all patients undergoing cystoprostatectomy for multifocal bladder tumors. All patients in whom the urethra is left in place need regular washout cytologies of the urethra for the rest of their lives to ensure early diagnosis of any urethral tumor recurrences.

Continent urinary diversion and bladder augmentation in children: the Mainz pouch procedure

The formation of a bowel reservoir of large capacity at low pressure by using small and large bowel (ileocaecal segment) has proved reliable for achieving continent urinary diversion (n = 80), for bladder augmentation (n = 42) as well as for total bladder replacement (n = 24). Encouraged by the results we obtained in our adult patients, we have used this technique during the last 3.5 years in 29 children. Indications for urinary diversions in children have been: neurogenic bladder with diplegia (n = 8), bladder exstrophy (n = 2), traumatic loss of the bladder (n = 1), urogenital sinus (n = 1) and rhabdomyosarcoma of the prostate or bladder (n = 2). Bladder augmentation was indicated in 6 children with iatrogenic bladder loss, in 5 children with neurogenic bladder without diplegia and in 4 boys with incontinent epispadias or exstrophy. In children with bladder exstrophy or incontinent epispadias, continence was achieved using a modified Young-Dees technique with formation of a long intra-abdominal muscular tube made out of the bladder plate or the low-capacity bladder. The capacity of the urinary reservoir was guaranteed by bladder augmentation or bladder replacement with an ileocaecal pouch. During a mean follow-up period of 26 months (bladder augmentation) and 21 months (continent diversion) there was only one postoperative complication (intussusception ileus) which required operative revision. Two children had to undergo reoperation because of nipple problems. Follow-up, with monitoring of biochemical and metabolic parameters, is necessary to show whether this technique will provide a long-term successful solution for these problems.

Ureterosciatic hernia. A rare cause of pyonephrosis

A female patient presented as an emergency case with pyonephrosis and septicemia as a result of ureterosciatic hernia. Septicemia was treated successfully by immediate percutaneous nephrostomy tubing. After complete disappearance of symptoms, the hernia was closed operatively. Topographic anatomy of ureterosciatic hernia is presented.

Treatment of iatrogenic functional or morphologic bladder loss

From 1984 to 1986, six children from 4 to 13 years of age, received a bladder augmentation by ileocecal cystoplasty (Mainz-pouch technique) because of an iatrogenic functional or morphologic bladder loss. Indications for operation were incontinence due to the low bladder capacity or threat to the upper urinary tract due to ureteral obstruction or vesicorenal reflux. Two of the children had already undergone supravesical urinary diversion by sigmoid conduit. After a follow-up period of 2 to 19 months, (mean 11 months), five of the six children are completely continent. One boy with a known weak sphincter still has slight, but decreasing, enuresis nocturna in periods of complete filling of the pouch, 1 month after the operation. All children are able to void their augmented bladders without residual urine.

Local shock-wave lithotripsy of distal ureteral calculi

Since the initiation of the clinical trial utilizing a second-generation lithotripor (Lithostar, Siemens, Erlangen, FRG), 96 patients with distal ureteral calculi (i.e. calculi below the pelvic brim) underwent local shock-wave lithotripsy. Routine treatment was conducted under intravenous sedation and light analgesia only. Complete stone disintegration was achieved in 84 patients (87.5%), 11 requiring two sessions and 1 patient, three. In 7 patients ureteroscopy became necessary after unsuccessful local shock-wave treatment. In 2 of these patients a 9-french flexible ureteroscope and the Storz Q-switched neodymium-YAG laser was used for stone disintegration. In 3 cases loop extraction and in 2 cases open surgery had to be performed for definitive stone removal. All pre- and postoperative manipulations (except open surgery) were done on the Lithostar. Local shock-wave lithotripsy is a highly successful, noninvasive, time-saving and easily applicable technique. It has become our primary approach in the treatment of distal ureteral calculi.

Radical cystectomy--often too late?

From 1967 to 1985, 246 cystectomies for treatment of transitional cell carcinoma of the urinary bladder were performed. Perioperative mortality decreased from 15% in the early years to 0% in 1985. Preoperative radiotherapy was not given. Patients who underwent cystectomy immediately following the diagnosis of invasive bladder carcinoma had a significantly better prognosis than those having cystectomy after recurrence of a transurethrally resected invasive carcinoma in spite of identical G and T criteria. A total of 26 patients who were cystectomized because of tumor recurrence after definitive radiotherapy (salvage cystectomy) represented the group with the worst prognosis: they had a 5-year survival rate of less than 10%. It is concluded from these results that recurrence of an infiltrating bladder tumor is an indication of poor prognosis. Early cystectomy after diagnosis of tumor infiltration can improve survival rates. Transurethral resection without adjuvant therapy cannot be regarded as reliable curative treatment of bladder cancer infiltrating the lamina propria (pT1). Modern surgical techniques of continent urinary diversion or total bladder replacement combined with sparing of the pelvic nerves (and thus preservation of potency) reinforce our view that radical cystoprostatectomy need no longer be regarded as mutilating surgery.