Laparoscopic en bloc partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma

Clinical, Pathological, and Prognostic Analysis of Urachal Carcinoma

OBJECTIVE

The aim of this study was to improve understanding the clinical, pathologic, and prognostic features of urachal carcinoma (UrC), a retrospectively descriptive study was done in 2 clinical centers.

METHODS

After excluding the 2 missed patients, the clinical and pathological data of 59 patients with UrC, who were diagnosed or treated at 2 clinical centers between 1986 and 2019, was retrospectively analyzed. SPSS 22.0 (IBM) and GraphPad Prism 8.0.1 were used for statistics and data visualization. Survival data were analyzed by the Kaplan-Meier method and Log-rank tests. Cox proportional hazards regression were performed for find risk factors on predicting the prognosis.

RESULTS

Of all 59 patients, 47 were male and 12 were female. The median age at diagnosis was 51.6 years (range: 22-84 years). Gross hematuria was the most common symptom (79.66%). The majority of urachal neoplasms were adenocarcinomas (94.92%). Forty-two patients (72.41%) underwent extended partial cystectomy with en bloc resection of the entire urachus. The mean follow-up was 52 months (3-277 months). Median overall survival was 52.8 months (4-93 months). The 3-year cancer-specific survival (CSS) rate and 5-year CSS rate were 69.1% and 61.2%. There was no significant difference among localized T stage, tumor histologic grade and surgical procedures in determining prognosis by survival analyze. While patients with high-risk TNM stage (local abdominal metastasis, lymph node metastasis, or distant metastasis) (p = 0.003) and positive surgical margin (p < 0.001) had significantly worse prognosis.

CONCLUSIONS

The results indicate that high-risk TNM stage and positive surgical margin are risk predictors of prognosis. Localized T stage, histologic grade, and surgical procedure cause no significant effect on patient prognosis. The extended partial cystectomy is the recommended surgical approach for patients with UrC. Active multimodal treatments may improve the survival of patients with recurrent and metastatic disease.

Cystoscopy-assisted laparoscopic partial cystectomy for muscle-invasive bladder cancer: Initial experience in Cipto Mangunkusumo Hospital, Jakarta

INTRODUCTION

We report the experience with patients of urachal adenocarcinoma of the bladder, a rare malignancy in the urinary bladder, treated with laparoscopic partial cystectomy.

AIM

Solitary transitional cell carcinoma (TCC) of the dome/anterior wall of the bladder in some cases. As compared to radical surgery, partial cystectomy has a lower morbidity rate and similar oncological outcomes. We present our experience with laparoscopic partial cystectomy (LPC) in patients with urachal adenocarcinoma.

CASE PRESENTATION

Until being admitted to the hospital, a 60-year-old woman had been suffering from painless, sporadic gross hematuria for the previous year. Her physical examination was undistinguished. Computed tomography revealed an enhancing firmly bordered mass on the anterior-superior aspect of the bladder wall. The patient then underwent cystoscopy and laparoscopic partial cystectomy simultaneously.

CONCLUSION

Based on our first experience in LPC, we suggest that cystoscopy assisted LPC is a reasonable and safe procedure with fewer complications and does not extend the operating time. The procedure's effectiveness hinges on the patient's selection. However, many cases needed to emphasize the effectiveness and safety of LPC.

Partial cystectomy for muscle-invasive bladder cancer: a review of the literature

The radical cystectomy (RC) for muscle-invasive bladder cancer is one of the most morbid and complex urologic procedures performed today. To avoid these complications, the partial cystectomy (PC) has been offered as an alternative in carefully selected patients as a means of achieving equal oncologic efficacy with less morbidity. Selection criteria should include solitary tumors without concomitant carcinoma in situ (CIS) and amenable to resection with 1–2 cm margins in a normally functioning bladder. In addition to the standard work-up, random bladder and prostatic biopsies may be performed. The PC can be performed through an open, laparoscopic, or robot-assisted approach, each with acceptable outcomes. A number of techniques have been developed to identify and resect the tumor completely with negative margins, while preventing tumor spillage within the abdomen. While there are no randomized trials, single institution series have demonstrated acceptable oncologic outcomes in appropriately selected patients. Therefore, offering PC in the appropriate candidate, including those patients who do not accept or are unfit for the associated morbidity of a RC, represents an acceptable alternative.

Impact of Surgical Technique on Surgical Margin Status Following Partial Cystectomy

INTRODUCTION

We assessed the impact of open or minimally-invasive partial cystectomy on surgical margin status in a nationwide hospital-based cohort.

MATERIALS AND METHODS

Patients who underwent partial cystectomy from 2010 to 2014 were identified in the National Cancer Data Base. The primary outcome was surgical margin status. A multivariable logistic regression model was fitted to identify patient, hospital, and surgical factors associated with positive surgical margins (PSMs).

RESULTS

Partial cystectomy was performed in 1,118 patients via open (n = 715, 64%), laparoscopic (n = 209, 19%), and robotic (n = 194, 17%) approaches. Overall, 220 (19.7%) patients had PSMs. The PSM rate by surgical approach was 19.6% for open, 18.2% for laparoscopic, and 21.6% for robotic (P = 0.678). Compared to open partial cystectomy, the laparoscopic (aOR 1.06, 95%CI 0.70-1.60, P = 0.782), and robotic (aOR 1.28, 95%CI 0.85-1.91, P = 0.235) approaches were not significantly different in terms of PSM rate. There were higher odds of PSMs in non-Hispanic blacks (aOR 1.93, 95%CI 1.09-3.39, P = 0.023) compared to non-Hispanic whites, and in patients with muscle invasive bladder cancer (aOR 3.28, 95%CI 2.00-5.37, P < 0.001) or tumor size ≥ 3 cm (aOR 1.67, 95%CI 1.21-2.30, P = 0.002). Tumors in a dome/urachal location had lower odds of a PSM compared to tumors in a nondome/urachal location (aOR 0.67, 95%CI 0.47-0.94, P = 0.022).

CONCLUSIONS

Our results suggest that partial cystectomy using a laparoscopic or robotic-assisted approach is not associated with an increased risk of PSMs compared to open partial cystectomy.

Biomarkers in Urachal Cancer and Adenocarcinomas in the Bladder: A Comprehensive Review Supplemented by Own Data

Urachal cancer (UrC) is a rare but aggressive cancer. Due to overlapping histomorphology, discrimination of urachal from primary bladder adenocarcinomas (PBAC) and adenocarcinomas secondarily involving the bladder (particularly colorectal adenocarcinomas, CRC) can be challenging. Therefore, we aimed to give an overview of helpful (immunohistochemical) biomarkers and clinicopathological factors in addition to survival analyses and included institutional data from 12 urachal adenocarcinomas. A PubMed search yielded 319 suitable studies since 1930 in the English literature with 1984 cases of UrC including 1834 adenocarcinomas (92%) and 150 nonadenocarcinomas (8%). UrC was more common in men (63%), showed a median age at diagnosis of 50.8 years and a median tumor size of 6.0 cm. No associations were noted for overall survival and progression-free survival (PFS) and clinicopathological factors beside a favorable PFS in male patients (p = 0.047). The immunohistochemical markers found to be potentially helpful in the differential diagnostic situation are AMACR and CK34βE12 (UrC versus CRC and PBAC), CK7, β-Catenin and CD15 (UrC and PBAC versus CRC), and CEA and GATA3 (UrC and CRC versus PBAC). Serum markers like CEA, CA19-9 and CA125 might additionally be useful in the follow-up and monitoring of UrC.

Umbilical laparoendoscopic partial cystectomy

OBJECTIVE

To present our center's experience in single-port umbilical laparoendoscopic partial cystectomies, in both benign and malignant pathologies. Patient characteristics, perioperative aspects and the surgical techniques used are reviewed.

MATERIAL AND METHOD

Since May 2012, five patients have undergone a transumbilical single-port laparoendoscopic partial cystectomy with curved equipment through a reusable multichannel system and a 3.5mm accessory trocar. Patients were three males and two females aged between 28 and 78 (median: 44±42.5) years. The etiologies were endometriosis (in 2 cases), a tumor in the diverticulum, a congenital bladder diverticulum and ureterocele (1 case of each).

RESULTS

Median surgery time was 273±163.4minutes, and intraoperative bleeding 250±175ml. None of the patients required transfusion. The postoperative period was uneventful, with good results and no complications. The hospital stay was 3±1 days. With monitoring of 20±17.5 months, morphological and functional recovery in the bladder and ureter was confirmed in all cases and the patient with neoplastic disease was disease-free more than 2 years after the surgery.

CONCLUSIONS

An umbilical laparoendoscopic partial cystectomy represents a viable surgical option and ensures that excellent surgical and cosmetic results are achieved.

Extraperitoneal and transperitoneal laparoscopic partial cystectomy for benign non-urothelial bladder tumors: an initial experience

OBJECTIVE

This study presents our initial experience with extraperitoneal and transperitoneal laparoscopic partial cystectomy (LPC) in the treatment of benign non-urothelial bladder tumors.

METHODS

Eleven patients with benign non-urothelial bladder tumors underwent extraperitoneal or transperitoneal LPC. The five cases with tumors located on the anterior/anterolateral bladder wall received the extraperitoneal approach. The six cases with tumors located around the bladder dome or over the posterior bladder wall received the transperitoneal approach. Key perioperative parameters were recorded.

RESULTS

All patients underwent laparoscopic resection smoothly without requiring a conversion to a traditional open procedure, and no patient displayed perioperative complications. Pathology showed benign non-urothelial bladder tumors with normal margins in all eleven patients, including five leiomyoma cases, three pheochromocytoma cases, two paraganglioma cases and one inflammatory fibrous histiocytoma case. Follow-up cystoscopy and imaging studies in all eleven patients (mean follow-up period 32 months) revealed neither residual nor local recurrence.

CONCLUSIONS

LPC is safe and feasible in select patients with benign non-urothelial bladder tumors and yields satisfactory oncological and functional results. Extraperitoneal LPC should be preferred for lesions located on the anterior/anterolateral bladder wall, while transperitoneal LPC should be preferred for lesions around the bladder dome or over the posterior bladder wall.

Initial experience with robotic-assisted laparoscopic partial cystectomy in urachal diseases

Purpose

In this study, we report our initial experience with robot-assisted laparoscopic partial cystectomy (RLPC) in urachal diseases.

Materials and Methods

Two men and two women with a mean age of 51.5±9.3 years underwent RLPC between June 2009 and December 2009. In each case, a single surgeon using the da Vinci-S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) used a transperitoneal approach with a 0° robotic camera. After careful observation of the intravesical portion of the mass, the mass was excised by use of monopolar scissors circumferentially. The bladder was closed in two layers with watertight running sutures made with 2-0 Vicryl.

Results

The mean operative time was 198 minutes (range, 130-260 minutes), the mean console time was 111 minutes (range, 70-150 minutes), and the mean estimated blood loss was 155 ml. The urethral catheter was removed on postoperative day 7 after a normal cystogram, and the surgical drain was removed on postoperative day 2.5 (range, 2-3 days). The mean hospital stay was 6 days (range, 4-7 days). There were no major complications. The pathology report revealed that one patient had a urachal cystadenoma, two patients had a urachal cyst, and one patient had a patent urachus.

Conclusions

Our initial experience with RLPC for benign urachal disease is that it is a safe and feasible treatment modality. However, more cases are required to confirm the efficacy of RLPC.

Robotic partial cystectomy for bladder cancer: a single-institutional pilot study

OBJECTIVE

Open partial cystectomy has been used as a curative option for select group of patients with bladder cancer. In recent years, the da Vinci Surgical Robotic System is being increasingly used to perform complex urologic cancer surgeries. We report first on a consecutive cohort of patients undergoing robotic partial cystectomy (RPC) for bladder cancer.

METHODS

Three consecutive patients underwent RPC, two with diagnosis of papillary neoplasm of bladder and one with urachal adenocarcinoma at our institution from July 2008 to January 2009. Perioperative parameters were prospectively collected and analyzed after Institutional Review Board approval.

RESULTS

All three patients in the study were men with a median age of 50 years (range, 24-70 years). The RPC was completed transperitoneally in all three patients without the need for open conversion. The operative time, estimated blood loss, and time to hospital discharge for the three patients undergoing RPC were 185, 135, and 165 minutes; 25, 20, and 20 mL; and 5, 2, and 2 days, respectively. The percentage change in hematocrit after surgery was within 5% in all patients. There were no postoperative complications before discharge; however, one patient was readmitted and underwent small bowel resection secondary to bowel obstruction. Final pathology demonstrated high-grade carcinoma pT2bNxMx and pTaNxMx papillary urothelial carcinoma in two patients and invasive adenocarcinoma of the bladder pT3aNxMx in the remaining patient. The median follow-up was 6 months (range, 3-10 months). All three patients were alive with no signs of recurrent or metastatic disease on cystoscopic, cytological, or radiological follow-up.

CONCLUSIONS

RPC is technically feasible using the da Vinci Surgical Robotic System in select patients with bladder cancer without disease recurrence in the short term. A larger cohort with long-term follow-up is necessary to validate our results.

Robotic-assisted partial cystectomy with en bloc excision of the urachus and the umbilicus for urachal adenocarcinoma

We report two cases of urachal adenocarcinoma managed with robotic-assisted partial cystectomy. A detailed description of the robotic technique including methods used to resect the tumor, urachus, and umbilicus en bloc is described. A review of the management of urachal adenocarcinoma is presented. The robotic approach is technically feasible and safe, and is an attractive alternative to traditional open or laparoscopic-assisted partial cystectomy for this uncommon genitourinary malignancy.

Laparoscopic treatment of mucinous urachal adenocarcinoma with mucocele

We present a case of an asymptomatic 76-year-old woman treated laparoscopically for an urachal mucocele owing to a nonmetastatic urachal mucinous adenocarcinoma. Since laparoscopic en bloc resection of the urachus and partial cystectomy, the patient has been healthy and disease-free for 12 months. Modern surgical treatment of urachal adenocarcinoma is discussed in the light of this case.

Laparoscopic partial cystectomy for urachal and bladder cancer

PURPOSE

To report our initial experiences with laparoscopic partial cystectomy for urachal and bladder malignancy.

MATERIALS AND METHODS

Between March 2002 and October 2004, laparoscopic partial cystectomy was performed in 6 cases at 3 institutions; 3 cases were urachal adenocarcinomas and the remaining 3 cases were bladder transitional cell carcinomas. All patients were male, with a median age of 55 years (45-72 years). Gross hematuria was the presenting symptom in all patients, and diagnosis was established with trans-urethral resection bladder tumor in 2 patients and by means of cystoscopic biopsy in the remaining 4 patients. Laparoscopic partial cystectomy was performed using the transperitoneal approach under cystoscopic guidance. In each case, the surgical specimen was removed intact entrapped in an impermeable bag. One patient with para-ureteral diverticulum transitional cell carcinoma required concomitant ureteral reimplantation.

RESULTS

All six procedures were completed laparoscopically without open conversion. The median operating time was 110 minutes (90-220) with a median estimated blood loss of 70 mL (50-100). Frozen section evaluations of bladder margins were routinely obtained and were negative for cancer in all cases. The median hospital stay was 2.5 days (2-4) and the duration of catheterization was 7 days. There were no intraoperative or postoperative complications. Final histopathology confirmed urachal adenocarcinoma in 3 cases and bladder transitional cell carcinoma in 3 cases. At a median follow-up of 28.5 months (range: 26 to 44 months), there was no evidence of recurrent disease as evidenced by radiologic or cystoscopic evaluation.

CONCLUSIONS

Laparoscopic partial cystectomy in carefully selected patients with urachal and bladder cancer is feasible and safe, offering a promising and minimally invasive alternative for these patients.

Robot-assisted laparoscopic partial cystectomy and diverticulectomy: initial experience of four cases

PURPOSE

We report our initial experience with four cases of robot-assisted laparoscopic partial cystectomy and diverticulectomy performed between June 2005 and August 2007.

PATIENTS AND METHODS

The series consisted of three male patients and one female with a mean age of 64 years (range 36-77 years). In each case, a transperitoneal laparoscopic approach was used to mobilize the bladder. Next the bladder lesion was scored circumferentially cystoscopically with a Collings knife. The remainder of the excision and bladder reconstruction was performed with the da Vinci robot.

RESULTS

Mean operative time was 194 minutes with a mean blood loss of 35 mL. The urethral catheter was removed between 5 and 14 days following a normal cystogram. There were no significant complications. Postoperative hospital stay was 2 to 3 days.

CONCLUSION

Robot-assisted laparoscopic partial cystectomy and diverticulectomy are technically feasible and represent an alternative to open and conventional laparoscopic approaches.

[Urachal diseases]

Urachal diseases are infrequent. Congenital affections include cysts, fistula, diverticulum, external sinus, and alternating drainage sinus. Ultrasonography and fistulography are useful for the diagnosis. Treatment of malformations is rarely conservative; it consists in urachal resection. Urachal tumours are frequently malignant and adenocarcinomas are the main histological form. CT scanning is useful for staging. Treatment of urachal carcinomas consists in urachal, umbilicus and bladder removal. Prognosis is poor.

Laparoscopic partial cystectomy with en bloc resection of the urachus for urachal adenocarcinoma

Urachal carcinoma accounts for less than 1% of bladder cancers. The preferred treatment is wide local excision with partial or radical cystectomy. Two patients who presented with urachal carcinoma underwent laparoscopic partial cystectomy with en bloc resection of the urachus and bilateral pelvic lymphadenectomy as a less morbid, minimally invasive surgical alternative. Laparoscopic excision was successfully carried out in two cases with an uneventful convalescence.

Necrotic mass after transurethral resection of a bladder tumor: novel management with robotic partial cystectomy

A 76-year-old female with a history of high-grade transitional cell carcinoma (TCC) of the bladder presented with persistent nocturia and urge incontinence and was diagnosed with a necrotic bladder lesion. Cystoscopy revealed a 4 cm area of necrosis, ulceration, calcification, and fat. Transurethral biopsy confirmed the lesion to be benign, and two attempts to re-epithelialize the area of necrosis with cold scraping of exudate failed. Decision was then made to proceed with removal of necrotic lesion with bladder preservation. With the aid of concomitant cystoscopic visualization of the necrotic lesion, a robotic partial cystectomy with bladder reconstruction was performed. The patient tolerated the procedure, had an uneventful post-operative course, and remains asymptomatic and disease-free at last follow-up of 6 months. To our knowledge, this case represents the first report of a necrotic lesion as a complication of transurethral resection of a bladder tumor (TURBT) and the first description of a robotic partial cystectomy for the management of either benign or malignant bladder disease.

Clinical and therapeutic significance of aberrant differentiation patterns in bladder cancer

Pure urothelial carcinoma makes up 90-95% of all bladder cancer. The remaining 5-10% represent urothelial carcinoma with aberrant differentiation patterns and nonurothelial carcinoma. Reviews on this topic often focus on the pathological features of these histologic subtypes. In this review we have summarized the clinical significance of each major histologic pattern and analyzed the response of each to standard treatment modalities. The main limitation to optimizing management is the inability to perform clinical trials owing to the rarity of these tumors. This can be circumvented to some degree by extrapolating knowledge acquired from more common similar tumors in other organ sites. Ultimately, however, multicenter clinical trials will need to be organized to address some key management issues.

Urachal Carcinoma: Contemporary Surgical Outcomes

PURPOSE

We determined surgical outcomes in a contemporary series of patients who underwent surgery for urachal carcinoma.

MATERIALS AND METHODS

A cohort of 50 patients with clinically staged localized urachal carcinoma underwent extended partial cystectomy, including the urachal tumor mass and entire urachus. The patients were followed a median of 5+ years for cancer-free survival.

RESULTS

Of the 50 patients 93% (26 of 28) with tumor confined to the urachus and bladder survived compared to 69% (9 of 13) with extravesical or peri-urachal tumor invasion and none (9 patients) with tumor invasion into the peritoneal cavity. Local recurrence was noted in 9 patients (18%) and 2 had salvage therapy. The most significant predictors of survival were pathological tumor stage and negative surgical margins.

CONCLUSIONS

Wide resection of the tumor mass and entire urachus resulting in negative soft tissue and bladder margins cures the majority of nonmetastatic urachal cancers.

Case Report: Laparoscopic Partial Cystectomy with Endo-GIA Stapling Device in Bladder Diverticular Carcinoma

BACKGROUND AND PURPOSE

The incidence of bladder diverticular carcinoma is low, ranging from 0.8% to 10%. Traditionally, treatment consisted of open surgical excision or transurethral resection. More recently, laparoscopic surgery has become widely accepted. We report here a case of bladder diverticular carcinoma treated with laparoscopic partial cystectomy.

CASE REPORT

A 56-year-old man presented with gross hematuria and was found to have transitional-cell carcinoma in a bladder diverticulum. We performed transurethral resection of the tumors and laparoscopic partial cystectomy. A 45-mm Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT) was used for direct resection of the diverticular tissue, and the specimen was removed en bloc. Suture of the seromuscular layer was performed with the intracorporeal knotting technique. Lymph-node dissection also was performed. At 3-month follow-up, it was noted that there was tumor recurrence that was not at the original diverticular site, and transurethral resection was carried out. After 1 year, cystoscopy and CT scans showed neither recurrence nor metastasis. No encrustation or erosion was induced by the staples.

CONCLUSION

Laparoscopic partial cystectomy can be an alternative treatment for bladder diverticular carcinoma.

Laparoscopic partial cystectomy for various bladder pathologies

OBJECTIVE

To present our initial experience with laparoscopic partial cystectomy (LPC) in selected patients with various bladder pathologies.

PATIENTS AND METHODS

Between December 2004 and April 2006, four patients had LPC at our centre (mean age 52 years, range 35-70); the transperitoneal approach was used for three and a pre-peritoneal approach for one. The surgical procedures used sequentially included transurethral incision around the lesion, laparoscopic excision of the lesion (partial cystectomy) and intracorporeal suturing. Laparoscopic pelvic lymphadenectomy was also used for the two patients with malignancy.

RESULTS

All operations proceeded smoothly; the bladder pathologies included one bladder endometriosis, one bladder leiomyoma, one urothelial carcinoma within the bladder diverticulum and one urachal adenocarcinoma. The mean (range) operative duration was 197.5 (120-300) min, the estimated blood loss 70 (50-100) mL, the hospital stay 6.75 (5-9) days, and duration of Foley catheterization 7.25 (6-9) days. No open conversion was required and no patient had peri-operative complications. The surgical margins were free of cancer and the dissected lymph nodes were negative in those two patients with bladder malignancy.

CONCLUSIONS

LPC is safe and feasible in selected patients with various bladder pathologies.

Urachal carcinoma: surgical and chemotherapeutic options

The urachal ligament is an embryologic remnant connecting the dome of the bladder to the umbilicus via the ligamentum commune. Autopsy series suggest that in approximately a third of subjects, the urachal remnant may persist with tubular or cystic structures. However, tumors of this site are extremely rare. Patients usually present with hematuria and upon imaging, have evidence of a cystic or solid structure in the bladder dome or in the bladder midline. If a biopsy confirms adenocarcinoma, these tumors should be considered an urachal cancer until proven otherwise. Although there are no prospective clinical trials reported to date, large single-institution reports suggest surgical resection with a partial cystectomy and en bloc resection of the urachal ligament with umbilicus as the treatment of choice in the setting of localized disease. Although there is currently no definitive role for neoadjuvant or adjuvant chemotherapy in this tumor, risk factors predicting progression may allow for the selection of patients at higher relapse risk for prospective studies. Unfortunately, there are many patients who present with metastatic disease that currently is not likely to be curable. There is no standard chemotherapy regimen for these patients; however, there is new-found hope with a currently accruing clinical trial exploring a 5-fluorouracil-based chemotherapy combination in this patient population.