Bladder preservation in muscle-invasive bladder cancer

Organ Preservation for Muscle-Invasive Bladder Cancer by Transurethral Resection

OBJECTIVES

To determine the feasibility of bladder preservation using transurethral resection for patients with muscle-invasive cancer and to determine the proportion of patients with muscle-invasive disease who would be eligible for this approach.

METHODS

A retrospective review demonstrated that 327 patients with muscle-invasive bladder cancer were treated in our institution from 1997 to 2002. Resection was repeated in all patients, and bladder preservation was offered to patients with no residual tumor, normal examination findings under anesthesia, and normal upper urinary tract findings. Patients were followed up by routine cystoscopy for a median of 2.45 years. The study endpoints included overall and disease-specific survival rates, the need for additional systemic chemotherapy, and cystectomy-free survival.

RESULTS

Of 327 patients, 35 (11%) were eligible for bladder preservation; 27 elected to pursue this approach and 8 opted for immediate cystectomy. Of the 27 patients, 15 experienced subsequent tumor recurrence, 8 of whom underwent radical cystectomy. Thus, the bladder was preserved in 19 (70%) of the 27 patients. Of the patients who underwent cystectomy, 5 also received chemotherapy. Five patients died, including three of unrelated diseases, one of metastatic cancer, and one of surgical complications. The overall and disease-specific survival rate was 81% and 93%, respectively.

CONCLUSIONS

Bladder preservation using transurethral resection is feasible in selected patients. Only a small proportion of patients with muscle-invasive bladder cancer, however, are candidates for this approach.

Function-preserving surgery for urologic cancer

Radical surgery that is intended to cure cancer disease tends to cause some damage to the operated organ and the quality of life of the patient. It is now a worldwide trend to preserve the function and minimize the operative damage to the patient, without compromising the oncological outcome. In urologic cancers, nephron-sparing surgery for kidney tumors, and nerve-sparing procedures in radical cystectomy and radical prostatectomy for retaining potency are now more frequently used for providing better quality of life after surgery. New constructive surgeries such as neobladder formation and nerve graft techniques after complete removal of the cavernous nerve have been developed for recovering the lost function.

Value of frozen sections of lymph nodes in pelvic lymphadenectomy in patients with invasive bladder tumor

AIM

We examined the reliability of classical lymph node evaluation methods. We compared the results of preoperative computed tomography (CT) and perioperative frozen section examination of lymph nodes in patients on whom radical cystectomy was performed because of invasive bladder tumors.

METHODS

A total of 142 patients, in whom radical cystectomy was performed because of invasive bladder tumors between the years 1994 and 2005 in our clinic, and 284 pelvic lymph node regions were evaluated retrospectively. For each of the pelvic lymph node region, the conditions of the lymph nodes according to CT and in frozen sections were compared with the final pathology reports of the surgical specimens.

RESULTS

Lymph node involvement was found in 36 pelvic regions out of 284 in the final pathology. It had been possible to show only two of the 36 positive lymph nodes in preoperative CT. Frozen section results of the 29 pelvic lymph node regions out of 36 that were involved according to the final pathology were positive also according to frozen section results. On the other hand, in all the 29 lymph node regions those that were positive according to frozen section had lymph node involvement in the final pathology.

CONCLUSIONS

We recommend the performance of frozen section examination on obturator plus internal iliac lymph nodes when deciding extended lymph node dissection, and the performance of extended lymph node dissection only if the result is positive.

Clinico-pathological features of bladder carcinoma: Experience from a tertiary care hospital of Pakistan

Bladder carcinoma is most common urological malignancy in Pakistan. The objective of the study was to determine the clinico-pathological characteristics of histologically confirmed bladder carcinoma at a tertiary care hospital of South Punjab, Pakistan.

METHODS

In two hundreds and twenty one patients (172 male and 49 female) bladder carcinoma was diagnosed from Jan 1998 to June 2005. All patients were evaluated with regards to clinical presentation, cystoscopic findings and histo-pathological data.

RESULTS

Male female ratio was 3.5:1. The median age was 58 years (range 18-87 years). 65% men had history of cigarette smoking while 51% women had long history of smokeless tobacco (nasal snuff or chewable) use. Most patients presented with painless hematuria. Primary transitional cell carcinoma was the most common (i.e. 96%) histological variety of bladder carcinoma. 63% patients had muscle invasive disease at the time of presentation. Even in superficial bladder carcinoma, most patients had invasion of lamina propria (pT1 disease).

CONCLUSION

More than 90% of primary bladder carcinoma are of transitional cell variety and over 60% having muscle invasive disease at the time of diagnosis. Even in patients with superficial disease, majority (i.e. 98%) have invasion of lamina propria.

Lymphadenectomy in patients with transitional cell carcinoma of the urinary bladder; significance for staging and prognosis

OBJECTIVE

To determine the need to standardize the number and location of lymph nodes to be removed during radical cystectomy in patients with invasive bladder carcinoma.

PATIENTS AND METHODS

The pelvic lymph nodes from 447 patients (mean age 62.8 years) who underwent radical cystectomy between 1986 and 1997 were evaluated. The number of lymph nodes was correlated with the depth of invasion of the primary tumour (pT), occurrence of nodal metastases, clinical outcome, the operating surgeons and the pathologists dissecting the nodes.

RESULTS

The clinical follow-up was available for 302 patients (mean follow-up 38.7 months). The mean (range) number of lymph nodes removed was 14.7 (1-46). The number of lymph nodes removed varied significantly among different surgeons but not among pathologists. In pT3 and pT4 tumours, a more extended lymphadenectomy (>/= 16 lymph nodes) correlated with a higher percentage of patients with documented nodal metastases. There was a significant correlation between the number of lymph nodes removed and the tumour-free 5-year survival in patients with pT1, pT2 or pT3 tumours, and in patients with 1-5 positive lymph nodes (P < 0.01).

CONCLUSION

Extensive lymphadenectomy significantly improves the prognosis of patients with invasive bladder cancer and represents a potentially curative procedure in patients with nodal metastases, including micrometastases that may escape detection during routine histopathological evaluation. The results indicate the need for a standardized lymph node dissection.