D. Mitropoulos

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion.

PURPOSE Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion. PATIENTS AND METHODS 43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded. RESULTS The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains. CONCLUSIONS This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

Radical cystectomy over the age of 75 is safe and increases survival.

BackgroundRadical cystectomy (RC) is probably underused in elderly patients due to a potential increased postoperative complication risk, as reflected by their considerable comorbidities. Our objective was to estimate the overall complication rate and investigate a potential benefit to patients over the age of 75 subjected to RC in terms of disease-free survival.MethodsA total of 81 patients, 61 men and 20 women, from two urological departments, with a mean age of 79.2 ± 3.7 years, participated in the study. The mean follow-up period was 2.6 ± 1.6 years. All patients underwent RC with pelvic lymphadenectomy. An ileal conduit, an orthotopic ileal neobladder and cutaneous ureterostomies were formed in 48.1%, 6.2% and 45.7% of the patients, respectively. The perioperative and 90-day postoperative complications were recorded and classified according to the modified Clavien classification system. Survival plots were created based on the oncological outcome and several study parameters.ResultsThe perioperative morbidity rate was 43.2%; the 90-day morbidity rate was 37%, while the 30-day, 90-day and overall mortality rates were 3.7%, 3.7% and 21%, respectively. Overall mortality rates were recorded at the final year of data gathering (2009). Increased age, increased body mass index (BMI), longer hospitalization and age-adjusted Charlson comorbidity index (ACCI) more than six, were associated with greater hazard for 90-day morbidity. The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7%, 77.5%, 70.4%, and 62.3%, respectively. Tumour stage and positive nodes were prognostic predictors for oncological outcome.ConclusionsRC in patients over 75 is justified and feasible, due to acceptable complication rates and high 5-year cancer-specific survival, which support an aggressive approach. Prospective studies are needed for the verification of the above results.

Clear cell carcinoma of the lower urinary tract in a male patient. Presentation and update on histogenesis and management.

To the Editor: Clear cell carcinoma (CCC) of the lower urinary tract is a rare condition, especially in men. Only 11 cases have been reported worldwide since then. The differential diagnosis of the disease is problematic for the pathologist. We encountered such a case of invasive CCC of the bladder in a middleaged man with lymph node metastasis, in which clinical information and immunohistochemistry provided significant assistance. Differential diagnosis of CCC includes (i) vesical adenocarcinoma of Müllerian origin; (ii) tubular cystic clear cell adenocarcinoma of the prostate or the seminal vesicles, probably of Müllerian origin; (iii) small papillary urothelial carcinoma of the bladder; (iv) clear cell adenocarcinoma of the urethra; (v) hepatic adenocarcinoma of the bladder with clear cell pattern; (vi) metastatic CCC, such as renal cell carcinoma with coexistence of urothelial carcinoma; and (vii) nephrogenic adenoma, a benign process that may cause a significant diagnostic confusion. In the present case the nephrogenic adenoma was excluded due to the large size of the lesion and the absence of some form of mucosal irritation such as infection, urinary calculi, immunosuppressive treatment, genitourinary trauma or genitourinary tract procedures. Cells were cuboid or flat, in contrast to the CCC, occasionally with a mild to moderate nuclear atypia and a rare mitotic figure. The possibility of a metastatic renal CCC was also ruled out because no renal involvement was evident (Fig. 1). The tumor was identified as a high-grade CCC (Fig. 2), which fully infiltrated the bladder wall, extending into the perivesical fat, the prostate, the spermatic vesicles and four of the resected pelvic lymph nodes. Focal areas with typical characters of high-grade urothelial carcinoma were present. The clear cell element of the malignancy was characterized by a solid, pseudopapillae pattern without a clear vascular axis. The tumor cells were medium sized with an almost spherical and open colored nucleus, clearly visible nucleolus and abundant clear cytoplasm. The tumor infiltrated a great number of blood and lymphatic vessels. No signs of endometriosis or Müllerian duct remnants were recognized. Furthermore, no typical glandular configuration was observed in the outer layer of cells, which had a characteristic hobnail nuclear pattern. The immunohistological phenotype of the CCC is focally or diffusely positive for CA125, which is not a specific marker for this tumor. Moreover, the tumor is positive for cytokeratin 7 (CK7), a keratin that is sensitive but not specific for the urothelial origin of the tumor. CK20 is present in adenocarcinomas and urothelial carcinomas, but is negative or weakly positive in CCC. Positive immunostaining for uroplakin III is also demonstrated in approximately 50% of cases. In the present patient’s mass, neoplastic cells were strongly positively stained for CK7, CK20 (Fig. 3), p53, PAS, weakly positive for CA125, and negative for prostate-specific antigen, CD10, AFP, and hepatocyte, while Ki 67 was highly expressed. The histological origin of these tumors is uncertain, but interesting. A theory of a Müllerian origin was initially proposed. In men the prostatic utricle is considered to be a remnant of the Müllerian duct, while there is also the possibility of remnant elements in the bladder or the urethra. Another theory describes a glandular differentiation of the urothelial carcinoma. A third hypothesis is that CCC are probably adenocarcinomas of non-Müllerian origin, which have a clear cell pattern for unknown reasons. Very recently, compelling evidence was reported for a urothelial origin of CCC of the lower urinary tract, in which urothelial and CCC share common chromosomal mutations. CCC seems to be a particularly aggressive tumor and radical surgery with adjuvant chemotherapy is considered to be the treatment of choice. In contrast, the accumulated experience confirms that despite high stage at diagnosis, a favorable prognosis is maintained regardless of length of follow up. Figure 1 CT of the bladder. Pathology International 2009; 59: 595–597 doi:10.1111/j.1440-1827.2009.02413.x

S70 Benign renal tumor prevalence and its correlation with patient characteristics and pathology report data

Objectives: To correlate the incidence of benign renal tumours with parameters associated with patient characteristics and pathology. Materials and Methods: The files of 192 patients who underwent radical or partial nephrectomy were reviewed. The investigated variables consisted of tumour size, kidney and renal pole location, age and gender. Tumour size was categorized according to the TNM system. The incidence of malignant renal tumours and their subtypes was also calculated. Results: We recorded 31.5% of benign and 69.5% of malignant tumours with a diameter < 4cm (p<.001). Between 4.1-7 cm, 90% were malignant and 10% were benign. For tumours measuring 7.1-10 cm, 94.4% were malignant and 5.6% were benign. For tumours larger than 10cm, the percentages were 92.3% and 7.7%, respectively. No other variable was presented as a considerable independent factor. Conclusions: 30% of the renal lesions measuring < 4 cm proved to be of benign histology. Tumour size seems to be correlated with benign renal tumour frequency, assisting the physician, along with the surgical experience and the imaging modalities, in deciding the optimum management.