Daniel Beurton

Tumor progression and survival in patients with T1G3 bladder tumors: multicentric retrospective study comparing 94 patients treated during 17 years

OBJECTIVES To compare tumor recurrence, progression, and patient survival in T1G3 bladder tumors treated with transurethral resection (TUR) alone, early cystectomy, or TUR with an adjuvant 6-week course of bacille Calmette-Guérin (BCG) and followed up for a minimum of 5 years. METHODS Between 1979 and 1996, 94 patients with T1G3 bladder tumors (lamina propria invasion) were treated at nine different centers. The time to tumor recurrence, tumor stage and grade progression, number of delayed cystectomies, and patient survival were analyzed retrospectively in relation to the initial treatment. RESULTS The mean follow-up was 62 months. Thirty patients were treated by TUR alone (32%), 50 patients by TUR plus BCG (53%), and 14 patients by primary cystectomy (15%). The recurrence, progression, and cystectomy rates were significantly different between patients treated by TUR alone and TUR plus BCG (Fishers exact test, P = 0.0005, P = 0.02, and P = 0.005, respectively). The disease-free survival was also significantly different when comparing TUR plus BCG with TUR alone or primary cystectomy (Kaplan-Meier analysis, log-rank test, P = 0.02). CONCLUSIONS Endoscopic resection plus BCG treatment of pT1G3 tumors allows an 80% rate of disease-free 5-year survival with bladder preservation. This conservative option has been widely accepted as first-line treatment, offering good cancer control with excellent quality of life. Very accurate surgical and pathologic evaluations before treatment and lifelong follow-up are obviously required.

Reappraisal of Endoscopic Sphincterotomy for Post-Traumatic Neurogenic Bladder: A Prospective Study

PURPOSE We assessed the results of endoscopic sphincterotomy in patients with detrusor-sphincter dyssynergia secondary to spinal cord injury. MATERIALS AND METHODS A prospective study was done of 92 patients with a mean followup of 20.6 months. RESULTS The morbidity rate was 10.9%. Results demonstrated objective (assessed by the decrease in voiding pressure) and subjective (expressed by the patient) improvement in quality of micturition in 83.7% and 73% of the cases, respectively. Subjective autonomic dysreflexia resolved in 93.2% of the cases. CONCLUSIONS Sphincterotomy is a useful and effective therapeutic method for neurogenic bladder when all available pharmacological treatments and clean intermittent catheterization have failed.

Twenty-year experience with jejunal conduits

OBJECTIVES To assess the results of jejunal conduit urinary diversion, with particular attention to electrolyte imbalance and long-term renal function. METHODS From 1976 to 1994, 50 patients underwent urinary diversion using a short jejunal loop (10 to 12 cm) placed transperitoneally. Of these patients, 18 received pelvic irradiation before diversion. Renal function and configuration of the upper urinary tract were assessed by creatinine clearance and excretory urography. RESULTS Median follow-up was 26 months (3 to 204). Of 50 patients, 22 had a follow-up more than 5 years later (median 86 months). Eight patients (16%) underwent 10 revision procedures postoperatively. Late complications related to urinary diversion included renal calculi (12%), parastomal hernia (6%), pyelonephritis (4%), ureterojejunal obstruction (4%), and stomal prolapse (2%). Electrolyte imbalance occurred in 2 patients (4%) and was easily corrected by 4 g sodium bicarbonate. No significant decrease in creatinine clearance (P = 0.6) was found in 22 patients with a follow-up of more than 5 years; however, of these patients, 2 had a decrease in creatinine clearance of greater than 20%, due to ureterojejunal obstruction. Of 42 ureterorenal units, hydronephrosis occurred and increased in 1 and 2 cases, respectively, and renal scarring occurred and progressed in 2 and 2 cases, respectively. CONCLUSIONS Urinary diversion using a short length of jejunum placed transperitoneally is a reliable procedure and gives good long-term renal function. Electrolyte imbalances are rare. Moreover, jejunal conduit can be used in almost all situations, especially after pelvic irradiation.

Urinary continence following radical prostatectomy assessed by a self-administered questionnaire.

Objectives: A total aim of this study was to assess the incidence of urinary incontinence in patients following radical prostatectomy and determine the factors that may influence this incidence.Methods: A total of 135 men underwent radical retropubic prostatectomy at our center between 1987 and 1997. 120 patients were sent a questionnaire regarding preoperative and postoperative voiding habits. Data collected included preoperative and postoperative continence status, interval to postoperative continence status, associated urinary symptoms, willingness to undergo radical prostatectomy again if need be and additional postoperative procedures. Patient age, date of surgery, number of neurovascular bundles resected at prostatectomy and duration of follow–up were also noted.Results: Of the 120 patients, 116 (96.7%), a mean of 65.2 (range 48–76) years old, responded to the questionnaire. Mean follow–up was 4.3 years (range 1–10.8). Continence was defined as no regular use of pads. Our overall urinary incontinence rate was 14.4%. Of the respondents, 88.8% (103/116) had achieved final continence status by 6 months postoperatively, and 95% (110/116) would undergo surgery again if need be. Of the patients considered incontinent postoperatively, 66.6% had associated urgency. Age, year of surgery, number of neurovascular bundles resected at prostatectomy, preoperative urinary leakage of postvoiding dribbling, postoperative pelvic floor exercises, and anastomotic stricture had no significant impact on postoperative continence status.Conclusions: Using an anonymous self–administered questionnaire, we found a 14.4% incontinence rate after radical prostatectomy. These results allow patients to have realistic expectations when counseled prior to this operation.

Combined Modified Rectus Fascial Sling and Augmentation Ileocystoplasty for Neurogenic Incontinence in Women

PURPOSE We assessed results of a combined modified rectus fascial sling procedure and augmentation ileocystoplasty in women with neurogenic urinary incontinence. MATERIALS AND METHODS We prospectively evaluated 21 patients (mean followup 28.6 months). RESULTS A total of 20 patients (95.2%) was dry during the day on intermittent catheterization and none had difficulty with catheterization. Subsequently surgery was necessary in 1 case for perforation of the augmented bladder. CONCLUSIONS A combined modified rectus fascial sling procedure and augmentation ileocystoplasty are safe and effective when all available pharmacological treatments and clean intermittent catheterization have failed.

Pregnancy and vaginal delivery after augmentation cystoplasty

Pregnancy after augmentation cystoplasty is becoming more common as women with congenital anomalies and neurogenic bladders and who have had complex urological reconstructions reach reproductive age. The recommendation for all patients who have undergone bladder neck surgery is to have a Caesarean section [1]. The present three cases illustrate successful pregnancies with vaginal delivery in neurogenic patients treated by augmentation ileocystoplasty combined, in two patients, with a modified rectus fascial sling. In all cases the continence did not deteriorate.

Urinary continence after salvage radiation therapy following radical prostatectomy, assessed by a self-administered questionnaire: a prospective study.

To evaluate urinary continence after salvage radiotherapy following radical prostatectomy (RP) for clinically localized prostate cancer.

Diagnosis and prediction of recurrence and progression in superficial bladder cancers with DNA image cytometry and urinary cytology

ObjectiveTo investigate the roles of urinary cytology and image cytometric analysis of nuclear DNA ploidy pattern in the diagnosis and prediction of recurrence and/or progression of superficial bladder cancers.

Heterogeneity of DNA distribution in diploid cells: a new predicitive discriminant factor for solid tumour behaviour

Spatial nuclear DNA heterogeneity distribution of Feulgen‐stained DNA diploid cells was studied by image cytometry in voided urine of 119 patients without bladder tumour (n=20) and with initial (n=23) or previous (n=76) diagnosed bladder tumour. For each patient, repetitive DNA measurements were performed during 1–4 years of follow up. Only cells of diploid DNA histograms and diploid subpopulations of aneuploid DNA histograms were used for analysis. DNA heterogeneity distribution of these diploid cells was quantified by statistical parameters of each nuclear optical density distribution. Discriminant analysis was performed on three groups of DNA histograms. Group A (n=44): aneuploid DNA histograms of patients with bladder tumour. Group D (n=55): 38 diploid DNA histograms of the 20 patients without bladder tumour (subgroup D1) and 17 diploid DNA histograms of patients with a non‐recurrent bladder tumour (subgroup D2). Group R (n=27): diploid DNA histograms of patients with bladder tumour recurrence. No statistically significant discriminant function was found to separate D1 and D2. However, the first canonical discriminant function C1 differentiated diploid cells of diploid DNA histograms (group D and group R) from diploid cell subpopulations of aneuploid DNA histograms (group A). Mean C1 values were 1.06, 0.84 and –1.45 for groups R, D and A, respectively. The second canonical discriminant function C2 differentiated diploid DNA histograms of patients with bladder tumour recurrence (group R) from diploid DNA histograms of patients without bladder tumour or without bladder tumour recurrence (group D). Mean C2 values were 1.78 and –0.76 for groups R and D, respectively. In 95% confidence limit, the rate of rediscrimination using the two first canonical discriminant functions C1 and C2 were 86.4, 74.5 and 74.1% for groups A, D and R, respectively. Percent of “grouped” cases correctly classified was 78.6%. Thus spatial DNA heterogeneity distribution of diploid cells seems to quantitate probable genetic instability as a function of clinical evolution such as tumour recurrence, and suggests the possible presence of aneuploid stemlines in a heterogeneous tumour, even if a diploid DNA histogram is observed in a single sample. From standardized C1 and C2 canonical discriminant function coefficients, a DNA heterogeneity index (2c‐HI) is proposed to characterize diploid cells providing a descriptive and predictive discriminant factor for solid tumour behaviour.

Diagnosis and prediction of recurrence and progression in superficial bladder cancers with DNA image cytometry and urinary cytology: DNA IMAGE CYTOMETRY IN SUPERFICIAL BLADDER CANCER

Objective To investigate the roles of urinary cytology and image cytometric analysis of nuclear DNA ploidy pattern in the diagnosis and prediction of recurrence and/or progression of superficial bladder cancers.