Dario Ratti

Upper Urinary Tract Recurrence Following Radical Cystectomy for Bladder Cancer: A Meta-Analysis on 13,185 Patients

PURPOSE Patients who undergo radical cystectomy for urothelial cancer are at risk for upper urinary tract disease in the remnant transitional tissue. Previous studies have identified several risk factors for upper urinary tract recurrence but the predictive value of each factor remains controversial. Furthermore, the schedule for surveillance of the upper urinary tract with imaging techniques and cytology has not been established. International guidelines do not address these topics and refer only to isolated works with a large case based analysis. We performed this meta-analysis to evaluate the effective incidence of upper urinary tract recurrence after cystectomy for bladder cancer, to analyze the risk factors so we can create subgroups of patients at high risk for recurrence and to investigate the real role of screening in the detection of upper tract lesions at an early stage. MATERIALS AND METHODS A bibliographic search covering the period from January 1970 to July 2010 was conducted using PubMed®, MEDLINE and EMBASE®. This analysis is based on the 27 studies that fulfilled the predefined inclusion criteria. Data were analyzed using a fixed effect logistic regression approach and classic meta-analysis. RESULTS A total of 13,185 participants were included in the analysis. Followup was described in 22 studies and ranged from 0.36 to 349.2 months. The overall prevalence of upper tract transitional cell cancer after cystectomy ranged from 0.75% to 6.4%. Recurrence appeared at a range of 2.4 to 164 months, and in an advanced (64.6%) or metastatic state (35.6%) as reflected in poor survival rates. Patients with low grade vs high grade lesions at cystectomy showed as strong a significant difference in incidence as those with carcinoma in situ and superficial cancer vs invasive cancers and as strong as in those without lymph node involvement, with multifocal disease, with a history of multiple urothelial recurrences, with positive ureteral margins, with positive urethral margins, with urethral involvement and a history of upper urinary tract urothelial cancer. Data do not support a statistically significant difference in recurrence among patients with a history of carcinoma in situ, solitary lesion and among various types of urinary diversion adopted. In 24 studies the followup schedule included periodic radiological assessment of the upper urinary tract and in 20 it included urinary cytology. In 14 studies in 63 of 166 patients (38%) upper urinary tract recurrence was diagnosed by followup investigation whereas in the remaining 62% diagnosis was based on symptoms. When urine cytology was used in surveillance the rate of primary detection was 7% and with upper urinary tract imaging it was 29.6%. Of 5,537 patients who underwent routine cytological examination, recurrence was diagnosed in 1.8/1,000 and of those who underwent upper urinary tract imaging recurrence was diagnosed in 7.6/1,000. CONCLUSIONS The recurrence values could appear low when considering the pan-urothelial field defect theory, but these values reflect, in part, the mortality associated with the initial bladder cancer. Based on anamnesis and pathological examination of cystectomy specimens, a group of patients is at high risk. Extensive regular followup with cytology, urography and loopgraphy yields insufficient benefits. Periodic computerized tomography with urography combines the ability to study the upper urinary tract oncologically and functionally, and the identification of any parenchymal, osseous or lymph node secondary lesion.

Inverted papilloma of the bladder: A review and an analysis of the recent literature of 365 patients

OBJECTIVES Until the 1970s, inverted urothelial papilloma (IUP) of the bladder was generally regarded as a benign neoplasm. However, in the 1980s, several reported cases suggested the malignant potential of these papillomas, including cases with features indicative of malignancy, recurrent cases, and cases of IUP synchronous or metachronous with transitional cell carcinoma. The aim of this systematic review and analysis of the literature since 1990 to date is to contribute to unresolved issues regarding the biological behavior and prognosis of these neoplasms to establish some key points in the clinical and surgical management of IUP. MATERIALS AND METHODS Database searches yielded 109 references. Exclusion of irrelevant references left 10 references describing studies that fulfilled the predefined inclusion criteria. RESULTS One problem regarding these neoplasms is the difficulty of obtaining a correct histopathologic diagnosis. The main differential diagnosis is endophytic urothelial neoplasia, including papillary urothelial neoplasia of low malignant potential or urothelial carcinoma of low or high grade, while other considerably rare differential diagnoses include nephrogenic adenoma, paraganglioma, carcinoid tumor, cystitis cystica, cystitis glandularis, and Brunns cell nests. The size of the lesions ranged from 1 to 50 mm (mean 12.8 mm). Most cases occurred in the fifth and sixth decade of life. The mean age of affected patients was 59.3 years (range 20-88 years). Analysis of the literature revealed a strong male predominance with a male/female ratio of 5.8:1. The most commonly reported sites of IUP were the bladder neck region and trigone. Of 285 cases included in 8 studies, 12 cases (4.2%) were multiple. Out of the total of 348 patients, 6 patients (1.72%) had a previous history of transitional cell carcinoma of the urinary bladder, 5 patients (1.43%) had synchronous transitional cell carcinoma of the urinary bladder, and 4 patients (1.15%) had subsequent transitional cell carcinoma of the urinary tract. The time before recurrence was <45 months (range 5-45 months, mean 27.7 months) after surgery. CONCLUSIONS Inverted papilloma could be considered a risk factor for transitional cell carcinoma, and it is clinically prudent to exclude transitional cell cancer when it is diagnosed. Follow-up is needed if the histologic diagnosis is definitive or doubtful. We recommend 4-monthly flexible cystoscopy for the first year and then every 6 months for the subsequent 3 years. Routine surveillance of the upper urinary tract in cases of inverted papilloma of the lower part of the urinary tract is not deemed necessary.

One day surgery in the treatment of benign prostatic enlargement with thulium laser: A single institution experience

Purpose Various articles have previously addressed the introduction of new surgical laser therapies for an enlarged prostate gland causing obstructive symptoms. The objective of this study was to report the feasibility of performing the thulium laser vapo-enucleation of the prostate (ThuVEP) procedure for benign prostatic obstruction in a 1-day surgery. Materials and Methods From September 2011 to September 2013, we conducted a prospective study on patients who underwent ThuVEP in a 1-day surgery. The primary outcomes measured perioperatively included operative time, resected tissue weight, hemoglobin decrease, transfusion rate, postoperative irrigation and catheterization time, and postoperative hospital stay. Also, the preoperative and postoperative International Prostate Symptom Score (IPSS) and results of uroflowmetry performed on the 7th and 30th postoperative days were recorded. All perioperative and postoperative complications were monitored. Results A total of 53 patients underwent the surgical treatment in a 1-day surgery. Seven patients continued antiaggregant therapy with aspirin. Mean preoperative prostatic adenoma volume was 56.6 mL. Mean operative time was 71 minutes. The average catheter time was 14.8 hours. The peak urinary flow rate on day 7 improved from 9.3 to 17.42 mL/s (p<0.001) and the IPSS improved from 18 to 10.2 (p<0.01). Patients were routinely discharged on the day of catheter removal. No complications were recorded. Conclusions ThuVEP can be safely conducted as a 1-day surgical procedure. This strategy results in cost savings. ThuVEP shows good standardized outcomes with respect to improvement in flow parameters and length of bladder catheterization.

Thulium Laser Prostate Enucleation in Refractory Urinary Retention: Operative and Functional Outcomes in a Large Cohort of Patients

OBJECTIVE To evaluate the functional and operative results of thulium laser enucleation of the prostate (ThuLEP) in patients with indwelling catheters for refractory urinary retention. METHODS Patients with indwelling catheter, undergoing ThuLEP for benign prostate hyperplasia, were prospectively enrolled. Every episode of urinary retention was treated with urinary catheter positioning followed by at least 2 attempts of catheter removal. Patients were investigated with flowmetry and the self-administered International Prostate Symptom Score questionnaire at 30 and 90 days following ThuLEP. RESULTS Three hundred eighty-one patients underwent ThuLEP, and 99 of these had indwelling catheters, but only 93 (24%) were eligible according to the inclusion criteria. In 46 patients the bladder catheter was removed on the first postoperative day, in 31 patients on the second postoperative day, in 5 patients on the third postoperative day, in 6 patients on the fourth postoperative day, in 1 patient on the fifth postoperative day, and in 2 patients each on the sixth and seventh postoperative days. The average hospital stay was 2.3 (±1.7) days. No patients undergoing ThuLEP, at the 90-day follow-up, required further catheterization. Flowmetry showed significant improvement in all parameters, and the mean International Prostate Symptom Score dropped from 21.33 preoperatively to 3.2 (P = .004) at 90 days postoperatively. CONCLUSION This prospective study shows that ThuLEP is a safe and effective approach in refractory urinary retention patients. In our case series, no patients required postoperative intermittent catheterization. All functional outcomes investigated reported a statistical significant improvement.