Dimitri D. Kuznetsov

Intravesical valrubicin in the treatment of carcinoma in situ of the bladder.

The propensity of patients with carcinoma in situ (CIS) of the bladder to progress to invasive and metastatic disease is clearly established. Today, the standard therapy in treating patients with CIS of the bladder is intravesical bacillus Calmette-Guerin (BCG). Nevertheless, patients who fail intravesical BCG have few viable options except to undergo a radical cystectomy. Valrubicin (N-trifluoroacetyladriamycin-14-valerate) is a new semisynthetic derivative of the anthracycline antibiotic doxorubicin that has been shown to benefit patients with BCG-refractory CIS of the bladder. Intravesical instillation of valrubicin is well-tolerated, safe and can be durable. Early non-randomised studies show promise and the current utilisation of this drug is limited to patients with BCG-refractory CIS of the bladder who are not good surgical candidates. Randomised studies of intravesical valrubicin for the treatment of superficial bladder cancer are ongoing.

Urethral substitution using an intestinal free flap: A novel approach

PURPOSE Patients who have extensive stricture disease, those in whom hypospadias repair fails and those who sustain significant urethral trauma pose a reconstructive challenge for genitourinary surgeons. We developed an additional reconstructive option for men with a severely diseased urethra when grafting procedures and local tissue flaps have failed or are otherwise contraindicated. MATERIALS AND METHODS A genitourinary reconstructive team performed novel intestinal free flap substitution urethroplasty in 2 patients. A segment of jejunum is harvested on a vascular pedicle and plicated into an appropriate size urethral substitute. Microvascular anastomoses allow this segment to remain viable and functional. The technical aspects of repair and surgical considerations are detailed. RESULTS The 2 patients have a satisfactory functional and cosmetic outcome. At short followup the urethral lumen remained patent and the intestinal urethra remained viable and intact. Both patients have good urinary streams and are able to void in the standing position. CONCLUSIONS This initial experience in 2 patients indicates that intestinal segment urethral substitution may be considered within the reconstructive armamentarium of genitourinary surgeons when more conventional options have failed or are contraindicated. Continued vigilant followup is necessary to detail any secondary complications. In addition, further experience with this technique by other surgeons would help determine its overall usefulness.

Prospective evaluation of ureteral stent durability in patients with chronic ureteral obstruction.

OBJECTIVES To prospectively evaluate the durability of ureteral stents in patients with chronic ureteral obstruction. METHODS Twenty-nine renal units from 22 patients with known chronic ureteral obstruction treated with indwelling ureteral stents were studied at 3, 6, 9, and 12 months after initial stent placement (7 to 8F Percuflex) by abdominal x-ray, serum creatinine, and renal and bladder ultrasonography. Renal ultrasound scans were performed by a single senior radiologist with specific attention paid to any increase in hydronephrosis and to the presence of ureteral jets. The stent was changed when calcifications were seen along the stent on abdominal x-ray, if an increase in serum creatinine occurred, or if any increase in hydronephrosis or absence of ureteral jets was seen on ultrasonography. In addition, the stents were changed if new-onset flank pain and/or pyelonephritis developed. If none of the above occurred, the stents were changed after 12 months. RESULTS Two patients died of metastatic cancer, leaving 25 renal units available for follow-up. The mean and median time to stent change were 6 months. At 3, 6, 9, and 12 months, the number of renal units that did not meet the criteria warranting stent change was 18 (72%), 12 (48%), 6 (24%), and 2 (8%), respectively. Only 2 (8%) of 25 renal units did not meet any exclusion criteria at 12 months. The most common reasons for requiring the stent to be changed were new-onset flank pain in 8 (35%), an increase in serum creatinine in 7 (30%), and new-onset or increased hydronephrosis in 7 (30%). No criteria were useful in predicting how long stents could be maintained in an individual patient. CONCLUSIONS The stents were maintained for more than 6 months in 12 (48%) of 25 renal units. However, very few patients were able to maintain chronic ureteral stents for 12 months without requiring stent change based on our criteria.