Hassan Abol-Enein

Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

To develop a technique of nerve‐sparing robot‐assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer.

Postoperative nomogram predicting risk of recurrence after radical cystectomy for bladder cancer

PURPOSE Radical cystectomy and pelvic lymphadenectomy (PLND) remains the standard treatment for localized and regionally advanced invasive bladder cancers. We have constructed an international bladder cancer database from centers of excellence in the management of bladder cancer consisting of patients treated with radical cystectomy and PLND. The goal of this study was the development of a prognostic outcomes nomogram to predict the 5-year disease recurrence risk after radical cystectomy. PATIENTS AND METHODS Institutional radical cystectomy databases containing detailed information on bladder cancer patients were obtained from 12 centers of excellence worldwide. Data were collected on more than 9,000 postoperative patients and combined into a relational database formatted with patient characteristics, pathologic details of the pre- and postcystectomy specimens, and recurrence and survival status. Patients with available information for all selected study criteria were included in the formation of the final prognostic nomogram designed to predict 5-year progression-free probability. RESULTS The final nomogram included information on patient age, sex, time from diagnosis to surgery, pathologic tumor stage and grade, tumor histologic subtype, and regional lymph node status. The predictive accuracy of the constructed international nomogram (concordance index, 0.75) was significantly better than standard American Joint Committee on Cancer TNM (concordance index, 0.68; P < .001) or standard pathologic subgroupings (concordance index, 0.62; P < .001). CONCLUSION We have developed an international bladder cancer nomogram predicting recurrence risk after radical cystectomy for bladder cancer. The nomogram outperformed prognostic models that use standard pathologic subgroupings and should improve our ability to provide accurate risk assessments to patients after the surgical management of bladder cancer.

FUNCTIONAL RESULTS OF ORTHOTOPIC ILEAL NEOBLADDER WITH SEROUS-LINED EXTRAMURAL URETERAL REIMPLANTATION: EXPERIENCE WITH 450 PATIENTS

PURPOSE We report functional results of the orthotopic ileal neobladder using a serous-lined extramural tunnel as an antireflux procedure. MATERIAL AND METHODS One-stage radical cystectomy and orthotopic ileal W-shaped neobladder creation were performed in 353 male and 97 female patients for invasive bladder cancer. The ureters were reimplanted using a serous-lined extramural tunnel for reflux prevention. Of the patients 344 were evaluable at a mean followup plus or minus standard deviation of 38 +/- 25 months. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes. RESULTS Four patients (0.8%) died in the hospital. Early complications in 42 patients (9%) were treated conservatively but 3 women underwent vaginal repair of a pouch-vaginal fistula. During the observation period there were 90 oncological failures, of which 3 were isolated urethral recurrence. Late complications included pouch stones in 10 cases, outflow obstruction in 11, mucous retention in 2, adhesive bowel obstruction in 3 and hypercontinence in 9 females. The incidence of daytime and nighttime continence was 93.3% and 80%, respectively. The upper tracts remain unchanged or improved in 96.2% of the reimplanted renal units, while reflux was observed in 3%. CONCLUSIONS The serous-lined extramural tunnel has proved its efficiency and durability as an antireflux technique.

Radical cystectomy for carcinoma of the bladder: 2,720 consecutive cases 5 years later.

PURPOSE We performed a critical analysis of the results of radical cystectomy for invasive bladder carcinoma treated at 1 center. MATERIALS AND METHODS Between 1970 and 2000, 2,090 men and 630 women with invasive bladder cancer were treated with 1-stage radical cystectomy and urinary diversion. Followup ranged from 0 to 34.2 years with a mean of 5.5 +/- 5.7. Survival data were correlated to patient and tumor characteristics using univariate and multivariate analysis. RESULTS Postoperative mortality was 2.6%. Squamous tumors accounted for 49.4% of cases, transitional cell carcinoma for 36.4% and adenocarcinoma for 9.6%. Regional lymph nodes were involved in 20.4% of cases. The 5 and 10-year disease-free survival rates were 55.5% and 50.03%, respectively. Evidence was provided that tumor stage, histological grade and lymph node status are the only independent variables which affect survival probability. CONCLUSIONS Contemporary cystectomy can be performed with minimal mortality. Radical cystectomy for organ confined disease is followed by good therapeutic results and enhances the possibilities for functional restoration. With stage progression there is a stepwise reduction in survival probability. The radical operation can provide disease-free survival for an important subgroup of node positive cases (27.3%). Additional therapy is needed to improve the oncological outcome for advanced locoregional disease.

A Novel Uretero-Ileal Reimplantation Technique: The Serous Lined Extramural Tunnel. A Preliminary Report

A novel technique for an anti-refluxing uretero-ileal reimplantation entailing creation of 2 serous lined extramural tunnels in a detubularized ileal W-bladder is presented. The operation was done on 12 patients in whom an orthotopic bladder substitute was indicated. Mean followup was 18 months. Evidence indicated that this method could provide a nonobstructed unidirectional flow of urine in all of the examined renal units.

ICUD-EAU International Consultation on Bladder Cancer 2012: Urinary diversion.

CONTEXT A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications. OBJECTIVE To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD). EVIDENCE ACQUISITION An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis. EVIDENCE SYNTHESIS Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%. CONCLUSIONS RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

Does the Extent of Lymphadenectomy in Radical Cystectomy for Bladder Cancer Influence Disease-Free Survival? A Prospective Single-Center Study

BACKGROUND Controversy exists regarding the optimal extent of lymphadenectomy and the number of lymph nodes to be retrieved at radical cystectomy (RC). OBJECTIVE To compare the disease-free survival of patients with standard lymphadenectomy (endopelvic region composed of the internal, external iliac, and obturator groups of lymph nodes) versus extended lymphadenectomy (up to the level of origin of the inferior mesenteric artery) at RC in a prospective cohort of patients at a single, high-volume center. DESIGN, SETTING, AND PARTICIPANTS Prospective data were collected from 400 consecutive patients treated with RC for bladder cancer by two high-volume surgeons at Mansoura Urology and Nephrology Center. Of the 400 patients, 200 (50%) received extended lymphadenectomy and the other 200 (50%) underwent standard lymphadenectomy at RC. The patients did not receive any neoadjuvant or adjuvant therapy. MEASUREMENTS Patient characteristics and outcomes are evaluated. RESULTS AND LIMITATIONS Median patient age for the entire group was 53.0 yr. Ninety-six patients (24.0%) had lymph node metastases. Median follow-up was 50.2 mo. Estimates of 5-yr disease-free survival in the extended lymphadenectomy group were 66.6% compared with 54.7% for patients with standard lymphadenectomy (p = 0.043). Extended lymphadenectomy was associated with better disease-free survival after adjusting for the effects of standard pathologic features (p = 0.02). When restricting the analyses to lymph node-positive patients, patients with extended lymphadenectomy had much better 5-yr disease-free survival compared with patients with standard lymphadenectomy (48.0% vs 28.2%; p = 0.029). The study was nonrandomized. CONCLUSIONS Extended lymphadenectomy is associated with better disease-free survival for bladder cancer patients with endopelvic lymph node involvement and should be considered in these patients.

Treatment of Urethral Defects: Skin, Buccal or Bladder Mucosa, Tube or Patch? An Experimental Study in Dogs

PURPOSE We studied 3 graft materials and 2 urethroplasty techniques in 24 adult male mongrel dogs. MATERIALS AND METHODS The animals were divided into 2 equal groups. In group 1 a 4 cm. segment of perineal urethra was excised and tubed urethroplasty was performed using free full-thickness skin, buccal and bladder mucosa grafts in 4 dogs each. In group 2 a 4 cm. urethral strip was excised and onlay urethroplasty was performed using the same graft materials in 4 dogs each. Retrograde urethrography was done and the animals were sacrificed at week 12. Autopsy specimens were calibrated with a 10Fr catheter. Hematoxylin and eosin stained sections were examined. Massons trichrome stain was used to determine the extent of fibrosis. RESULTS Urethral stricture was diagnosed by radiology and confirmed by calibration in 8 of the 12 dogs (66%) in group 1 but in only 1 of the 12 (8%) in group 2 (p <0.004). Buccal mucosa grafts were associated with the lowest stricture rate of 12%, followed by 37% for bladder mucosa and 62% for skin (p <0.2). There was no difference in neovascularization among the 3 grafts. Graft shrinkage was less than 10% for buccal mucosa compared with 20% to 40% for skin and bladder mucosa. The shrinkage rate was similar for the onlay and tube techniques. The intensity of chronic inflammation and fibrosis was highest in the skin grafts. Circumferential fibrosis was noted in association with tubed urethroplasty but not with the onlay technique. CONCLUSIONS The theoretical advantages of buccal mucosal grafts were pathologically demonstrated. When possible, grafts should be used as an onlay rather than as a complete tube.

Prognostic and functional significance of thromboxane synthase gene overexpression in invasive bladder cancer.

Thromboxane synthase (TXAS) is one of the enzymes downstream from cyclooxygenase-2 and catalyzes the synthesis of thromboxane A(2) (TXA(2)). TXAS was among the genes we identified based on its overexpression in invasive bladder tumors. TXAS is overexpressed in common forms of bladder tumors: 69 of 97 (71.1%) transitional cell carcinoma (TCC), 38 of 53 (71.6%) squamous cell carcinoma, and 5 of 11 (45.5%) adenocarcinoma relative to nontumor tissue. Overall, 112 of 161 (69.5%) invasive tumors exhibited elevated expression. Significantly, patients with tumors having >4-fold levels of TXAS expression showed significant statistical evidence of lower overall survival expressed by the estimated hazard ratio of 2.74 with P = 0.009 in Coxs regression analysis. TXAS mRNA expression was found to be an independent prognostic marker for patients with bladder cancer. Treatment of bladder cancer cell lines (T24 and TCC-SUP) with TXAS inhibitors and TXA(2) (TP) receptor antagonists reduced cell growth, migration, and invasion, whereas TP agonists stimulated cell migration and invasion. The positive correlation between elevated TXAS expression and shorter patient survival supports a potential role for TXAS-regulated pathways in tumor invasion and metastases and suggests that modulation of the TXAS pathway may offer a novel therapeutic approach.