J.A. Nieuwenhuijzen

Unusual complication after immediate postoperative intravesical mitomycin C instillation.

Immediate adjuvant Mitomycin C (MMC) instillation is routine practice in the treatment of superficial bladder cancer. Despite relative safety we describe a case of MMC extravasation after intravesical instillation. This resulted in severe continuous pain in the pelvic region without tendency of spontaneous healing, and required surgical debridement. To assess perivesical soft tissue injury prior to surgery MRI imaging turned out to be more accurate than computer tomography. Suggestions about how to avoid, diagnose and treat this symptomatic extravasation are made.

Long-term survival after combined modality treatment in metastatic bladder cancer patients presenting with supra-regional tumor positive lymph nodes only

AIMSnTo evaluate if combined treatment should be offered to bladder cancer patients presenting with supra-regional lymph node metastases only and a clinical complete or partial response after chemotherapy.nnnPATIENTS AND METHODSnWe identified 14 patients with supra-regional lymph node metastases out of 394 patients with transitional cell carcinoma (TCC) treated in our institute with cystectomy and regional and supra-regional lymph node dissection between 1987 and 2007. Prior to cystectomy, neoadjuvant chemotherapy had been given. The patients received a total of four cycles of platinum-based chemotherapy.nnnRESULTSnFive patients had a CR, nine patients had a PR after neoadjuvant chemotherapy. Histopathological proof of complete response in the bladder was confirmed in all five cases. One of these five patients had a CR in the bladder but pelvic lymph nodes still contained vital tumor. Five patients had no tumor in the lymph nodes, whereas four had tumor in the lymph nodes. Eleven patients died due to bladder cancer, seven of them within 1 year after cystectomy. The 3- and 5-year disease-specific survival rates were 36% (95% CI: 10-60%) and 24% (95% CI: 0-49%). Mean follow-up was 2.5 years.nnnCONCLUSIONSnCombination therapy consisting of neoadjuvant chemotherapy and surgery in selected patients with tumor positive supra-regional lymph nodes only can result in durable long-term survival rates (24% 5-year survival). Response evaluation after neoadjuvant chemotherapy might play a decisive role in the selection of patients undergoing subsequent surgical removal of all known tumor sites.

Prostate‐sparing cystectomy: long‐term oncological results

To analyse the oncological outcome of prostate‐sparing cystectomy (PSC).

Outcome of treatment of bladder cancer: a comparison between low-volume hospitals and an oncology centre

PurposeTo evaluate the effect of volume of cystectomies in the Greater Amsterdam region on postoperative outcomes.MethodsAll primary bladder tumours diagnosed between 1989 and 2003 were selected from the Amsterdam Cancer Registry, a population-based cancer registry (population 3.0xa0million). For all patients who underwent cystectomy during 1989–2003 at 20 participating hospitals, medical records were reviewed for information on postoperative mortality, locoregional recurrences and relative risk of death. To assess the effect of volume, outcomes at an oncology centre and low-volume hospitals were compared.ResultsDuring 1989–2003 a total of 1,185 cystectomies were performed in 20 hospitals of the Greater Amsterdam region. Postoperative mortality was 3.2%. During 1989–1997, 8% of cystectomies were performed at the oncology centre, increasing to 30% in 1998–2003. Although postoperative mortality at this centre decreased from 4.0% in 1989–1997 to 1.1% in 1998–2003, the latter percentage was not statistically significantly different from the other hospitals during 1998–2003 (OR 0.3; Pxa0=xa00.09). No statistically significant difference in locoregional recurrence rate and in the relative risk of death was observed between the oncology centre and all other hospitals combined.ConclusionsWe observed a lower postoperative mortality rate in the oncology centre compared to the low-volume hospitals; however, this difference did not reach statistical significance. We could neither prove a statistically significant relation between hospital volume, local recurrence rate and survival after cystectomy. To answer the question if centralisation of cystectomies is beneficial more procedures have to be compared.

221 Prostate sparing cystectomy: 20 years single center experience

INTRODUCTION AND OBJECTIVES: Patients who experience disease recurrence after radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB) have a very poor prognosis. Most recurrences occur during the first two years following RC. The incidence, patterns, and prognosis of late recurrences (LRs) following RC have not been well described. METHODS: We queried our prospectively maintained institutional database and identified 1953 consecutive patients who underwent RC for UCB from 1995-2010. We identified patients who experienced disease recurrence following RC and analyzed both nonurothelial tract disease recurrence and urothelial recurrence. Late recurrence was defined as a non-urothelial tract recurrence occurring three or more years following RC. RESULTS: Of 648 UCB patients who experienced non-urothelial tract disease recurrence following RC, 93 (14%) occurred greater than 3 years following RC, and 42 (6%) occurred after 5 years (range 3.01 e 12.89 years). Of these 93 LRs, 22 (24%) were local, 54 (58%) were distant, and 17 (18%) were both local and distant. Sites of metastasis in patients with LRs included 21 (23%) lung, 20 (22%) bone, 47 (51%) lymphatic, 18 (19%) liver, 20 (22%) pelvis, and 5 (5%) other. Urothelial tract recurrences were identified in 44 of 93 patients with LR, 30 upper tract and 18 urethral. After excluding 17 patients in whom the LR could be ascribed to an invasive upper tract second primary tumor, 76 LR patients were left for analysis. The stage distribution at RC for LR patients was pT0 (7%), pTa (5%), pTis (18%), pT1 (12%), pT2 (26%), pT3 (21%), and pT4 (8%). Twelve LR patients (16%) had LN-positive disease. Eleven LR patients had received pre-operative cisplatin-based chemotherapy and 8 received adjuvant chemotherapy. LR patients were more likely to have organ-confined disease at RC (62% vs. 21%, p<0.001) and concomitant CIS (78% vs. 61%, p1⁄40.02) than patients experiencing recurrence within 3 years. However, the prognosis following recurrence was similarly poor for patients experiencing LR as it was for early recurrence, although LR patients had a slightly longer time from recurrence to death (p1⁄40.002). CONCLUSIONS: Bladder cancer patients treated with RC remain at risk for disease recurrence for many years, although the majority of patients who will recur do so within the first two years. Patients who experience late recurrence have different disease characteristics than those who experience early recurrence. Continued surveillance for detection of local, distant, and urothelial recurrences following RC may be beneficial.

693 Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer

OBJECTIVEnTo evaluate the long-term results of salvage cystectomy after interstitial radiotherapy (IRT) and external beam radiotherapy (EBRT) for transitional cell carcinoma, and to assess the morbidity and functional results of the different urinary diversions used.nnnPATIENTS AND METHODSnThe records of 27 patients treated with salvage cystectomy in one institution between 1988 and 2003 were retrospectively analysed.nnnRESULTSnSalvage cystectomy was used after failure of IRT in 14 or EBRT in 13 patients, with a 3- and 5-year survival probability of 46% (95% confidence interval 26-65) and 33 (11-54)%. The 5-year overall survival after cystectomy was 54% after IRT and 14% after EBRT (P = 0.12). Tumour category, response to radiation, American Society of Anesthesiology score, and complete tumour resection had a significant influence on survival. Five of seven patients with incomplete resection died because of local disease, with a median survival of 5 months. There was clinical understaging after radiotherapy in 41% of patients. Nine patients had an orthotopic neobladder, with complete day- and night-time continence in eight and four, respectively. All patients but one had good voiding function. There were early complications in two and late complications in six patients (for Bricker, seven of 14 and none; for Indiana, none of four and two of four). The duration of hospitalization was not influenced by the type of diversion. Erectile function was maintained in four of six patients after a sexuality-preserving cystectomy and neobladder.nnnCONCLUSIONSnSalvage cystectomy can be performed with acceptable morbidity using any type of urinary diversion. Understaging after radiotherapy is common, but preoperative selection needs improving. A very significant factor for an adverse outcome and death from local tumour recurrence was incomplete resection, suggesting that salvage cystectomy should only be attempted if complete resection is probable.