Jorge Huguet

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment

Study Type – Prognosis (case series)

Management of Urethral Recurrence in Patients with Studer Ileal Neobladder

OBJECTIVE The overall risk of urethral recurrence (UR) of transitional cell carcinoma (TCC) in patients with orthotopic neobladder ranges from 2% to 6%. We are presenting herein our experience in order to evaluate and define the management of these patients, since the cases with urethral recurrence in patients with orthotopic neobladder are very scarce. MATERIALS AND METHODS Five hundred and sixteen radical cystectomies due to TCC were performed at our Centre between January 1990 and February 1998. One hundred and thirty-eight of them (26.7%) underwent an orthotopic neobladder procedure with the Studers technique. We are reviewing five cases of UR in patients with orthotopic neobladder, the cystectomy indications and the differences between the clinical and the pathologic stages. We are also assessing its clinical presentation, diagnosis, treatment and evolution. RESULTS Five patients (3.6%) from 50 to 71 years old with Studers orthotopic neobladder presented with UR. All of those neobladders were initially superficial TCC, mostly multifocal, and all had failed the endovesical treatment. Endoscopic treatment was administered in two cases with superficial UR. One patient with urethral CIS received intraurethral BCG instillations. One case because of multiplicity, and another due to the presence of an infiltrating urethral tumour, underwent urethrectomy and neobladder exeresis. In both cases, the intact 15-20cm isoperistaltic proximal ileal limb of the Studer-type orthotopic neobladder was used as an ileal conduit. CONCLUSIONS UR in patients with orthotopic bladder substitution is unusual. A conservative approach is possible when dealing with superficial recurrences. In cases of urethrectomy, the isoperistaltic proximal ileal limb of the Studer neobladder may be used as an ileal conduit.

CT Findings in Urinary Diversion after Radical Cystectomy: Postsurgical Anatomy and Complications

Numerous surgical procedures have been developed for urinary diversion in patients who have undergone a radical cystectomy for bladder cancer or, less frequently, a benign condition. Because urinary diversion procedures are complex, early and late postsurgical complications frequently occur. Possible complications include alterations in bowel motility, anastomotic leaks, fluid collections (abscess, urinoma, lymphocele, and hematoma), fistulas, peristomal herniation, ureteral strictures, calculi, and tumor recurrence. Computed tomography (CT) is an accurate method for evaluating such events. Multiplanar reformatting and three-dimensional volume rendering of multidetector CT image data are particularly useful for achieving an accurate and prompt diagnosis of complications and obtaining information that is essential for adequate surgical management. In addition, knowledge of urinary diversion procedures, normal postsurgical appearances, and optimal CT technique for postsurgical evaluations is essential for detecting complications and avoiding misdiagnosis.

Recurrence at Three Months and High-grade Recurrence as Prognostic Factor of Progression in Multivariate Analysis of T1G2 Bladder Tumors

OBJECTIVES To evaluate the risk factors for disease progression in the frequent subgroup of Stage T1G2 (World Health Organization 1973) bladder tumors using an analysis of a large cohort of patients with Stage T1G2 disease. METHODS A cohort of 616 patients with Stage T1G2 were treated with transurethral resection and random bladder biopsies. The mean follow-up was 4.2 years. Univariate and multivariate analyses were done using Cox regression analysis. The independent variables were multiplicity, association with carcinoma in situ (CIS), tumor size, tumor recurrence at 3 or 6 months, tumor grade, and association with CIS at first recurrence. The dependent variable was progression to muscle-invasive disease. RESULTS Progression to muscle-invasive disease was identified in 28 of the 616 patients (4.5%). On multivariate analysis, when considering recurrence at 3 months, this factor was the principal prognostic factor, with a relative risk of 4.0 (95% confidence interval 1.2-13.3), followed by the presence of high-grade disease or CIS at first recurrence (relative risk 2.8, 95% confidence interval 1.3-5.8) and CIS associated with the primary tumor (relative risk 1.8, 95% confidence interval 1.1-2.9). When considering recurrence at 6 months, more prognostic factors were involved for progression, including as multiple tumors, CIS associated with the primary tumor, recurrence at 6 months, and the presence of high-grade disease or CIS at the first recurrence. CONCLUSIONS In primary urothelial T1G2 bladder cancer, recurrence at 3 months was the main prognostic factor related to progression. Additional factors were the association of CIS with the primary tumor and the presence of high-grade disease and/or CIS at first recurrence.

Low testosterone level predicts prostate cancer in re-biopsy in patients with high grade prostatic intraepithelial neoplasia.

Study Type – Prognosis (case series)

Second to fourth digit ratio, adult testosterone level and testosterone deficiency

Study Type – Diagnostic (exploratory cohort)

Cistectomía radical en tumores vesicales no músculo-infiltrantes que fracasan al tratamiento con bacilo de Calmette-Guérin

Objetivos: evaluar las caracteristicas y evolucion de los pacientes con tumores vesicales no musculo-infiltrantes (TVNMI) sometidos a cistectomia radical por fracaso a la terapia con bacilo de Calmette-Guerin (BCG). Material y metodos: de 864 cistectomias radicales (CR) realizadas en nuestro centro entre 1989 y 2002, 95 (11%) se indicaron en pacientes que habian recibido tratamiento previo con BCG. En 62 casos (65,2%) la CR se realizo por presencia de TVNMI recidivado de alto grado o carcinoma in situ, a pesar del tratamiento con BCG. En 17 de ellos (27%) la pieza de cistectomia mostro un estadio ? pT2. Se considero que estos pacientes fueron infraestadiados. En 33 casos (34,7%) la CR se hizo por progresion clinica a enfermedad musculo-infiltrante (? T2) durante el seguimiento. Analizamos las caracteristicas y evolucion de los pacientes cistectomizados por fracaso a la terapia con BCG y si existian diferencias entre los infraestadiados y los que presentaron progresion clinica durante el seguimiento. Resultados: la supervivencia cancer-especifica a los 5 anos fue del 90% en los 45 casos con estadio clinico y patologico de TVNMI, y del 50,6% en los 50 pacientes con progresion a enfermedad musculo-infiltrante (progresion clinica e infraestadiados) (p < 0,05). No hubo diferencias en la supervivencia entre los pacientes infraestadiados y con progresion clinica. La mediana de tiempo entre el diagnostico del tumor y la progresion fue de 24 meses (percentil 10-90; 6-98 meses).Los pacientes con progresion clinica presentaron de forma significativa mayor proporcion de tumores T1 (p = 0,015) en la RTU previa a la progresion y mas pT3 (p < 0,01) en pieza de CR. Los pacientes infraestadiados tuvieron mas estadios patologicos pT4 (p < 0,02). Conclusiones: en TVNMI de alto riesgo que fracasan a la BCG, la CR debe realizarse antes de la progresion a tumor musculo-infiltrante. Los T1 de alto grado son responsables de la mayor parte de progresiones clinicas y tempranas. Ciertos TVNMI pueden presentar progresion subclinica a traves de la prostata.

[Radical cystectomy in patients with non-muscle invasive bladder cancer who fail BCG therapy].

OBJECTIVE To assess the characteristics and outcomes of patients with non-muscle invasive bladder cancer (NMIBC) undergoing radical cystectomy (RC) due to BCG failure. MATERIALS AND METHODS Ninety-five (11%) of the 864 patients undergoing radical cystectomy (RC) at our center from 1989 to 2002 had received prior treatment with BCG. Of these, 62 (65.2%) underwent RC due to relapsing, high-risk NMIBC or CIS despite BCG therapy. A stage >or= pT2 tumor was reported in the cystectomy specimen in 17 (27%) of these patients, who were considered to have been understaged. RC was performed for clinical progression in 33 patients (34.7%). Their last transurethral resection before RC showed invasive disease. A retrospective analysis was made of the outcomes of patients who underwent RC for BCG failure and the clinical and pathological differences between understaged patients and those with clinical progression. RESULTS Five-year CSS was 90% in 45 patients with clinical and pathological NMIBC and 50.6% in 50 patients with progression to muscle-infiltrating disease (clinical progression and understaged) (p < 0,05). There were no differences in survival in patients with clinical progression as compared to understaged patients. Median time from tumor diagnosis to tumor progression was 24 months (10th-90th percentile, 6-98 months). Patients with clinical progression had significantly more T1 tumors (p = 0.015) in TUR before progression and more pT3 tumors (p < 0.01) in the RC specimen. Understaged patients more often had pathological pT4 stages (p < 0.02). CONCLUSION In patients with high-risk NMIBCs who fail BCG therapy, RC should be performed before progression because survival is decreased when the RC specimen shows muscle-invasive disease. High-grade T1 tumors are responsible for most early clinical progressions. Patients with NMIBC may have subclinical progression, mainly within the prostate.

Esquema práctico del manejo de los efectos adversos asociados con la instilacion de BCG

Resumen es: Objetivos: La morbilidad secundaria al tratamiento con Bacilo de Calmette-Guerin (BCG) intravesical puede presentarse tanto local como sistemicamente. La...

The Role of Surgery in Local Recurrences after Radical Cystectomy for Bladder Cancer

Introduction: Local recurrence (LR) after radical cystectomy (RC) for bladder cancer has a bad prognosis. Treatment options include chemotherapy, radiation therapy and surgical excision, but few data is available on the advantages of surgery for these patients. Patients and Methods: We evaluated our series of 8 selected patients who underwent surgery for locally recurrent bladder cancer after RC. Results: The median time to recurrence after cystectomy was 20.8 months. The complications rate and severity were not negligible. Pathology report confirmed urothelial carcinoma with negative margins in all patients. After LR treatment, 4 patients recurred locally for a second time and 3 developed distant metastasis. They all died after a median follow-up of 10.4 months. One patient remained disease free after 14 months. Conclusions: The prognosis of patients with LR is poor regardless of surgical treatment and reflects the aggressive biological nature of urothelial tumors.