Keith N. Van Arsdalen

An Interval Longer than 12 Weeks Between the Diagnosis of Muscle Invasion and Cystectomy is Associated with Worse Outcome in Bladder Carcinoma

PURPOSE The standard of care for muscle invasive transitional cell carcinoma of the bladder is radical cystectomy. Definitive therapy may often be delayed for various reasons. We assessed whether pathological stage and survival correlated with the length of time between diagnosis of muscle invasion and cystectomy. MATERIALS AND METHODS The records of 290 consecutive patients who underwent radical cystectomy between February 1987 and July 2000 were reviewed. Of 265 (91.4%) cystectomies performed for transitional cell carcinoma data were available for 247 (85.2%) and 189 (65.2%) patients were identified who underwent surgery for muscle invasive disease (T2 or greater). The interval between diagnosis of muscle invasion and cystectomy was calculated for each patient. Patients were divided into groups based on time to surgery as group 1-less than 4 weeks, 2-4 to 6 weeks, 3-7 to 9 weeks, 4-10 to 12 weeks, 5-13 to 16 weeks, and 6-greater than 16 weeks. Exploratory univariate and multivariate analyses were performed to test the association of time lag with clinical features and postoperative survival. RESULTS Mean patient age was 66 years (range 37 to 84) and overall 3-year Kaplan-Meier estimated survival was 59.1% +/- 4% (median followup 36 months). For all patients mean interval from diagnosis to cystectomy was 7.9 weeks (range 1 to 40). Extravesical disease (P3a or greater) or positive nodes were identified in 84% (16 of 19) of patients when the delay was longer than 12 weeks, compared with 48.2% (82 of 170) in those with a time lag of 12 weeks or less (p < 0.01). Similarly 3-year estimated survival was lower (34.9% +/- 13.5%) for patients with a surgery delay longer than 12 weeks compared to those with a shorter interval 62.1% +/- 4.5% (hazards ratio 2.51, 95% CI 1.30-4.83, p = 0.006). When adjusted for nodal status, and clinical and pathological stages the interval was still statistically significant (adjusted hazards ratio 1.93, 95% CI 0.99-3.76, p = 0.05). CONCLUSIONS In patients undergoing radical cystectomy a delay in surgery of greater than 12 weeks was associated with advanced pathological stage and decreased survival. Although this relationship persisted after adjusting for nodal status, and clinical and pathological stages, the presence of lymph node metastasis remained the strongest predictor of patient outcome.

Acute Biochemical and Functional Alterations in The Partially Obstructed Rabbit Urinary Bladder

Rapid structural and functional alterations have been noted in several models of partial outlet obstruction. To better characterize the rapid progression of alterations, the partially obstructed urinary bladders of mature NZW male rabbits were studied at 1, 3, 5, 7 and 14 days of outlet obstruction with respect to muscarinic receptor density, DNA, RNA, lipid and hydroxyproline content. Functional characteristics were assessed by measuring the in vitro response of the whole bladder to cholinergic and field stimulation. Wet weight increased eight-fold by day 7, decreasing to four-fold at day 14. Receptor density decreased by 50% by day 1 and remained low throughout. Although DNA concentration varied only slightly from controls, RNA increased four-fold by day 7. Hydroxyproline concentration per mg. tissue decreased in the obstructed bladder, yet total hydroxyproline content of the obstructed bladder significantly increased. Total lipids increased significantly during day 3 through 7 and decreased by day 14. Cystometry revealed a large capacity low pressure system at day 1 which rapidly changed to a low compliance system of lesser volume by day 14. Bladder emptying was significantly impaired in all obstructed specimens. Additionally, electrical field stimulation was significantly less effective than cholinergic stimulation in effecting bladder emptying. The above findings suggest that rapid changes in biochemical parameters occur during the early stage of acute obstruction which may in part be secondary to metabolic or inflammatory alterations in the detrusor. It additionally suggests that the myogenic alterations in partial outlet obstruction are rapid and partially adaptive, while neurogenic alterations appear degenerative and display a lesser degree of short term adaptation.

Collagen injection therapy for post-radical retropubic prostatectomy incontinence : Role of valsalva leak point pressure

PURPOSE We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. MATERIALS AND METHODS Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. RESULTS Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compared to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). CONCLUSIONS Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.

Extracorporeal Shock Wave Lithotripsy Treatment of Calculi in Horseshoe Kidneys

From June 1985 to November 1986, 17 patients with calculi in horseshoe kidneys presented to our hospital for evaluation and possible treatment with extracorporeal shock wave lithotripsy. Of these patients 14 were treated with extracorporeal shock wave lithotripsy; the calculi in 2 could not be localized and focused at the F2 focal point, and 1 was asymptomatic and has been followed conservatively. Four patients required repeat extracorporeal shock wave lithotripsy. Adjunctive procedures included preoperative retrograde catheter placement (5 patients), postoperative percutaneous nephrostolithotomy (1), ureteroscopy for ureteral fragments (2) and placement of a double pigtail stent (1). Of 14 patients 11 (79 per cent) have been rendered free of fragments with extracorporeal shock wave lithotripsy and adjunctive measures as needed. We conclude that most patients with calculi in a horseshoe kidney can be managed primarily with extracorporeal shock wave lithotripsy.

The Management of Transitional Cell Carcinoma in Solitary Renal Units

Ten patients with urothelial malignancies involving a solitary functioning renal unit were treated at our center for an average of 24 months or until death. These patients were all managed by parenchyma-sparing methods, including percutaneous as well as ureteroscopic tumor resection. Of our patients 9 have received adjunctive chemotherapy in the form of bacillus Calmette-Guerin instillations. At the time of this report 5 of our patients were alive without evidence of disease, 4 were alive with evidence of either residual or recurrent neoplasia and 1 was dead of disease 5 years after original presentation. Patients with higher grade tumors or carcinoma in situ did less well than patients with low grade disease. We present an analysis of our experience with this complex patient population and discuss the implications of these data within the context of a growing literature on the topic of upper tract urothelial malignancy.

Effect of Lithotripsy on Immature Rabbit Bone and Kidney Development

Although extracorporeal shock waves have been used to treat kidney stones for several years, little is known to their effect on developing tissue. In order to determine if lithotripsy has any negative effects on development, immature rabbits were used to study the relationship of extracorporeal shock waves to renal and skeletal growth. Rabbits in both the control and treatment groups had metallic clips placed surgically to demarcate the kidneys. Following unilateral kidney and femoral head treatment of the respective study groups with the Dornier Lithotripter Model HM-3, the rabbits were allowed to grow to maturity (six months). Plain radiographs were taken at three months. There was no significant difference between control and study groups when length of the kidneys or femurs, the diameter of the femoral heads, or the rabbits weights were compared. At six months of age, the rabbits were weighed, then sacrificed. The kidneys and femurs were removed. Comparisons between the control and study groups were then made for weight of the rabbit, weight and volume of the individual kidneys, femoral length, and femoral head diameter. Following these measurements sectioning and histologic examinations were done. In all parameters grossly and histologically, there was no statistically significant difference. It is concluded from this study that treatment with extracorporeal shock waves does not adversely affect overt rabbit renal or bone growth, making treatment of pediatric patients with ESWL appear safe in regard to these parameters. Future studies will be directed at confirming these findings in children.

Percutaneous Ultrasonic Lithotripsy: Choice of Irrigant

Extravasation of glycine irrigant during percutaneous ultrasonic lithotripsy has caused a transurethral resection syndrome consisting of hypertension, confusion and hyponatremia. With a rabbit model this complication is recreated with the intraperitoneal instillation of 1.5 per cent glycine solution tagged with 14carbon-glycine. Significant quantitative absorption of glycine into blood and other organs is demonstrated. A review of the literature reveals few guidelines as to the choice of irrigant for intrarenal endoscopy. Since this procedure involves no electric current it is suggested that physiological saline rather than glycine be used for ultrasonic stone disintegration.

Impact on renal function of percutaneous thermal ablation of renal masses in patients with preexisting chronic kidney disease.

PURPOSE To examine the effect of percutaneous thermal ablation of renal masses on renal function among patients with baseline chronic kidney disease (CKD). MATERIALS AND METHODS Patients with baseline CKD (initial glomerular filtration rate [GFR] < 60 mL/min/1.73 m(2)) who underwent percutaneous cryoablation or radiofrequency (RF) ablation of renal masses were reviewed. RESULTS A total of 48 patients with a GRF of 60 mL/min/1.73 m(2) or lower were treated with renal cryoablation or RF ablation and had follow-up GFR measurement 1 month afterward. Mean patient age was 73 years (range, 47-89 y). Cryoablation was performed in 22 patients and RF ablation was performed in 26. Mean tumor diameter was 3.4 cm (range, 0.9-10.2 cm). Mean overall GFRs were 39.8 mL/min/1.73 m(2) at baseline and 39.7 mL/min/1.73 m(2) at 1 month after ablation (P = .85). A total of 38 patients had 1-year follow-up GFR measurement (cryoablation, n = 18; RF ablation, n = 20), and their mean GFR was 40.9 mL/min/1.73 m(2) ± 11.4 (SD), compared with a preablation GFR of 41.2 mL/min/1.73 m(2)(P = .79). In the cryoablation group, mean GFRs at 1 month and 1 year were 41.4 mL/min/1.73 m(2) and 44.4 mL/min/1.73 m(2), compared with respective baseline GFRs of 41.1 mL/min/1.73 m(2) and 42.1 mL/min/1.73 m(2) (P = .75 and P = .19, respectively). In the RF ablation group, mean GFRs at 1 month and 1 year were 38.2 mL/min/1.73 m(2) and 37.8 mL/min/1.73 m(2), compared with respective baseline GFRs of 38.7 mL/min/1.73 m(2) and 40.4 mL/min/1.73 m(2) (P = .58 and P = .09, respectively). CONCLUSIONS Independent of ablation modality, percutaneous renal mass ablation does not appear to affect renal function among patients with CKD.

The presence of lymphovascular invasion in radical cystectomy specimens from patients with urothelial carcinoma portends a poor clinical prognosis.

To assess the prognostic significance of lymphovascular invasion (LVI) on clinical outcomes in patients with transitional cell carcinoma of the bladder treated with radical cystectomy (RC).

Deep vein thrombosis and prostatectomy

A research protocol to evaluate the prevention of deep vein thrombosis in sequential patients undergoing prostatectomy is presented. There is an overall incidence of deep vein thrombosis in 8 per cent of patients. There was no advantage with intermittent leg compression when compared with elastic stockings.