Lucas R. Wiegand

Bladder cancer: a review of non-muscle invasive disease.

BACKGROUND Bladder cancer is one of the most common cancers affecting men and women and thus has a profound impact on health care. The majority of patients (75%) with newly diagnosed urothelial tumors have non-muscle invasive disease confined to the bladder mucosa or the lamina propria. METHODS The authors review the literature as well as recently published clinical guidelines regarding the bladder cancer risk and causative factors, diagnostic and pathologic evaluation, prognostic variables, and management strategies for patients with non-muscle invasive bladder cancer. RESULTS Recurrence and progression remain problematic for many patients and are dependent on multiple clinical and pathological features, the most important of which are tumor stage, grade, multifocality, size, recurrence patterns, and the association with carcinoma in situ. Accurate assessment of clinical stage and tumor grade is critical in determining management and surveillance strategies. Intravesical therapies positively influence tumor recurrence rates. Disease progression rates may be impacted in high-risk patients who receive both induction bacille Calmette-Guérin (BCG) and a maintenance BCG regimen. Cystectomy still plays a pivotal role in patients with high-risk tumors and in patients who fail more conservative attempts to eradicate non-muscle invasive disease. CONCLUSIONS Non-muscle invasive bladder cancers represent a broad group of tumors with varying biologic potential. Successful treatment depends on the careful integration of diagnostic and surveillance tests, macroablation through transurethral resection, accurate assessment of clinical stage, and the timely and appropriate delivery of intravesical chemotherapeutic and immunomodulatory agents.

Surgical management of lymph‐node‐positive prostate cancer: improves symptomatic control

Study Type – Therapy (case series)
Level of Evidence 4

Ureteral Replacement and Onlay Repair with Reconfigured Intestinal Segments

PURPOSE Ureteral loss represents a surgical challenge to provide low pressure drainage while avoiding urinary stasis and reflux. The ideal replacement should optimize drainage while minimizing absorption, allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract. We reviewed our experience with ureteral repair, focusing on the use of reconfigured intestine. We report what is to our knowledge the novel use of reconfigured intestine as an onlay flap on the preserved ureteral segment and as a circumferential interpositioned segment. MATERIALS AND METHODS A total of 16 ureters were repaired in 4 men and 9 women using reconfigured ileum, colon or appendix. Mean patient age was 45 years (range 26 to 66). The etiology of the ureteral defect was iatrogenic in 8 patients, retroperitoneal fibrosis in 3, trauma in 3 and ureteritis cystica in 1. Mean defect length was 10 cm (range 5 to 20) in the 10 right and 6 left ureters, and the defect was proximal in 3, mid in 4, distal in 7 and panureteral in 2. Ureteral replacement was performed using a segment of ileum in 13 cases or colon in 1. The segment was detubularized and reconfigured according to the Yang-Monti principle and used as a complete retubularized interposed segment in 7 cases or as an onlay flap on the opened ureter without resection in 7. Also, 2 ureters were reconstructed with an incised appendiceal flap onlayed over the preserved ureteral plate. At a mean followup of 44 months (range 12 to 78) all patients underwent antegrade nephrostogram, followed by renal scan and upper tract imaging. RESULTS All patients tolerated the procedure without initial bowel or urinary tract complications. In 1 patient who had received radiation a ureteral fistula developed to a blind Hartmann pouch at 9 months, requiring repair. Ultimately, cystectomy was done for irradiation cystitis (onlay group). Another patient with bilateral obstruction at presentation lost unilateral renal function during 5 years. Urinary drainage was achieved in all 14 remaining renal units with preservation of function, as shown on renal scan. Patients reported minor mucous production without renal colic or stone formation. CONCLUSIONS Long ureteral defects require tissue replacement when bladder flaps do not suffice. Ureteral replacement can be achieved by reconfigured intestinal segments, which are readily mobilized and secured as interposed segments or as an onlay flap on the preserved ureter. A relatively short segment can be used to repair a lengthy defect along any segment of ureter, also allowing for nonrefluxing reimplantation.

Cutaneous ureterostomy technique for adults and effects of ureteral stenting: an alternative to the ileal conduit.

PURPOSE We present surgical modifications that improved the outcome of cutaneous ureterostomies. MATERIALS AND METHODS A total of 310 patients with a median age of 71 years (range 38 to 88) underwent cutaneous ureterostomy as urinary diversion. Median followup was 25 months (range 1 to 172). The technique included 1) transposition of the left ureter above the inferior mesenteric artery, 2) mobilization of the ileocecal segment with repositioning above each terminal ureter, 3) abdominal wall hiatus fixation with 4 angle sutures and 4) YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. In the 161 group 1 patients (59.1%) the Double-J® stents were removed in less than 3 months. Stents remained longer than 3 months in the 111 group 2 patients (40.8%). RESULTS Of the 272 patients ureteral obstruction developed in 36 (13.2%). Ureteral obstruction was on the right side in 6 patients (2.2%), on the left side in 27 (9.9%) and bilateral in 3 (1.1%). Ureteral obstruction was treated with restenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). Ureteral obstruction developed on the right side, on the left side and bilaterally in 3.7%, 13.7% and 1.82% of the patients in group 1, and in 0%, 4.5% and 0%, respectively, of those in group 2. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p = 0.01). CONCLUSIONS As with other types of urinary diversion, left ureteral obstruction is a common complication of bilateral cutaneous ureterostomies. Long-term stenting for greater than 3 months and the applied surgical modifications improved the clinical outcome of this type of urinary diversion.

The UREThRAL stricture score: A novel method for describing anterior urethral strictures

BACKGROUND : Urethral stricture description is not standardized. This makes surgical decision-making less reproducible and increases the difficulty of objectively analyzing urethroplasty literature. We developed a standardized system, the UREThRAL stricture score (USS), to quantify the characteristics of anterior urethral stricture disease based on preoperative imaging and intraoperative findings. METHODS : To develop the USS, we retrospectively analyzed 95 consecutive patients with urethral strictures who underwent open urethroplasty by a single surgeon (SBB) at Barnes-Jewish Hospital from 2009 to 2011. The USS is a numerical score based on five components of anterior urethral stricture disease that help dictate operative decision-making: (1) (UR)ethral stricture (E)tiology; (2) (T) otal number of strictures; (3) (R)etention (luminal obliteration); (4) (A)natomic location; and (5) (L)ength. Stricture management was categorized by increasing surgical complexity: excision/primary anastomosis (EPA), buccal mucosal graft urethroplasty (BMG), augmented anastomotic urethroplasty (AAU), flap urethroplasty, and a combination of flaps and/or grafts. Multinomial logistic regression analysis was used to compare USS to surgical complexity. RESULTS : The mean USS for EPA, BMG, AAU, flap, and combination flaps/grafts was 5.78, 8.82, 9.23, 11.01, and 14.97, respectively. Increasing USS was significantly associated with surgical complexity (p < 0.0001). INTERPRETATION : The USS describes the essential factors in determining surgical treatment selection for urethral stricture disease. The USS is a concise, easily applicable system that delineates the clinically significant features of urethral strictures. Valuable comparison of anterior urethral stricture treatments in clinical practice and in the urological literature could be facilitated by using this novel UREThRAL stricture score.

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer

This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.

Robotic Ileal Interposition for Radiation-induced Ureteral Stricture Disease

OBJECTIVE To present a novel surgical concept using preoperative imaging to estimate length needed for ileal segment. This enables robotic ileal interposition to be completed with only 1 position change during surgery. MATERIALS AND METHODS The index patient is a 69-year-old woman with a history of stage IIIB cervical cancer treated with chemotherapy and radiation 5 years prior to presentation. The patient subsequently developed a long segment stricture of the left ureter, which had been managed with ureteral stents. The patient decided to proceed with robotic ileal ureter for management of her ureteral stricture disease. We used preoperative computed tomography scan measurements to estimate length needed for ileal segment. This eliminated the need for multiple position changes during surgery. RESULTS The patient tolerated the procedure well. Estimated blood loss was 50 cc. Kidney ultrasound at 1 month post-op revealed no hydronephrosis. Renal scan at 12 months post-op revealed stable function at 32% and no evidence of obstruction. The patient reports she is doing well and is pain free at this time. CONCLUSION Robotic ileal interposition is a technically feasible procedure with good functional outcomes. By using preoperative imaging to estimate length needed for ileal segment, only 1 position change is needed during surgery.

Pancake Kidney With Obstructed Moiety: A Rare Renal Fusion Anomaly

Renal fusion abnormalities are rare. Even more rare is pancake kidney. We present a case of a 28-year-old male with symptomatic obstruction of a non-functioning moiety of a pancake kidney. He underwent ureterectomy with a finding of only atretic renal parenchyma at exploration. He recovered well and had resolution of his pain at 3-month follow-up.

Survival Outcomes Associated With Female Primary Urethral Carcinoma: Review of a Single Institutional Experience

Micro‐Abstract Female primary urethral carcinoma is rare, and treatment standards are nonexistent, particularly for the use of multimodal therapy in locally advanced disease. We reviewed 39 patients with primary urethral carcinoma in regard to presentation, treatment, and outcomes. Multimodal therapy shows a nonsignificant interval increase in overall and recurrence‐free survival, but the sequence, type, and delivery of multimodal therapy is poorly defined. Background Primary urethral carcinoma (PUC) is rare, and standard treatment recommendations are lacking. We examined the variation in treatments and survival outcomes of female PUC at a single, tertiary referral cancer center. Methods Records of women with PUC referred to our multidisciplinary genitourinary oncology service between 2003 and 2017 were reviewed. Clinical, demographic, pathologic, primary and salvage therapy details, and overall (OS) and recurrence‐free survival (RFS) were recorded. Survival outcomes were analyzed for the entire cohort, and cases of locally‐advanced (≥ T2 tumor), non‐metastatic PUC were evaluated according to treatment intensity. Multimodal treatment (cystourethrectomy + concomitant therapy) was compared with non‐multimodal therapy. Contingency analyses and Kaplan‐Meier estimates were performed. Results Thirty‐nine women with PUC were identified. In total, median OS was 36 months (95% confidence interval, 10.6‐61.4 months). Twenty‐four had T3 to T4 disease, 12 were node‐positive, and 3 had distant metastases. Histology included 22 adenocarcinomas, 11 urothelial, 5 squamous, and 1 neuroendocrine. Patients with locally advanced, non‐metastatic disease (n = 25) had significantly reduced OS (36 vs. 99 months; P = .016) and RFS (46 months vs. unmet; P = .011) compared with patients with locally confined tumors. Approximately one‐half of locally advanced cases were managed with multimodal therapy (4 with neoadjuvant therapy + cystourethrectomy, 8 with cystourethrectomy + adjuvant therapy, and 1 with chemoradiation + consolidative cystourethrectomy). Multimodal therapy had nonsignificant longer OS (36 vs. 16 months) and RFS (58 vs. 16 months), P > .05. Conclusions Locally advanced female PUC has relatively poor survival outcomes. Although we observed a nonsignificant interval improvement in survival with multimodality therapy, the treatment paradigm is inconsistent. Because it is a rare disease, collaborative multi‐institutional studies are needed.

EDITORIAL COMMENT: ROBOTIC URETEROURETEROSTOMY FOR TREATMENT OF A PROXIMAL URETERIC STRICTURE

Ureteral reconstruction can be challenging when done open or in a minimally-invasive manner. Ureteral reconstruction is a perfect use of the surgical robot. Here Andrade et al. (1) present a well-made and illustrative video that demonstrates the steps needed to complete a technically sound, minimally-invasive proximal ureteral repair. This will add to the body of literature and video instruction that improves and propels the field of robotic/minimally-invasive urologic reconstruction. doi: 10.1590/S1677-5538.IBJU.2015.0249.1