Marcus L. Quek

Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate

BACKGROUND Recent studies based on symptomatic outcomes analyses have shown that laparoscopic repair of large type III hiatal hernias is safe, successful, and equivalent to open repair. These outcomes analyses were based on a relatively short followup period and lack objective confirmation that the hernia has not recurred. The aim of this study was to compare the outcomes of laparoscopic and open repair of large type III hiatal hernia using both symptomatic evaluation and barium study to assess the integrity of the repair. STUDY DESIGN Fifty-four patients underwent repair of a large type III hiatal hernia between 1985 and 1998. The surgical approach was laparotomy in 13, thoracotomy in 14, and laparoscopy in 27. An antireflux procedure was included in all patients. Symptomatic outcomes were assessed using a structured questionnaire at a median of 24 months and was complete in 51 of 54 patients (94%). A single radiologist, without knowledge of the operative procedure, assessed the integrity of the repair using video esophagram. Videos were performed at a median of 27 months (35 months open and 17 laparoscopic) and were completed in 41 of 54 patients (75%). RESULTS Symptomatic outcomes were similar in both groups with excellent or good outcomes in 76% of the patients after laparoscopic repair and 88% after an open repair. Reherniation was present in 12 patients and was asymptomatic in 7. A recurrent hernia was present in 12 of the 41 patients (29%) who returned for a followup video esophagram. Forty-two percent (9 of 21) of the laparoscopic group had a recurrent hernia compared with 15% (3 of 20) of the open group (p < 0.001 log-rank value on recurrence-free followup). CONCLUSIONS Laparoscopic repair of type III hiatal hernias is associated with a disturbingly high (42%) prevalence of recurrent hernia. More than half such recurrences have few, if any, symptoms.

A Critical Analysis of Perioperative Mortality From Radical Cystectomy

PURPOSE Operative mortality from radical cystectomy has decreased as a result of improvements in surgical and anesthetic care. We reviewed the perioperative deaths from a large group of patients treated with radical cystectomy for primary bladder cancer. MATERIALS AND METHODS All perioperative mortalities from radical cystectomy were identified from a single high volume institution. The medical records were reviewed to assess the cause of death as well as possible contributing factors. RESULTS From August 1971 to December 2001, 1,359 patients with primary bladder cancer were treated with radical cystectomy and pelvic iliac lymphadenectomy at our institution. Of these patients, 27 (2%) died within 30 days of surgery or before discharge from hospital. Median patient age at surgery was 67 years (range 47 to 78) and males accounted for 81% of the patients. The median time to death was 28 days from cystectomy (range 0 to 80). Most deaths were cardiovascular related (including acute myocardial infarction, cerebrovascular accident, arterial thrombosis) or due to septic complications with resulting multi-organ system failure, followed by pulmonary embolism, hepatic failure and hemorrhage. Septic related mortality was most often associated with postoperative urine or bowel leak. While most deaths occurred before hospital discharge, 2 patients died at home due to a late pulmonary embolus. No association was seen between pathological stage or type of urinary diversion and mortality. CONCLUSIONS Perioperative mortality from radical cystectomy is low in this group of patients. Most deaths are due to cardiovascular or septic complications. Careful patient selection and meticulous surgical technique may help decrease the incidence of perioperative mortality.

Long-term urodynamics followup of bladder augmentation for neurogenic bladder

PURPOSE Augmentation enterocystoplasty is well tolerated by patients with neurogenic bladder in whom conservative therapy has failed. However, few studies exist on long-term urodynamic evaluation of these patients. We assessed the clinical and urodynamic outcomes of patients with neurogenic bladder treated with augmentation enterocystoplasty with at least 4 years of followup. MATERIALS AND METHODS A total of 26 patients with neurogenic voiding dysfunction underwent augmentation enterocystoplasty alone or in conjunction with various continence or antireflux techniques. Clinical outcomes regarding incontinence, medications, catheterization schedule, subsequent interventions, bowel function and patient satisfaction were addressed. Urodynamic evaluation was performed to assess the long-term durability of bladder augmentation. RESULTS Mean followup was 8.0 years (range 4 to 13). All but 1 patient (96%) in our series had near or complete resolution of urinary incontinence. Mean total bladder capacity +/- SD increased from 201 +/- 106 to 615 +/- 204 ml. (p <0.001) and mean maximum detrusor pressure decreased from 81 +/- 43 to 20 +/- 12 cm. H O (p <0.01). Mean interval between catheterizations was 5 hours, with volumes ranging from 314 to 743 ml. Only 2 patients (8%) needed a low dose of oxybutynin postoperatively to maintain continence consistently. Of the 26 patients 23 (88%) reported no significant change in bowel function and nearly all patients expressed extreme satisfaction with urological management. A subsequent urological procedure was required in 12 patients (46%) at a mean of 4.4 years after initial surgery.(2) CONCLUSIONS Bladder augmentation provides durable clinical and urodynamic improvement for patients with neurogenic bladder dysfunction refractory to conservative therapy. Furthermore, there is a high level of patient satisfaction with bladder augmentation.

Lymphadenectomy for invasive bladder cancer. II. technical aspects and prognostic factors.

An ‘extended’ lymphadenectomy must include all lymph nodes in the boundaries of: the aortic bifurcation and common iliac vessels (proximally); the genitofemoral nerve (laterally); the circumflex iliac vein and lymph node of Cloquet (distally); the hypogastric vessels (posteriorly), including the obturator fossa, pre-sciatic nodes bilaterally, and the presacral lymph nodes anterior to the sacral promontory. An extended dissection may also extend superiorly to the level of the inferior mesenteric artery. A so-called ‘standard’ lymphadenectomy is more limited, with the cephalad extent generally beginning at the level of the common iliac bifurcation. The lateral and distal limits are similar to the extended dissection. In general, the proximal dissection extending along the common iliacs and great vessels includes all nodal tissue anterior and lateral, while the nodal dissection along the external iliacs is completely circumferential.

Diagnostic Utility of Antibody to Smoothelin in the Distinction of Muscularis Propria From Muscularis Mucosae of the Urinary Bladder : A Potential Ancillary Tool in the Pathologic Staging of Invasive Urothelial Carcinoma

Accurate recognition of urinary bladder muscularis propria (MP) invasion by urothelial carcinoma is crucial as it is the critical crossroad between conservative and aggressive management for the patient. It is now widely known that an inconsistent layer of muscularis mucosae (MM) muscle exists in the lamina propria, which can mimic the MP muscle, particularly when hyperplastic, making staging extremely challenging in some limited, unoriented, or highly cauterized specimens. Smoothelin is a novel smooth muscle-specific contractile protein expressed only by fully differentiated smooth muscle cells, and not by proliferative or noncontractile smooth muscle cells and myofibroblasts. We performed immunohistochemical staining in the bladder for smoothelin to: (a) evaluate its expression in MM and MP muscle in cystectomy specimens and by comparing the staining pattern with smooth muscle actin (SMA), (b) study MP variations in the bladder trigone and at the ureteric insertion in the bladder wall, and (c) assess the staining pattern of MM and MP in a representative group of transurethral resection of bladder tumor specimens. In contrast to SMA, which equitably stained both types of muscle fibers, smoothelin displayed striking differential immunoreactivity between MM and MP muscle. With smoothelin, the MM muscle (including hyperplastic forms) typically showed absent (19/42, 45%) or weak and focal (18/42, 43%) staining, whereas the MP muscle typically showed strong and diffuse staining (36/42, 86%). Smoothelin accentuated individual muscle fibers within groups of MP bundles only, a feature which was evident in both MM and MP stained by SMA. When only strong and diffuse immunoreactivity in muscle was set as a threshold for positivity, 100% specificity and positive predictive value of smoothelin for MP (vs. MM) was achieved in our study. Smoothelin staining confirmed the morphologic variations in MP muscle in the bladder wall of the trigone and at the ureteric insertion. In addition to the well-defined muscle layers of MM and MP, SMA staining revealed a continuous band of ill-defined haphazardly oriented compact spindle cells that were immediately subjacent to the urothelium in all cases. These spindle cells blended with the morphologically recognizable thin slender fascicles of the MM muscle. We designate this hitherto uncharacterized thin layer of SMA-positive [muscle-specific actin positive (6/6), Masson trichrome stain predominantly blue (5/6)] and smoothelin-negative cells as suburothelial band of myofibroblasts. In all 10 transurethral resection of bladder tumor sections, smoothelin staining was in agreement with the routine light microscopic presence and absence of MP muscle. In conclusion, the relatively distinct immunohistochemical staining pattern of smoothelin between MP and MM (including its hyperplastic forms) makes it a robust and attractive marker to be incorporated in the contemporary diagnostic armamentarium for the sometimes difficult area of staging bladder urothelial carcinoma.

Online Reviews of 500 Urologists

PURPOSE Patient demand for easily accessible information about physician quality has led to the development of physician review websites. These sites concern some physicians who argue that ratings can be misleading. In this study we describe the landscape of online reviews of urologists by looking at a sample of ratings and written reviews from popular physician review websites. MATERIALS AND METHODS A total of 500 urologists were randomly selected from a database of 9,940. Numerical ratings from 10 popular physician review websites were collected for each physician and analyzed. Written reviews from a single physician review website were also collected and then categorized as extremely negative/positive, negative/positive or neutral. RESULTS Our sample consisted of 471 male and 29 female urologists from 39 states including small and large cities and 4 census regions. There were 398 (79.6%) urologists who had at least 1 rating on any of the 10 physician review websites (range 0 to 64). On average the composite rating was based on scores from only 2.4 submitted ratings. Most physicians had positive ratings (86%), with 36% having highly positive ratings. No difference was seen in the median number of reviews when gender (p = 0.72), region (p = 0.87) and city size (p = 0.87) were compared. Written reviews were mostly positive or extremely positive (53%). CONCLUSIONS We advise physicians and patients to be aware that most urologists are rated on at least 1 physician review website, and while most ratings and reviews are favorable, composite scores are typically based on a small number of reviews and, therefore, can be volatile.

The RAZOR (randomized open vs robotic cystectomy) trial: Study design and trial update

The purpose of the RAZOR (randomized open vs robotic cystectomy) study is to compare open radical cystectomy (ORC) vs robot‐assisted RC (RARC), pelvic lymph node dissection (PLND) and urinary diversion for oncological outcomes, complications and health‐related quality of life (HRQL) measures with a primary endpoint of 2‐year progression‐free survival (PFS). RAZOR is a multi‐institutional, randomized, non‐inferior, phase III trial that will enrol at least 320 patients with T1–T4, N0–N1, M0 bladder cancer with ≈160 patients in both the RARC and ORC arms at 15 participating institutions. Data will be collected prospectively at each institution for cancer outcomes, complications of surgery and HRQL measures, and then submitted to trial data management services Cancer Research and Biostatistics (CRAB) for final analyses. To date, 306 patients have been randomized and accrual to the RAZOR trial is expected to conclude in 2014. In this study, we report the RAZOR trial experimental design, objectives, data safety, and monitoring, and accrual update. The RAZOR trial is a landmark study in urological oncology, randomizing T1–T4, N0–N1, M0 patients with bladder cancer to ORC vs RARC, PLND and urinary diversion. RAZOR is a multi‐institutional, non‐inferiority trial evaluating cancer outcomes, surgical complications and HRQL measures of ORC vs RARC with a primary endpoint of 2‐year PFS. Full data from the RAZOR trial are not expected until 2016–2017.

Molecular prognostication in bladder cancer: a current perspective

The optimal management of bladder cancer depends on the accurate assessment of the tumours biological potential. Advances in molecular biology and cytogenetics have spurred intense research in identifying and characterising prognostic markers for patients with transitional cell carcinoma (TCC) of the bladder. The molecular changes that occur can be categorised into (1) chromosomal alterations leading to carcinogenesis, (2) cellular proliferation as a result of dysregulation of cell cycle control, and (3) growth control processes such as angiogenesis leading to metastasis. The accumulation of these changes ultimately determines a tumours clinical behaviour and response to therapy. As the understanding of bladder cancer evolves, novel molecular markers for prognostication will make their way from the research laboratory to the clinical setting with the promise to improve patient care and outcomes.

Natural history of surgically treated bladder carcinoma with extravesical tumor extension

The current TNM classification for bladder carcinoma stratifies extravesical extension into microscopic (pT3a) and macroscopic (pT3b) tumor involvement. The authors evaluated the outcomes of patients with pT3a and pT3b disease after radical cystectomy.

New molecular markers for bladder cancer detection.

Purpose of review Bladder cancer continues to be one of the most common genitourinary malignancies. The mainstay of diagnosis remains cystoscopic visualization with transurethral biopsy or resection. As over two-thirds of bladder tumors recur, vigilant surveillance is required. Due to the invasiveness and expense of frequent cystoscopies and the lack of sensitivity of urinary cytology, especially for low-grade superficial lesions, novel molecular markers have been investigated as a means to detect bladder cancer noninvasively. Recent findings As our understanding of the pathogenesis of urothelial neoplasia improves, coupled with recent advances in molecular biological techniques, an array of new approaches to the diagnosis of bladder cancer has emerged. Several urine-based markers have been tested against the standard of urinary cytology with promising results. However, lack of standardization of technique and heterogeneity of bladder cancer itself may hinder the widespread dissemination of these diagnostic aids. Summary A host of new molecular markers based on the pathogenesis of bladder cancer have been investigated, such as telomerase, survivin, and multitarget fluorescence in situ hybridization, which may eventually improve detection and management of urothelial malignancies. By improving the sensitivity of urinary cytology for low-grade superficial lesions and detecting recurrent disease noninvasively early in its course, these new molecular markers might someday allow changes in the way bladder cancer is diagnosed and followed. At the present time, however, no single molecular marker provides 100% accuracy. Perhaps panels utilizing the most promising of these markers may alter bladder cancer detection and management policy.