Mohamed Abdel-Latif

Radical cystectomy for carcinoma of the bladder: 2,720 consecutive cases 5 years later.

PURPOSE We performed a critical analysis of the results of radical cystectomy for invasive bladder carcinoma treated at 1 center. MATERIALS AND METHODS Between 1970 and 2000, 2,090 men and 630 women with invasive bladder cancer were treated with 1-stage radical cystectomy and urinary diversion. Followup ranged from 0 to 34.2 years with a mean of 5.5 +/- 5.7. Survival data were correlated to patient and tumor characteristics using univariate and multivariate analysis. RESULTS Postoperative mortality was 2.6%. Squamous tumors accounted for 49.4% of cases, transitional cell carcinoma for 36.4% and adenocarcinoma for 9.6%. Regional lymph nodes were involved in 20.4% of cases. The 5 and 10-year disease-free survival rates were 55.5% and 50.03%, respectively. Evidence was provided that tumor stage, histological grade and lymph node status are the only independent variables which affect survival probability. CONCLUSIONS Contemporary cystectomy can be performed with minimal mortality. Radical cystectomy for organ confined disease is followed by good therapeutic results and enhances the possibilities for functional restoration. With stage progression there is a stepwise reduction in survival probability. The radical operation can provide disease-free survival for an important subgroup of node positive cases (27.3%). Additional therapy is needed to improve the oncological outcome for advanced locoregional disease.

A randomized study comparing an antireflux system with a direct ureteric anastomosis in patients with orthotopic ileal neobladders

Authors from Egypt conducted a randomized prospective study into the benefit of an anti‐reflux system in patients with orthotopic ileal neobladders. They found that anti‐reflux procedures were associated with a higher incidence of anastomotic structures. An editorial comment accompanies this paper, and together the two manuscripts make for interesting reading.

Preservation of the internal genital organs during radical cystectomy in selected women with bladder cancer: A report on 15 cases with long term follow-up

PURPOSE To prospectively present the technique, functional and oncological outcome of internal genitalia sparing cystectomy for bladder cancer in 15 selected women. PATIENTS AND METHODS Between January 1995 and December 2010, 305 women underwent orthotopic neobladder after radical cystectomy. Of these, 15 cases with a mean age of 42 years underwent genitalia sparing. Inclusion criteria included stage (T2b N0 Mo or less, as assessed preoperatively, unifocal tumors away from the trigone, sexually active young women and internal genitalia free of tumor. Cystectomy with preservation of the uterus, vagina and ovaries and Hautmann neobladder were performed. Oncological, functional, urodynamic and sexual outcome using Female Sexual Function Index (FSFI) were evaluated. RESULTS Definitive histopathology showed advanced stage not recognized preoperatively in 2 patients, who developed local recurrence and bony metastasis after 3-4 months. A third patient developed bony metastasis after 15 months. No recurrence developed in the retained genital organs. The remaining 12 patients remained free of disease with a mean follow-up of 70 months. Among women eligible for functional evaluation, daytime and nighttime continence were achieved in 13/13 (100%) and 12/13 (92)%, respectively. Chronic urinary retention was not noted. The urodynamic parameters were comparable to those in other patients without genital preservation. Sexual function (FSFI) was better in these patients than in others without genital preservation. CONCLUSIONS Genital sparing cystectomy for bladder cancer is feasible in selected women. It provides a good functional outcome, better sexual function and the potential for fertility preservation. So far, the oncological outcome is favorable.

Intracoronary isoflurane causes marked vasodilation in canine hearts.

Previous studies of coronary vasomotor effects of isoflurane were complicated by changes in systemic hemodynamic conditions and in global cardiac work demands. Accordingly, in the current study, the left anterior descending coronary artery (LAD) of 11 open-chest dogs anesthetized with fentanyl and pentobarbital was cannulated and perfused with isoflurane-free arterial blood or with arterial blood equilibrated in an extracorporeal oxygenator with isoflurane (0.5, 1.0, 2.0% in 95.5% oxygen-4.5% carbon dioxide). Steady-state changes in coronary blood flow (CBF) in LAD were measured electromagnetically, and their transmural distribution (endocardium: epicardium ratio) was evaluated with 15-microns radioactive microspheres. Venous blood was obtained from the anterior interventricular vein and analyzed for oxygen tension (PO2) and oxygen content. Myocardial oxygen consumption (MVO2) was calculated using the Fick equation. Cardiac responses during isoflurane were compared to those during maximal vasodilation with intracoronary adenosine. Perfusion pressure was maintained at 100 mmHg. CBF increased 271, 279, and 503% with 0.5, 1.0, and 2.0% isoflurane, respectively, with no change in the endocardium:epicardium ratio. With 2.0% isoflurane, the increase in CBF was 80% of the maximal, adenosine-induced response. The increases in CBF caused by isoflurane were accompanied by greater than proportional increases in venous PO2 and decreases in the arteriovenous oxygen difference, reflecting the reduction (approximately 40% in MVO2. In conclusion, isoflurane has a direct, concentration-dependent relaxing effect on coronary vascular smooth muscle in the canine heart in situ. The ability of isoflurane to increase CBF nearly maximally while also significantly reducing local myocardial oxygen requirements attests to the potency of isofluranes direct vasodilator action.

Radical cystectomy and urinary diversion in women: Impact on sexual function

Abstract Objective. The aim of this study was to assess the impact of radical cystectomy and different forms of urinary diversion on female sexual function. Material and methods. Seventy-three consecutive patients were included in the study. The mean age was 52.3 ± 6.5 years. All of them had undergone non-nerve-sparing radical cystectomy and urinary diversion for invasive bladder cancer. Patients were questioned about their current general relations with their husbands in comparison to the preoperative status. The Female Sexual Function Index (FSFI) was used to assess libido, lubrication, orgasm, satisfaction and painful sexual dysfunction. Patients were asked about any urinary complaints during or after sexual intercourse. Results. Twenty-nine patients (39%) reported worsening relations with their husbands. The mean frequency of sexual relations was 2.3 ± 2.3/month; however, sexual relations had ceased completely in 19 patients (26%). Overall satisfaction among sexually active women worsened in 32 (59.2%) and was completely lost in eight patients (14.8%). Absent libido, difficult intromission, dyspareunia, lack of orgasm and sexually related urinary complaints were reported in 89%, 63%, 48%, 63% and 63% of patients, respectively. The mean FSFI score dropped significantly from 18.3 ± 5.1 to 11.3 ± 7.4 postoperatively (p < 0.001). FSFI scores were significantly higher among patients with orthotopic versus non-orthotopic forms of diversion and also higher among patients with no stoma versus those with stomal forms of diversion. Conclusions. Radical cystectomy and urinary diversion have deleterious impacts on all domains of female sexual function. Female patients with orthotopic and non-stomal diversions had better sexual functions than those with stomal diversions.

The value of frozen-section analysis of ureteric margins on surgical decision-making in patients undergoing radical cystectomy for bladder cancer

To prospectively investigate the value of routine frozen‐section analysis (FSA) of the ureteric margin for detecting distal ureteric malignancy in patients undergoing cystectomy for bladder transitional cell carcinoma (TCC).

Asymptomatic bacteriuria in men with orthotopic ileal neobladders : possible relationship to nocturnal enuresis

The role of asymptomatic bacteriuria in patients with urinary diversion in general has been reported as having a significant role prognostically in several published studies. Authors from Mansoura, with considerable experience in the constructing the orthotopic ileal neobladder, have evaluated the incidence of asymptomatic bacteriuria in such patients prospectively, and have assessed its possible effect on neobladder function.

Prediction of Survival After Radical Cystectomy for Invasive Bladder Carcinoma: Risk Group Stratification, Nomograms or Artificial Neural Networks?

PURPOSE We compared 3 predictive models for survival after radical cystectomy, risk group stratification, nomogram and artificial neural networks, in terms of their accuracy, performance and level of complexity. MATERIALS AND METHODS Between 1996 and 2002, 1,133 patients were treated with single stage radical cystectomy as monotherapy for invasive bladder cancer. A randomly selected 776 cases (70%) were used as a reference series. The remaining 357 cases (test series) were used for external validation. Survival estimates were analyzed using univariate and then multivariate appraisal. The results of multivariate analysis were used for risk group stratification and construction of a nomogram, whereas all studied variables were entered directly into the artificial neural networks. RESULTS Overall 5-year disease-free survival was 64.5% with no statistical difference between the reference and test series. Comparisons of the 3 predictive models revealed that artificial neural networks outperformed the other 2 models in terms of the value of the area under the receiver operator characteristic curve, sensitivity and specificity, as well as positive and negative predictive values. CONCLUSIONS In this study artificial neural networks outperformed the risk group stratification model and nomogram construction in predicting patient 5-year survival probability, and in terms of sensitivity and specificity.

Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail.

PURPOSE We evaluated the functional outcome of continent catheterizable outlet using the serous lined extramural tunnel technique as a continence mechanism in children and adolescents. MATERIALS AND METHODS We retrospectively studied all patients who underwent continent catheterizable stoma using the serous lined extramural technique between May 1993 and March 2008. Patient records were reviewed for age, sex, indication for surgery, surgical details and postoperative course. All patients were evaluated for continence with emphasis on frequency of clean intermittent catheterization. Urodynamic evaluation was done for patients with leaking stoma. Stoma related complications were also recorded. RESULTS A total of 37 boys and 23 girls 3 to 18 years old underwent continent catheterizable stoma using the serous lined extramural technique. Total bladder substitution was performed in 13 patients using continent ileal W-shaped reservoir, and 47 patients underwent augmentation ileocystoplasty mounted with serous lined outlet. The outlet channel was appendix in 39 patients (65%), tapered ileal segment in 13 (21.5%) and Monti ileal tube in 8 (13.5%). After a median followup of 43 months (range 10 to 180) 55 patients (91.6%) achieved continence, with catheterization frequency of 3 to 5 times during the daytime and 1 to 2 times at night. Stoma related complications were leaking stoma in 5 patients (8.4%), stomal stenosis in 6 (10%), parastomal hernia in 2 (3.3%) and reservoir stones in 8 (13.3%). Reoperation rate was 18.3% (11 patients). CONCLUSIONS The serous lined continent outlet seems to be a durable and efficient technique for treating children with incontinence, with an acceptable complication rate.

Outcome of patients with continent urinary reconstruction and a solitary functioning kidney.

Authors from Mansoura evaluated the outcome of patients with continent urinary diversion who had a single functioning kidney. They recommend a regular follow‐up of renal function in such patients. They found that rectal diversion was associated with a higher renal functional loss than orthotopic or cutaneous reservoirs. In the second article, the authors from Cairo describe the value of dynamic three‐dimensional spiral CT cysto‐urethrography in evaluating post‐traumatic posterior urethral defects.