Nivedita Dhar

Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection

PURPOSE We compared recurrence patterns and survival of patients with urothelial bladder cancer undergoing radical cystectomy who either had limited or extended pelvic lymph node dissection at 2 institutions between 1987 and 2000. MATERIALS AND METHODS Two consecutive series of patients treated with radical cystectomy and limited pelvic lymph node dissection (336; Cleveland Clinic) and extended pelvic lymph node dissection (322; University of Bern) were analyzed. All cases were staged N0M0 prior to radical cystectomy, and none were treated with neoadjuvant radiotherapy or chemotherapy. Patients with PTis/pT1 and pT4 disease were excluded from analysis. Pathological characteristics based on the 1997 TNM system and recurrence patterns were determined. RESULTS The overall lymph node positive rate was 13% for patients with limited and 26% for those who had extended pelvic lymph node dissection. The 5-year recurrence-free survival of patients with lymph node positive disease was 7% for limited and 35% for extended pelvic lymph node dissection. The 5-year recurrence-free survival for pT2pN0 cases was 67% for limited and 77% for extended pelvic lymph node dissection, and the respective percentages for pT3pN0 cases were 23% and 57% (p <0.0001). The 5-year recurrence-free survival for pT2pN0-2 cases was 63% for limited and 71% for extended pelvic lymph node dissection, and for pT3pN0-2 cases the respective figures were 19% and 49% (p <0.0001). Incidence of local and systemic failure correlated closely with pathological stage for both series. CONCLUSIONS Our data suggest that limited pelvic lymph node dissection is associated with suboptimal staging, poorer outcome for patients with node positive and node negative disease, and a higher rate of local progression. Extended pelvic lymph node dissection allows for more accurate staging and improved survival of patients with nonorgan confined and lymph node positive disease.

Limited pelvic lymph node dissection does not improve biochemical relapse-free survival at 10 years after radical prostatectomy in patients with low-risk prostate cancer.

OBJECTIVES To compare the long-term differences in actuarial biochemical relapse-free survival rates from a contemporary series of patients who underwent radical prostatectomy with and without pelvic lymph node dissection (PLND). METHODS The records of 806 consecutive radical prostatectomy cases performed from January 1995 to June 1999 were reviewed. The entire subset of patients (n = 336) with low-risk disease, defined by a prostate-specific antigen level of 10 ng/mL or less, biopsy Gleason score of 6 or less, and clinical Stage T1 or T2a, who had not received adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 140) or omitted (no-PLND group, n = 196). A Cox proportional hazards model was used to analyze the effect of demographic, pretreatment, surgical, and pathologic factors on the likelihood of biochemical failure. Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. The median prostate-specific antigen follow-up time for the entire group was 89.0 months, with a similar follow-up for both cohorts (PLND group 94.5 months and no-PLND group 88.0 months, Mann-Whitney U test, P = 0.14). RESULTS The long-term biochemical relapse-free survival rate for the entire cohort was 86.1% at 10 years. The 10-year actuarial biochemical relapse-free rate for the PLND and no-PLND groups was 83.8% and 87.9%, respectively (log-rank, P = 0.33). On univariate analysis, PLND was not an independent predictor of outcome (Wald, P = 0.33). CONCLUSIONS The results of our study have shown that the omission of limited PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse-free survival at 10 years. Such patients can be spared the morbidity and cost of PLND without affecting their chance for cure.

Outcomes in patients with urothelial carcinoma of the bladder with limited pelvic lymph node dissection

To evaluate the rates of local and systemic progression (LP and SP), recurrence‐free survival and overall survival for patients with urothelial carcinoma of the bladder with limited pelvic lymph node dissection (PLND) in 1987–2000.

Presentation, location and overall survival of pelvic recurrence after radical cystectomy for transitional cell carcinoma of the bladder

To evaluate the presentation, location and overall survival of pelvic recurrence after radical cystectomy (RC) for transitional cell carcinoma (TCC) of the bladder.

Primary full-gland prostate cryoablation in older men (> age of 75 years): Results from 860 patients tracked with the COLD Registry

Study Type – Therapy (outcomes research)

Effect of Urinary Tract Infection on Reservoir Function in Patients With Ileal Bladder Substitute

PURPOSE We determined the functional consequences of urinary tract infection in patients with an ileal bladder substitute in terms of urinary continence, post-void residual and urinary retention. MATERIALS AND METHODS A total of 48 patients with culture documented urinary tract infection (single organism, 10(5) or greater cfu) were retrospectively evaluated before, during and after the infection for changes in continence, post-void residual and urinary retention as well as for resolution of symptomatology after appropriate antibiotic therapy. RESULTS Of the 48 patients 40 had a single infection while the remaining 8 had multiple urinary tract infection episodes. During daytime 27 of the 44 patients with previously good daytime continence experienced deterioration in their baseline voiding status while infected. Of the 40 patients who were previously continent at night 20 had incontinence while infected. There were 15 patients with documented post-void residual and urinary retention developed in 4 during the urinary tract infection. All patients returned to baseline continence status and reservoir function after appropriate antibiotic treatment based on objective and subjective assessments. CONCLUSIONS Urinary tract infection may cause urinary incontinence in patients with ileal bladder substitutes. Therefore, when there are complaints of de novo urinary incontinence, a finding of post-void residual or an acute presentation of urinary retention, a urinary tract infection should be excluded. When the urinary tract infection is appropriately treated urinary continence and reservoir function return to their baseline status.

Determining the success of vasectomy

To examine patient compliance, significance of rare nonmotile sperm (RNMS) and to determine the timing and number of semen analyses required to confirm sterility.

FOCAL /PARTIAL GLAND PROSTATE CRYOABLATION: RESULTS OF 795 PATIENTS FROM MULTIPLE CENTERS TRACKED WITH THE COLD REGISTRY

INTRODUCTION AND OBJECTIVES: Cryotherapy (cryo) for prostate cancer (PCa) traditionally targets treatment of the whole gland. While efficacious, this ablates healthy tissue thereby increasing morbidity. Focal prostate cryo addresses only known cancerous foci. We report the outcomes of focal cryo at a number of centers participating in the Cryo On-Line Database (COLD). These early data on 795 men comprise the first substantial multicenter report of focal cryo. METHODS: 795 focal cryo pts were stratified by D’Amico risk classifications. Biochemical failure was determined by the ASTRO and PHOENIX definitions. Biopsy was performed at the physician’s discretion, commonly due to a rising or suspicious PSA. Incontinence was the use of any pads. Return to intercourse was the ability to penetrate and complete with or without assistance. RESULTS: Median age of pts was 68 (37-85). Median followup is 1 yr. Table 1 reports demographic information. Actuarial disease free survivals (KM analysis) are reported in the figures. Positive biopsies were reported in 36 pts (4.5% of the cohort, 25% of pts undergoing biopsy). 3 (0.4%) rectal fistulas were reported between 6 weeks and 12 months postop. Incontinence was reported in 11 pts (2.8%). Of the 134 pts potent prior to cryo, 87 (65%) were sexually active 12 months postop. CONCLUSIONS: Focal prostate cryo is controversial. The procedure is associated with low morbidity most notably, a majority of men will resume intercourse. Early efficacy is supported by encouraging 60 month BDFS rates in men with low and intermediate risk, but men with high risk disease have less favorable outcomes. Larger, more mature datasets are required before these results should direct treatment decisions. Gleason score, % of pts with stage T2b,PSA & D’Amico risk classifications

Primary extraosseous ewing sarcoma of the kidney with level III inferior vena cava thrombus.

Ewing sarcoma typically presents as a skeletal-based tumor, with rare instances of peripheral primitive neuroectodermal tumor (PNET) arising in the soft tissues. Few examples of organ-based PNETs have been previously described in the literature. These tumors are exceedingly rare as a primary renal neoplasm. To our knowledge, this is the first report documenting a primary extraskeletal Ewing sarcoma of the kidney with thrombus extending into the intrahepatic inferior vena cava thrombus (level III).

Topical Anesthesia With EMLA does Not Decrease Pain During Vasectomy

PURPOSE Previous studies show conflicting results of the ability of EMLA (eutectic mixture of local anesthetics) to decrease pain during vasectomy. We examined the effectiveness of EMLA cream to decrease pain in patients undergoing bilateral percutaneous no-scalpel vasectomy. MATERIALS AND METHODS A prospective study was performed in which 316 patients used EMLA cream (178) or no topical anesthesia (138) before vasectomy. EMLA cream was applied by patients 1 hour before the scheduled time of surgery. Bilateral percutaneous no-scalpel vasectomy was then performed in the 2 groups with local infiltration of 1% lidocaine into the scrotal wall and vasal sheath. Following the procedure patients were asked to rate their associated pain using a visual analog scale. Statistical analysis was performed using the 2-sided Student t test. RESULTS Mean patient age was similar in the groups with and without EMLA (39.1 and 39.0 years, respectively). No significant difference in mean visual analog pain scores were noted between the EMLA and control groups (21.5 vs 21.0, p = 0.8). CONCLUSIONS Topical anesthesia with EMLA did not significantly decrease the pain associated with percutaneous vasectomy.