Pascal Rischmann

Complications for Radical Cystectomy

Objectives: To report the perioperative events after radical cystectomy and urinary diversion in bladder cancer in terms of major and minor complications and to seek statistical relationships with patient’s characteristics and surgical procedures. Methods: One hundred and sixty–one radical cystectomies performed in the modern era in two academic hospitals were reviewed. Preoperative patients characteristics (age, sex, hemoglobin, total protein, weight and height) and perioperative data (operative time, type of urinary diversion, associated procedures, blood transfusion, seniority of the surgeon) were recorded. Perioperative morbidity was defined by any adverse event during hospital stay or within 30 days after surgery, those requesting an additional stay of more that 3 days in the intensive care unit or a reoperation being classified as major complications. Significant relationships were sought for classes by Student’s t test for comparison of quantitative variables and Yate’s corrected χ2 test for categorical variables. Spearman’s rank correlation test was used for comparison of quantitative variables. Results: Major complications were observed in 41 patients (25.5%) and resulted in 14 reoperations (8.7% reoperation rate). Most of them were diversion–related and were statistically related to the ASA score ≧3 (p<0.01, 5.7 odds ratio). Compared to sophisticated means of diversion, cutaneous diversion resulted in minimal operative time and hospital stay. No relationships between age, body mass index, biological parameters, type of diversion, associated procedure, surgeon’s experience and postoperative complications could be evidenced. Uneventful recovery resulted in a 16.6 days mean hospital stay, minor complications induced a significant 3.8 days additional stay and major complications resulted in major lengthening of hospital stay (21.2 days mean additional stay). Conclusion: ASA scores equal to or greater than 3 were associated with major complications and most specially those related to the type of urinary diversion. Therefore, we recommend special care in the selection of the type of urinary diversion and further preoperative evaluation inclusive of nutritional assessment.

BCG Intravesical Instillations: Recommendations for Side-Effects Management

Adverse events following intravesical BCG therapy are related to strain virulence, allergic reactions or to nosocomial urinary tract infections. Low grade fever and irritative symptoms are common side-effects of BCG. They subside within 48 hours and do not require any specific treatment, apart from standard painkillers and antispasmodics. Further instillations should be postponed until symptoms have resolved completely. If symptoms do not resolve, complementary investigations are recommended including urine culture, and isoniazid may be prescribed for 15 days. The BCG dose should be reduced if symptoms increase after subsequent instillations. Complications of BCG infection – either local or systemic – have been reported with an incidence of 10–15%. These complications include: granulomatous prostatitis or epididymitis (treated with isoniazid and rifampicin for 3 months), contracted bladder may occur, mainly during maintenance courses, systemic infection such as granulomatous nephritis and abscesses, pneumonitis, hepatitis, osteomyelitis (treated with isoniazid, rifampicin and ethambutol for 6 months), and life-threatening adverse events may be related to septicaemia or to immunoallergic reactions, the onset of which may be delayed several months after the end of BCG therapy. Such conditions require urgent treatment with standard antituberculous antibiotics and prednisolone. These complications are an absolute contraindication for further BCG instillations. Despite its toxicity, the risk-benefit ratio favours the use of BCG in patients who have moderate- and high-risk tumours.

High prevalence of erectile dysfunction after renal transplantation.

BACKGROUND AND METHODS A cross-sectional study of multifaceted male sexual function in 323 consecutive kidney transplant recipients was conducted by mail by means of the validated International Index of Erectile Function (IIEF). All five IIEF domains (IIEF-5), i.e., erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction, were scored for each responder. IIEF-5 scoring that conformed to the National Institutes of Health definition of erectile dysfunction (ED) was computed for all patients sexually active within the past 4 weeks. RESULTS Two hundred and seventy-one patients replied. Compared to the controls used for IIEF psychometric validation, kidney transplant recipients gave lower erectile function (P<0.01) and intercourse satisfaction (P<0.05) scores, despite their being younger. ED, according to the IIEF-5 method, was demonstrated in 55.7% of the sexually active patients (n=212). Age, time on dialysis, and iterative transplants were significantly and negatively related to erectile dysfunction. CONCLUSION IIEF proved to be a valuable means of unveiling highly prevalent erectile dysfunction in male kidney transplant recipients. The negative impact of the time on dialysis was emphasized in the results.

Radical Cystectomy for Bladder Cancer: Morbidity of Laparoscopic Versus Open Surgery

PURPOSE We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. MATERIALS AND METHODS This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. RESULTS Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. CONCLUSIONS Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

Evaluation of male sexual function after pelvic trauma by the International Index of Erectile Function.

OBJECTIVES To assess the multifaceted male sexual function after pelvic ring fracture. METHODS A cross-sectional study of male sexual function after pelvic ring fractures was conducted, using the International Index of Erectile Function (IIEF). The department of traumatology database was scanned (June 1996 to April 1999) for 30 to 70-year-old male patients with pelvic fracture. Seventy-six consecutive, literate patients were then contacted by mail. IIEF domain scores were calculated for all responders. Cappelleris method for identification and grading of erectile dysfunction was applied for patients sexually active within the past 4 weeks. Students t test was used to compare the domain scorings of patients with those of the control population used for the IIEF psychometric validation. Relationships between IIEF results and patient characteristics were sought by Spearmans rank correlation coefficient for quantitative variables and Students t test for classes. RESULTS Forty-six patients answered (60.1% response rate). Thirty-seven patients had experienced sexual intercourse in the past 4 weeks during which 11 patients (29.7%) had exhibited various degrees of impaired erection. As a whole, compared with the published controls a significant decrease in overall satisfaction (P <0.05) was demonstrated. Pubic diastasis was further related to impaired erectile function and overall satisfaction; we suggest that cavernosal nerves might be damaged at the time of diastasis. CONCLUSIONS This study evidenced the impairment of sexual overall satisfaction after pelvic trauma and the specific decrease in erectile function and erection firmness and confidence associated with pubic diastasis. The IIEF questionnaire might be considered at the time of rehabilitation to identify those patients that could benefit from supportive treatments.

Renal Cell Carcinoma (RCC) in Patients With End-Stage Renal Disease Exhibits Many Favourable Clinical, Pathologic, and Outcome Features Compared With RCC in the General Population

BACKGROUND Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

Activation of Sphingosine Kinase-1 in Cancer: Implications for Therapeutic Targeting

Sphingolipid metabolites are critical to the regulation of a number of fundamental biological processes including cancer. Whereas ceramide and sphingosine mediate and trigger apoptosis or cell growth arrest, sphingosine 1-phosphate promotes proliferation, cell survival and angiogenesis. The delicate equilibrium between the intracellular levels of each of these sphingolipids is controlled by the enzymes that either produce or degrade these metabolites. Sphingosine kinase-1 is a crucial regulator of this two-pan balance, because its produces the pro-survival and pro-angiogenic sphingosine 1-phosphate and decreases the amount of both ceramide and sphingosine, the pro-apoptotic sphingolipids. Moreover, its gene is oncogenic, its mRNA is overproduced in several solid tumors, its overexpression protects cells from apoptosis, and its activity is down-regulated by anti-cancer treatments. Therefore, the sphingosine kinase-1/sphingosine 1-phosphate signaling pathway appears to be a target of interest for therapeutic manipulation.

Modified Extrafascial Radical Retropubic Prostatectomy Technique Decreases Frequency of Positive Surgical Margins in T2 Cancers 3

Objectives: In an effort to decrease the frequency of postoperative positive surgical margins (+SM), a modified extrafascial radical prostatectomy technique was developed and evaluated.Methods: 402 consecutive radical prostatectomy specimens removed for clinical stage T2 cancers from 1987 to 1994 were histologically examined prospectively for tumor volume, extraprostatic extension and +SM. Surgical technique modification was introduced in 1990. We compared the histologic status and biological outcome of the prostatectomy cases in 1987–1989 (n = 166) to those treated from 1990 to 1994 (n = 236).Results: The two series were comparable in (1) clinical stage and preoperative (PSA, (2) tumor volume, grade and location, and (3) capsular penetration, seminal vesicle and lymph node status. +SM fell from 32 to 25% overall, but for 146 (36%) prostates with a tumor volume <2 cm3, +SM fell from 21 to 6% which was statistically significant. Outcome measured by biological progression showed a decrease from 33% for +SM to 13% for –SM for cases with a tumor volume <2 cm3. For cancer volumes >2 cm3, the incidence of +SM did not vary significantly. We describe the anatomic details necessary for exposure of periprostatic fascias and extrafascial dissection at (1) the prostatourethral junction which ensures wide excision of the anterior and apical aspect of the prostate, (2) the posterior and apical area (development of the prerectal space), lateral and posterior areas at the base of the prostate which ensures wide excision of the rectoprostatic fascia (Denonvilliers’s fascia) and lateral prostatic fascia.Conclusions: Differences in surgical technique probably accounted for the significant decrease in +SM for those T2 cancers with volumes ≤2 cm3 which represents 36% of the T2 cancers in our series. Recent screening with PSA (T1c cancers) increases the incidence of these cancers ≤2cm3. This modified uni– or bilateral anatomic extrafascial prostatectomy with improved +SM and biological progression rates for T2 cases should be evaluated for T1c cases.

Sacral neuromodulation for treating neurogenic bladder dysfunction: clinical and urodynamic study.

The efficacy of sacral neuromodulation for treating refractory idiopathic lower urinary tract dysfunction is now well established. Nevertheless, results of this technique in neurological patients are still controversial. The aim of this retrospective study was to assess the results of sacral neuromodulation in neurogenic bladder dysfunction.

Focal High Intensity Focused Ultrasound of Unilateral Localized Prostate Cancer: A Prospective Multicentric Hemiablation Study of 111 Patients

BACKGROUND Up to a third of patients with localized prostate cancer have unilateral disease that may be suitable for partial treatment with hemiablation. OBJECTIVE To evaluate the ability of high intensity focused ultrasound (HIFU) to achieve local control of the tumor in patients with unilateral localized prostate cancer. DESIGN, SETTING, AND PARTICIPANTS The French Urological Association initiated a prospective IDEAL multi-institutional study (2009-2015), to evaluate HIFU-hemiablation as a primary treatment. INTERVENTION Multiparametric magnetic resonance imaging and biopsy were used for unilateral cancer diagnosis and control, and HIFU-hemiablation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary: absence of clinically significant cancer (CSC) on control biopsy at 1 yr (CSC: Gleason score ≥ 7 or cancer core length>3mm regardless of grade or > 2 positive cores). Secondary: presence of any cancer on biopsy, biochemical response, radical treatment free survival, adverse events, continence (no pad), erectile function (International Index of Erectile Function-5 ≥ 16), and quality of life (European Organization for Research and Treatment of Cancer QLQ-C28) questionnaires. RESULTS AND LIMITATIONS One hundred and eleven patients were treated (mean age: 64.8 yr [standard deviation 6.2]; mean prostate-specific antigen: 6.2 ng/ml [standard deviation 2.6]; 68% low risk, 32% intermediate risk). Of the 101 patients with control biopsy, 96 (95%) and 94 (93%) had no CSC in the treated and contralateral lobes, respectively. Mean prostate-specific antigen at 2 yr was 2.3 ng/ml (standard deviation 1.7). The radical treatment-free survival rate at 2 years was 89% (radical treatments: six radical prostatectomies, three radiotherapies, and two HIFU). Adverse events were Grade 3 in 13%. At 12 mo continence and erectile functions were preserved in 97% and 78%. No significant decrease in quality of life score was observed at 12 mo. One limitation is the number of low-risk patients included in this study. CONCLUSIONS At 1 yr, HIFU-hemiablation was efficient with 95% absence of clinically significant cancer associated with low morbidity and preservation of quality of life. Radical treatment-free survival rate was 89% at 2 yr. PATIENT SUMMARY This report shows that high intensity focused ultrasound half-gland treatment of unilateral prostate cancer provides promising results with high cancer control and low morbidity.