Pertti Puntala

Secondary Amyloidosis of the Bladder: a Cause of Massive Hematuria

Secondary amyloidosis of the bladder is a rare cause of hematuria, with only 10 previous reports. Findings and treatment in 5 patients with histologically verified bladder amyloidosis secondary to long-standing rheumatoid arthritis are presented. All patients were hospitalized for massive hematuria. One patient died before cystoscopy. Clot evacuation and fulguration through a cystoscope stopped the bleeding in 1 patient. In the other 3 patients hemostasis was achieved by cystotomy, bilateral percutaneous nephrostomy and continuous alum irrigation of the bladder, respectively.

Renal Artery Embolization in the Palliative Treatment of Renal Adenocarcinoma

Renal artery embolization without subsequent nephrectomy was used to treat renal adenocarcinoma in 25 patients. The tumour had metastasized in 15 cases, and was locally advanced in six cases and localized in four. The aim was palliation of local symptoms in 20 cases. It was achieved in 11 of 14 patients with gross haematuria and in three of six with severe local pain. No prolongation of survival time was evident, and all the patients died of renal adenocarcinoma within 38 months. Regression of metastases was not seen. In one patient, embolization with absolute ethanol was followed by infarction of the left colon and death.

Reliability of Aspiration Biopsy Cytology in the Grading of Renal Adenocarcinoma

Needle aspiration biopsy and histologic samples were taken from three corresponding regions of the surgical specimens immediately after nephrectomy from 150 renal parenchymal tumours. At review 144 of these were diagnosed as adenocarcinomas and 6 as oncocytomas. The adenocarcinomas were classified into three grades according to the degree of differentiation: High, moderate, poor. The grade, as evaluated on cytologic grounds, was in agreement with the histologic grade in 75.9% of the cases and in disagreement by one grade in 24.1%. The cytologic assessment was undergraded in 19.1% and overgraded in 5.0%. The 5-year survival rate for patients with histologically highly differentiated carcinomas was 82.7%, for moderately differentiated 48.7% and for poorly differentiated 28.1%. For corresponding cytologic groups the survival rates were 72.7%, 49.9% and 22.2%. The grade was variable in the same tumour in 24.2% of the cases. The assessment demands several samples, from which the least differentiated is significant. The prognostic significance of needle aspiration biopsy is reliable when cytologic differentiation is poor, but declines as the differentiation improves.

Intravesical dimethyl sulfoxide instillations in the treatment of secondary amyloidosis of the bladder.

A-22-year-old woman with long-standing rheumatoid arthritis and secondary amyloidosis of the bladder had recurrent profuse macroscopic hematuria. She was treated with intravesical dimethyl sulfoxide instillation every 2 weeks for 1 year. She remained asymptomatic during the treatment and at 6 months. Progressive disappearance of amyloid from the superficial mucosa of the bladder was demonstrated in sequential histological examinations.

Intravesical epirubicin with and without verapamil for the prophylaxis of superficial bladder tumours

Seventy-five patients with recurrent bladder carcinoma were randomized after electroresection to receive either epirubicin (E) or epirubicin + verapamil (E + V) instillation of the bladder at regular intervals for 2 years. Samples of the bladder wall, tumour tissue and peripheral blood were taken from 20 patients. The average follow-up period was 21 months. Fifty per cent of the patients in the E group and 37% in the E + V group developed recurrent tumours. Recurrence rates (RR) were 6.3 and 4.7, respectively. Before the instillation therapy the RR was 16.0. There was a highly significant reduction of RR during the instillation therapies; in group E p less than 0.005 and in group E + V p less than 0.001. The difference between the treatment groups was not statistically significant. Verapamil increased epirubicin concentrations in both the bladder wall and the tumour tissue, but did not affect concentrations in the peripheral blood. Side effects were few and did not lead to discontinuation of treatment.

Reliability of CT in preoperative evaluation of bladder carcinoma.

Sixty patients with bladder carcinoma were examined by CT prior to radical cystectomy. CT indicated perivesical tumour growth or extension to neighbouring organs correctly in 68% of these cases. Overstaging was observed in 23% and understaging in 8% of the cases. Most of the difficulties concerned assessment of tumours in the anterior bladder wall and identification of the plane between the bladder and the seminal vesicle. In most instances CT provided no supplementary information to clinical staging, but was useful when obesity or previous irradiation impeded clinical staging.

Diagnosis and Treatment of Renal Angiomyolipoma

A series of nine patients surgically treated for histologically verified renal angiomyolipoma is presented. Only one patient had extrarenal stigmata of tuberous sclerosis. No evidence of malignancy was found. In three cases a preoperative diagnosis was achieved with computed tomography (CT), use of which is recommended in evaluation of renal tumours. Six angiomyolipomas were solitary and three bilateral. Abdominal or flank pain was present in eight cases and perirenal haemorrhage in four. Solitary tumours were treated with nephrectomy. For bilateral tumour, nephrectomy and conservative renal surgery were used in two cases and bilateral nephrectomy and kidney transplantation were performed in the third case. When adipose tissue containing renal tumour is demonstrated at CT, conservative surgery should be considered.

Urethral recurrence after cystoprostatectomy for bladder carcinoma

Eighty-nine male patients underwent cystoprostatectomy for bladder carcinoma. Prophylactic urethrectomy was performed only on 7 patients whose tumour extended to or beyond the bladder neck. During the follow-up period 9 of 82 patients (11%) developed a urethral recurrence. Eight out of these 9 patients had carcinoma in situ or multiple papillary tumours in the bladder. Of all those patients who had carcinoma in situ, either primary or concomitant with papillary tumour, 18% developed urethral recurrence. The corresponding figure for patients with multiple tumours in the bladder was 15%. Thus the presence of carcinoma in situ or multiple tumours in the bladder seem to be important risk factors for urethral recurrence after cystoprostatectomy.

Evaluation of Upper and Lower Urinary Tracts after Camey Operation

Ten male patients with bladder carcinoma underwent radical cystoprostatectomy and Camey bladder substitution. Six months after surgery 3 of 19 ureters were refluxing in cystography. IVP demonstrated slight dilatation of two and moderate dilatation of one renal unit. The median maximum capacity of the bladder substitutes was 400 ml and the median residual volume was 40 ml. In 7 cases high pressure waves were demonstrated in cystometry. Nine patients had normal continence during day but only three patients during night. In addition three patients were dry during night if they voided frequently but four had varying degrees of enuresis. The results are otherwise satisfactory but the night-time incontinence may be troublesome.

Transabdominal and Lumbar Nephrectomy for Renal Adenocarcinoma

The results of 178 transabdominal and 79 lumbal nephrectomies were compared, based on a consecutive series of patients with renal adenocarcinoma. The corrected 5-year survival rate for patients without distant metastases was 64% for transabdominal and 57% for lumbar nephrectomy. This difference is not statistically significant. The transabdominal approach made possible a more extensive operation in patients with tumours extending to neighbouring organs, but none has survived as long as three years. Duration of surgery, need for blood transfusion and duration of postoperative hospital care were similar. Splenic injury occurred in 9.6% of the patients with transabdominal nephrectomy, but this did not result in additional morbidity or mortality. There were a few other sporadic complications.