Randall G. Rowland

Indiana continent urinary reservoir.

AbstractCecoileal reservoirs were created in 29 patients. Tunneled ureteral implantations along the tenia of the cecum provided the antireflux mechanism. Plication or tapering of the terminal ileal segment along with the ileocecal valve provided the continence mechanism.The tubular configuration of the cecum was disrupted with either an ileal or sigmoid patch, or it was re-configured in a Heineke-Mikulicz type of closure to avoid bolus (unit) contractions. Shortterm followup examination with excretory urography showed no upper tract obstruction. X-rays of the pouch showed no reflux and interviews revealed satisfactory continence in 93 per cent of the patients.

Retroperitoneal Lymphadenectomy for Clinical Stage a Testis Cancer (1965 to 1989): Modifications of Technique and Impact on Ejaculation

Results with primary retroperitoneal lymphadenectomy in 464 patients with clinical stage A nonseminomatous germ cell testis cancer (1965 to 1989) were reviewed. The false-negative staging error by clinical methods remains at 30%. The relapse rate in pathological stage A cancer patients was 11% (37 of 323), with 2 deaths. For pathological stage B disease 64% of the patients were cured by retroperitoneal lymphadenectomy alone. With modern adjuvant chemotherapy no stage B tumor relapsed since 1979 and the survival rate was 100%. For all 25 years (464 patients) the relapse rate was 14% and the survival rate was 98.9% (3 cancer and 2 noncancer deaths). Because these results are based on preoperative clinical staging, they are directly comparable with series using radiotherapy or surveillance.

Nerve-Sparing Retroperitoneal Lymphadenectomy with Preservation of Ejaculation

The feasibility of sparing postganglionic fibers of lumbar sympathetic nerves during the course of retroperitoneal lymphadenectomy has been investigated at our university medical center beginning in 1978. We selected 75 patients for nerve-sparing retroperitoneal lymphadenectomy in an effort to preserve ejaculatory function postoperatively. This cohort of patients was selected on the basis of clinical stage. Of the 75 patients 73 had clinical stage I disease. However, 14 of these 73 patients had pathological stage II cancer. No patient was treated with adjuvant chemotherapy after nerve-sparing retroperitoneal lymphadenectomy. Of these 14 patients with pathological stage II disease 4 had relapse: 1 with proved retroperitoneal recurrence, and 3 with serological elevations of tumor markers and questionable clinical findings as to anatomical site of relapse. All 4 patients are free of disease after chemotherapy and/or surgical (1) rescue. There were no local recurrences in the 61 patients with negative nodes. All 75 patients ejaculate and had no evidence of disease more than 2 years after nerve-sparing retroperitoneal lymphadenectomy. It is clear that nerve-sparing retroperitoneal lymphadenectomy is a feasible technique. As noted, it can even be applied to selected patients with low volume positive nodes, yet maintaining relapse and survival figures that are acceptable. Ejaculation is reliably preserved when this nerve-sparing technique is applied accurately in retroperitoneal lymphadenectomy.

BLADDER CANCER CLINICAL GUIDELINES PANEL SUMMARY REPORT ON THE MANAGEMENT OF NONMUSCLE INVASIVE BLADDER CANCER (STAGES Ta, T1 AND TIS)

PURPOSE The American Urological Association convened the Bladder Cancer Clinical Guidelines Panel to analyze the literature regarding available methods of treating nonmuscle invasive bladder cancer, and to make practice policy recommendations based primarily on treatment outcomes data. MATERIALS AND METHODS The panel searched the MEDLINE database for all articles related to nonmuscle invasive bladder cancer published from 1966 to January 1998. Outcomes data were extracted from articles accepted after panel review and meta-analyzed to produce comparative probability estimates for alternative treatments. RESULTS All of the intravesical agents (thiotepa, bacillus Calmette-Guerin, mitomycin C and doxorubicin) when used as adjuvant therapy after transurethral resection resulted in a lower probability of recurrence compared to resection alone. However, there is no evidence that intravesical therapy affects long-term progression. CONCLUSIONS For patients with no prior intravesical therapy adjuvant intravesical chemotherapy or immunotherapy is a treatment option after endoscopic removal of low grade Ta bladder cancers. Intravesical instillation of bacillus Calmette-Guerin or mitomycin C is recommended for carcinoma in situ, and after endoscopic removal of T1 and high grade Ta tumors.

Correlation of computerized tomographic changes and histological findings in 80 patients having radical retroperitoneal lymph node dissection after chemotherapy for testis cancer

A total of 80 patients with stage B3 or B2/C germ cell testis tumors underwent computerized tomography before and after chemotherapy. The volume and computerized tomographic density of metastatic retroperitoneal tumor were measured on all scans. The patients then underwent full bilateral retroperitoneal lymphadenectomy. The change in volume and density of retroperitoneal disease was correlated with the histological type of the primary testis tumor and with the histological findings at retroperitoneal lymphadenectomy. In all 15 patients (100 per cent) without teratomatous elements in the original tumor and who had a greater than 90 per cent decrease in the volume of retroperitoneal masses as a response to systemic chemotherapy no teratoma or active cancer was found in the surgical specimen. In contrast, 7 of 9 patients (78 per cent) with teratomatous elements in the original specimen had either teratoma or carcinoma in the retroperitoneal lymphadenectomy specimens despite having a greater than 90 per cent decrease in tumor volume. This difference was significant (p less than 0.05). These data suggest that patients with no teratomatous elements in the original specimen and a greater than 90 per cent decrease in the volume of retroperitoneal masses in response to chemotherapy can be observed carefully for signs of recurrence rather than undergoing post-chemotherapy retroperitoneal lymphadenectomy.

Complications of post-chemotherapy retroperitoneal lymph node dissection.

The surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy there was a higher occurrence of postoperative chylous ascites. Most of the other complications (gastrointestinal, lymphatic, neurological and renal) were temporary and treated conservatively. Perioperative management of the post-chemotherapy testis cancer patient is different from that of the patient undergoing primary retroperitoneal lymphadenectomy. The latter operation is usually performed in physically fit patients and the surgical template of dissection is of a smaller scale. Thus, the complications in this group are minor and without mortality. Specific technical considerations and difficulties are common to post-chemotherapy patients. Factors, such as large volume of disease, post-chemotherapy desmoplastic reaction and extensive retroperitoneal dissection, make these patients more prone to have complications. Decreased pulmonary, renal and nutritional reserves add to the surgical morbidity. Knowledge of possible pitfalls and their causes can avoid unnecessary operative complications.

Original Articles: Testis Cancer: Complications of Post-Chemotherapy Retroperitoneal Lymph Node Dissection

ABSTRACTThe surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy the...

Complications of primary retroperitoneal lymph node dissection.

The surgical morbidity in 478 patients who underwent primary retroperitoneal lymphadenectomy for clinical stages I and II nonseminomatous testicular cancer from 1982 to 1992 was reviewed. There were 54 complications in 51 patients (10.6%) and no operative related mortality. Superficial wound infection was the most frequent complication, comprising 45% of the total number of complications. Most major complications were related to small bowel obstruction and atelectasis. No complications caused permanent disability. The complication rate was less in patients who underwent a modified unilateral procedure (9.4%) than in those who underwent bilateral dissection (19.3%). Complications were significantly less with procedures done during the latter 6 years of the study (1987 to 1992). The ejaculation rate of patients undergoing a nerve sparing procedure was 98%, which reflects the increase in experience gained with the technique of nerve sparing modified unilateral dissection for early stage testicular cancer. This study reinforces the view that primary retroperitoneal lymph node dissection is an operation with minimal morbidity and no long-term effects. Furthermore, this study serves as the basis for cost-benefit and risk-benefit analyses of primary retroperitoneal lymph node dissection in low stage testicular cancer, which can be set against surveillance and primary chemotherapy programs.

Teratoma following cisplatin-based combination chemotherapy for nonseminomatous germ cell tumors: a clinicopathological correlation.

From April 1975 through May 1981, 51 patients had teratoma resected from residual disease following cisplatin-based combination chemotherapy. All patients had normal serum markers before resection of abdominal (25), lung (12), mediastinal (5), thoracoabdominal (8) or other (1) disease. Teratoma was classified as mature in 29 cases, immature in 15 or immature with nongerm cell elements in 7. Of the 51 patients 31 (61 per cent) remain free of recurrent disease, while 20 either had recurrent carcinoma (10) or teratoma (10) requiring further therapy. Nine patients died, including 1 in whom angiosarcoma developed, which was thought to be secondary to previous radiation therapy. In 4 patients the initial relapse of carcinoma developed beyond 2 years after resection. Univariate factors predicting for relapse include tumor burden, immature teratoma with nongerm cell elements and site (mediastinum), while only immature teratoma with nongerm cell elements and site predicted for survival. Patients with immature teratoma had a comparable relapse-free and over-all survival as those with mature teratoma. Using a multivariate analysis, primary tumor site at the mediastinum was the most significant adverse factor predictive for relapse and survival. This study appears to support the various pre-clinical models that demonstrate multipotential capabilities of teratoma. Complete surgical excision of teratoma remains the most effective treatment with continued close followup recommended for high risk patients (immature teratoma with nongerm cell elements, large tumor burden and primary mediastinal tumors) with resected teratoma.

The cecoileal continent urinary reservoir

SummaryExperience with the Kock pouch prompted us to develop a new form of continent urinary reservoir. This is a composite structure using ileum and cecum. Tunnelled ureteral implantations along the tenia of the cecum provide the antireflux mechanism, while the ileocecal valve and plicated terminal ileal segment provide continence. An ileal patch on the cecum helps overcome the intermittent incontinence that can occur and is presumed to be due to a bolus contraction of the cecum. The cecoileal continent urinary reservoir offers the flexibility of either abdominal or pelvic placement.