Robert de Petriconi

THE ILEAL NEOBLADDER: COMPLICATIONS AND FUNCTIONAL RESULTS IN 363 PATIENTS AFTER 11 YEARS OF FOLLOWUP

PURPOSE Since 1986 orthotopic lower urinary tract reconstruction using the ileal neobladder has been our diversion of choice in patients of both sexes undergoing cystectomy. We report on experience and functional results of the first 363 men 11 years after this procedure. MATERIALS AND METHODS Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence and voiding pattern were individually evaluated via a detailed patient questionnaire. RESULTS Perioperative death occurred in 11 patients (3%). Neobladder related early and late complications occurred in 56 (15.4%) and 85 (23.4%) of the 363 patients, respectively. Neobladder related early and late abdominal reoperation rates were 0.3 and 4.4%, respectively. Perioperative neobladder unrelated early complications were observed in 122 patients (33.6%) and 44 (12.1%) required operative treatment. Late postoperative complications unrelated to the neobladder occurred in 45 patients (12.4%) and 19 required open surgical revision. Of 290 evaluable patients 96.1% void spontaneously, 3.9% perform clean intermittent catheterization in some form and 1.7% perform regular intermittent catheterization. Daytime and nighttime continence was reported as good by 95.9% and satisfactory by 95% of the patients. Unacceptable daytime continence requiring more than 1 pad per day occurred in only 4.1% of the patients and only 5% are wetting more than 1 pad a night. CONCLUSIONS The ileal neobladder produces good functional results and can be constructed with acceptable complications. Our data suggest that although it is not a complication-free procedure, we advocate its use when possible.

Predisposing Gene for Early-Onset Prostate Cancer, Localized on Chromosome 1q42.2-43

There is genetic predisposition associated with >=10% of all cancer of the prostate (CaP). By means of a genomewide search on a selection of 47 French and German families, parametric and nonparametric linkage (NPL) analysis allowed identification of a locus, on chromosome 1q42.2-43, carrying a putative predisposing gene for CaP (PCaP). The primary localization was confirmed with several markers, by use of three different genetic models. We obtained a maximum two-point LOD score of 2.7 with marker D1S2785. Multipoint parametric and NPL analysis yielded maximum HLOD and NPL scores of 2.2 and 3.1, respectively, with an associated P value of . 001. Homogeneity analysis with multipoint LOD scores gave an estimate of the proportion of families with linkage to this locus of 50%, with a likelihood ratio of 157/1 in favor of heterogeneity. Furthermore, the 9/47 families with early-onset CaP at age <60 years gave multipoint LOD and NPL scores of 3.31 and 3.32, respectively, with P = .001.

Radical Cystectomy for Urothelial Carcinoma of the Bladder Without Neoadjuvant or Adjuvant Therapy: Long-Term Results in 1100 Patients

BACKGROUND The optimal treatment strategy for muscle-invasive bladder cancer (BCa) remains controversial. OBJECTIVE Better define the long-term outcomes of radical cystectomy (RC) alone for BCa and determine the impact of pathologic downstaging after transurethral resection in a large and homogeneous single-center series. DESIGN, SETTING, AND PARTICIPANTS A cohort of 1100 patients undergoing RC with pelvic lymph node dissection (PLND) without neoadjuvant therapy for urothelial carcinoma of the bladder between January 1, 1986, and December 2009 was evaluated. Patients with other than metastases to the pelvic lymph nodes were excluded. Median age was 65 yr. Clinical course, pathologic characteristics, and long-term outcomes were evaluated. Follow-up was obtained until December 2009 with a median of 38 mo and a completeness of 96.5%. INTERVENTION RC with PLND; urinary diversion with ileal neobladder whenever possible. MEASUREMENTS Primary end points were disease-specific survival (DSS), recurrence-free survival (RFS), and overall survival (OS) according to the tumor stage of the RC specimen versus the maximum tumor stage. The log-rank test was used to compare subgroups. RESULTS AND LIMITATIONS The 30-d (90-d) mortality rate was 3.2% (5.2%). The 10-yr OS, DSS, and RFS rates were 44.3%, 66.8%, and 65.5%, respectively. Based on the tumor stage of the RC specimen, the 10-yr DSS rate was pT0/a/is/1 pN0: 90.5%, pT2a/b pN0: 66.8%, pT3a/b pN0: 59.7%, pT4a/b pN0: 36.6%, and pTall pN+: 16.7%. Downstaging by transurethral resection of the prostate was observed in 382 patients. Patients with maximum tumor stage pT2a/b pN0 had distinctly better 10-yr DSS rates than those with pT2a/b pN0 in the RC specimen: pT2a pN0: 92.2% versus 73.8%; pT2b: 75.0% versus 62.0%. A total of 49% female and 80% male patients received an ileal neobladder. CONCLUSIONS This contemporary and homogeneous single-center series found acceptable OS, DFS, and RFS for patients undergoing RC. Pathologic downstaging had a significant impact on survival.

25 Years of Experience With 1,000 Neobladders: Long-Term Complications

PURPOSE We analyzed the long-term complications (greater than 90 days postoperatively) in a large, single center series of patients who underwent cystectomy and substitution with an ileal neobladder. MATERIALS AND METHODS A total of 1,540 radical cystectomies were performed at our center between January 1986 and September 2008. Of the patients 1,013 received an ileal neobladder. Only the 923 patients with followup longer than 90 days (median 72 months, range 3 to 267) were included in analysis. All long-term complications were identified. The complication rate was calculated using the Kaplan-Meier method. RESULTS The overall survival rate was 65.5%, 49.8% and 28.3% at 5, 10 and 20 years, respectively. The overall long-term complication rate was 40.8% with 3 neobladder related deaths. Hydronephrosis, incisional hernia, ileus or small bowel obstruction and feverish urinary tract infection were observed in 16.9%, 6.4%, 3.6% and 5.7% of patients, respectively, 20 years postoperatively. Subneovesical obstruction in 3.1% of cases was due to local tumor recurrence in 1.1%, neovesicourethral anastomotic stricture in 1.2% and urethral stricture in 0.9%. Chronic diarrhea was noted in 9 patients. Vitamin B12 was substituted in 2 patients. Episodes of severe metabolic acidosis occurred in 11 patients and 307 of 923 required long-term bicarbonate substitution. Rare complications included cutaneous neobladder fistulas in 2 cases, and intestinal neobladder fistulas, iatrogenic neobladder perforation, spontaneous perforation and necrotizing pyocystis in 1 each. CONCLUSIONS Even in experienced hands the long-term complication rate of radical cystectomy and neobladder formation are not negligible. Most complications are diversion related. The challenge of optimum care for these elderly patients with comorbidities is best mastered at high volume hospitals by high volume surgeons.

THE ILEAL NEOBLADDER IN WOMEN: 9 YEARS OF EXPERIENCE WITH 18 PATIENTS

PURPOSE We present our surgical and functional experience with orthotopic bladder replacement in women. MATERIALS AND METHODS Since 1986, 18 women have undergone lower urinary tract reconstruction with an ileal neobladder. A nerve sparing cystectomy is done, and reservoirs are connected to the proximal urethra or urethrovesical junction. A total of 13 patients was available for complete followup as of March 1995. RESULTS There were no perioperative deaths and few early complications. The only 2 failures were a neobladder vaginal fistula and these cases, which were converted to a conduit, are excluded from this study. Late complications requiring rehospitalization or reoperation in 2 patients included urethroileal stenosis that had to be dilated without further sequelae and bilateral ureteroileal stenosis that was treated endoscopically. At 3 months postoperatively excellent continence was achieved in 8 patients, while 2 had grade 1 stress incontinence and 3 were hypercontinent. As of March 1995 only 4 patients voided to completion while 9 required intermittent catheterization (continuously in 5 and twice daily for residual urine in 4). We were unable to demonstrate a functional difference of the various resection lines located at the proximal urethra or urethrovesical junction. CONCLUSIONS Urethral support and nerve sparing cystectomy plus the ileal neobladder as a reservoir guarantee excellent continence in all patients. Despite our efforts, we have been unable to demonstrate any advantage of the nerve and urethral support sparing cystectomy technique as far as micturition is concerned. The development of hypercontinence in 70% of the patients with time demonstrates that our current understanding of the functional and anatomical basics of the voiding process is too limited to allow bladder replacement with a perfect functional result in all female patients. Our long-term experience, which is different from initial reports, justifies creation of an ileal neobladder in select female patients as long as they accept a 70% risk of clean intermittent catheterization in the long term. Overall patient satisfaction, including sexual life, is exceptional. However, disappointment is considerable when clean intermittent catheterization is required after periods of successful voiding per urethram.

Lessons Learned From 1,000 Neobladders: The 90-Day Complication Rate

PURPOSE We report the 90-day morbidity of the ileal neobladder in a large, contemporary, homogenous series of patients who underwent radical cystectomy at a tertiary academic referral center using a standard approach. MATERIALS AND METHODS Between January 1986 and September 2008 we performed 1,540 radical cystectomies. A total of 281 patients had an absolute contraindication for orthotopic reconstruction. The remaining 1,259 patients were candidates for a neobladder. Of these patients 1,013 (66%) finally received a neobladder and form the basis of this report. All patients had a thorough followup until December 2008 or until death. All complications within 90 days of surgery were defined, categorized and classified by an established 5 grade and 11 domain modification of the original Clavien system. RESULTS Of 1,013 patients 587 (58%) experienced at least 1 complication within 90 days of surgery. Infectious complications were most common (24%) followed by genitourinary (17%), gastrointestinal (15%) and wound related complications (9%). The 90-day mortality rate was 2.3%. Of the patients 36% had minor (grade 1 to 2) and 22% had major (grade 3 to 5) complications. On univariate analysis the incidence and severity of the 90-day complications rate correlate highly significantly with age, tumor stage, American Society of Anesthesiologists score and preoperative comorbidity. CONCLUSIONS Radical cystectomy and ileal neobladder formation represent a major surgery with potential relevant early complications even in the most experienced hands. The rate of severe and lethal complications is acceptably low.

A MULTICENTER STUDY OF THE MORBIDITY OF RADICAL CYSTECTOMY IN SELECT ELDERLY PATIENTS WITH BLADDER CANCER

PURPOSE We evaluated the morbidity of radical cystectomy for invasive bladder cancer in select patients older than 75 years using recent data from 2 academic hospitals. MATERIALS AND METHODS We analyzed 73 radical cystectomies performed from January 1995 to June 2000 in patients 75 to 89 years old (median age 79.3). Cases were categorized according to the American Society of Anesthesiologists classification with a score of 2 in 41, 3 in 30 and 4 in 2. External urinary diversion was performed in 51 cases and an ileal neobladder was constructed in 22. We evaluated the incidence and type of complications, clinical outcome, and postoperative care unit and hospital stay. Statistical analysis was done using the chi-square and Student t tests. RESULTS Median operative time was 263 minutes (range 95 to 451). The perioperative mortality rate was 2.7%. The intraoperative, early and late postoperative complication rates were 38.4%, 46.5% and 16.4%, respectively. Three reoperations (4.1%) were necessary. The most common early complications were pyelonephritis in 12.3% of cases, disorientation in 10.9%, pneumonia in 8.2% and prolonged ileus in 12.3%. The most common late complications were ureteroileal anastomotic stenosis in 5 cases and hernia in 3. Median postoperative care unit and hospital stays were 12 and 34 days, respectively. At a median followup of 14.4 months (range 6 to 74) the overall mortality rate was 31.5%. Hospital stay was significantly higher in patients with complications. The incidence of complications was similar in the 2 groups. CONCLUSIONS These data support the aggressive surgical management of bladder cancer in select elderly patients. A rigorous multidisciplinary team approach can provide acceptable perioperative morbidity.

[11C]Choline PET/CT for Targeted Salvage Lymph Node Dissection in Patients with Biochemical Recurrence after Primary Curative Therapy for Prostate Cancer

Introduction: In this prospective study we set out to investigate the diagnostic value of [11C]choline-PET/CT in patients with suspected lymph node metastases before salvage lymph node dissection. Patients and Methods: 15 consecutive patients with rising PSA underwent [11C]choline-PET/CT and consecutive open salvage pelvic/retroperitoneal extended lymph node dissection due to uptake of [11C]choline in at least 1 lymph node. Mean age was 62.1 (range 53–73). Results: [11C]choline-PET/CT results were compared with the histopathology reports and clinical follow-up (mean 13.7 months, range 6–24). Mean time to progression was 23.6 months (range 4–81). [11C]choline uptake was observed in nodes along the external and internal and common iliac arteries and in the paraaortic region. A positive histology was reported in 8/15 patients. Only one patient had a PSA nadir of <0.1 ng/ml after salvage surgery. Another patient had stable disease with a PSA of 0.5 ng/ml. Three patients developed bone metastases during follow-up. Conclusions: This interim analysis indicates that [11C]choline-PET/CT may be a useful technique in detection of lymph node metastases when rising PSA occurs after definite prostate cancer therapy. The presented cohort is limited in size, but there is still strong evidence that the patients benefit from [11C]choline-PET/CT and consecutive salvage lymph node dissection is rather small.

Effect of a pT0 cystectomy specimen without neoadjuvant therapy on survival

In some cases of radical cystectomy for bladder cancer, no residual tumor is found in the cystectomy specimen (the pT0 classification). The aim of this study was to evaluate the outcome of such patients in a large cystectomy series.

Laparoscopic partial nephrectomy with selective control of the renal parenchyma: initial experience with a novel laparoscopic clamp.

To report a laparoscopic device that facilitates regional ischaemia in laparoscopic partial nephrectomy (LPN).