Long-term functional outcome and late complications of Studer's ileal neobladder.
(73/407)
OBJECTIVE: The purpose of this study was to evaluate the long-term functional outcome and late complications of Studer's ileal neobladder. METHODS: The study included 57 patients who underwent radical cystectomy and bladder reconstruction with Studer's ileal neobladder, and were followed-up for at least 3 months after surgery. The voiding and storage function, and late complications were evaluated. The times of evaluation after surgery were categorized into periods I (3-23 months), II (24-59 months), III (60-95 months) and IV (> or =96 months). RESULTS: Daytime and night-time continence rates were 95.6 and 88.6%, respectively. The averages of functional capacity (439 ml), maximum flow rate (15.7 ml/s) and residual urine (35 ml) evaluated in period I were maintained in period IV. Of the 57 patients, intermittent self-catheterization was needed in five (8.8%) due to incomplete emptying or urinary retention. Urethroileal anastomotic stricture was found in two patients (3.5%), who were successfully treated by transurethral intervention. Inguinal hernia was found in seven patients (12.8%), five of whom developed it within 2 years after surgery. CONCLUSIONS: Our results indicate that Studer's ileal neobladder had a favorable long-term functional outcome. Although late complication rates were low, the incidence of inguinal hernia was relatively high, and this was considered as a definite late complication in our study. (+info)
Stapleless laparoscopic assisted radical cystectomy with ileal neobladder in a male and with ileal loop in a female: initial report from Brazil.
(74/407)
INTRODUCTION: Here, we report our initial experience with laparoscopic assisted radical cystectomy without the use of surgical staples. CASES REPORT: A 70 year old male and a 55 year old female were diagnosed to have T2G3 transitional cell carcinoma of the bladder with negative metastatic work-out. Both patients were scheduled and agreed to a laparoscopic assisted radical cystectomy. In both cases, urinary diversion (orthotopic ileal Studer neobladder in the male and ileal conduit in the female) was performed extracorporeally following radical cystectomy. In both cases control of the bladder vascular pedicle was accomplished with a combination of metallic and hem-o-lock clips. The total surgical time was 6.5 hours in both cases. Estimated intra-operative blood loss was 500 cc and 350 cc respectively, however both patients required postoperative blood transfusions. No intraoperative complications occurred. In both cases, pathology revealed negative surgical margins. CONCLUSIONS: Extracorporeal creation of urinary diversion decrease the overall operative time. Laparoscopic pelvic lymphadenectomy can be performed following the extended template. The use of surgical clips instead of vascular Endo-GIA titanium staples to control the bladder vascular pedicles is feasible and safe in selected patients, thus reducing intraoperative surgical costs. Considerable experience with laparoscopic radical prostatectomy is necessary before one attempts laparoscopic radical cystectomy. (+info)
Surgical treatment for abdominal aortic aneurysm in a patient with urinary diversion.
(75/407)
In two cases of abdominal aortic aneurysm (AAA) with urinary diversion after radical cystectomy, surgical aneurysm repair was successfully performed. Based on comprehensive preoperative examinations, the surgical strategy for aneurysm should be carefully planned so as not to injure diverted ureters. (+info)
Correlation between annual volume of cystectomy, professional staffing, and outcomes: a statewide, population-based study.
(76/407)
BACKGROUND: The association between high procedure volume and lower perioperative mortality is well established among cancer patients who undergo cystectomy. However, to the authors' knowledge, the association between volume and perioperative complications has not been studied to date and hospital characteristics contributing to the volume-outcome correlation are unknown. In the current study, the authors studied these associations, emphasizing hospital factors that contribute to the volume-outcome correlation. METHODS: Multiple-variable models of inpatient mortality and complications were developed among all 1302 bladder carcinoma patients who underwent cystectomy between January 1, 1999 and December 31, 2001 in all Texas hospitals. General estimating equations were used to adjust for clustering within the 133 hospitals. Data were obtained from hospital claims, the 2000 U.S. Census, and databases from the Center for Medicare and Medicaid Services and the American Hospital Association. RESULTS: Complications were reported to occur in 12% of patients, 2.2% of whom died. Mortality was higher in low-volume hospitals compared with high-volume hospitals (3.1% vs. 0.7%; P < 0.001); mortality in moderate-volume hospitals was reported to be intermediate (2.9%). After adjustment for advanced age and comorbid conditions, treatment in high-volume hospitals was associated with lower risks of mortality (odds ratio [OR] = 0.35; P = 0.02) and complications (OR = 0.53; P = 0.01). Hospitals with a high registered nurse-to-patient ratio also had a lower mortality risk (OR = 0.43; P = 0.04). CONCLUSIONS: Mortality after cystectomy was found to be significantly lower in high-volume hospitals, regardless of patient age. Referral to a hospital performing greater than 10 cystectomies annually is indicated for all patients. However, patients with poor access to a high-volume hospital may derive similar benefit from treatment at a hospital with a high-registered nurse-to-patient ratio. This finding requires further confirmation. (+info)
Marriage and mortality in bladder carcinoma.
(77/407)
BACKGROUND: Being married confers significant benefits in survival for patients with a variety of chronic conditions including breast and prostate carcinoma. The authors attempted to determine whether marital status is associated with survival in patients undergoing radical cystectomy for bladder carcinoma. METHODS: The authors identified 7262 subjects from the Surveillance, Epidemiology, and End Results public-use database who underwent radical cystectomy for transitional cell carcinoma of the bladder. They performed survival analyses using Kaplan-Meier estimates and Cox proportional hazards models. The authors created multivariate models to evaluate the independent association between marital status and survival, controlling for pathologic stage, lymph node status, age, race/ethnicity, and gender. RESULTS: Married subjects were older and more often male, white, and had earlier disease stage at diagnosis. Married subjects had significantly better survival than did single or widowed subjects (P < 0.001), and married subjects revealed a trend toward better survival than separated/divorced subjects (P = 0.20). Multivariate modeling revealed that compared with single subjects, those who were married had better survival, independent of age at the time of diagnosis, gender, race/ethnicity, disease stage, and lymph node status (P < 0.001). CONCLUSIONS: Marriage was associated with improved survival in patients with bladder carcinoma, independent of other factors known to influence mortality in this population. Although the mechanisms underlying this survival advantage are unknown, possibilities include differences in cancer screening, risk behaviors, and access to medical care. The interaction between psychosocial factors and the body's immune function may further explain the differential survival in this cohort. (+info)
Lymphovascular invasion is independently associated with overall survival, cause-specific survival, and local and distant recurrence in patients with negative lymph nodes at radical cystectomy.
(78/407)
PURPOSE: We hypothesized that bladder cancer patients with associated lymphovascular invasion (LVI) are at increased risk of occult metastases. METHODS: A multi-institutional group (University of Texas Southwestern [Dallas, TX], Baylor College of Medicine [Houston, TX], Johns Hopkins University [Baltimore, MD]) carried out a retrospective study of 958 patients who underwent cystectomy for bladder cancer between 1984 and 2003. Of patients with transitional-cell carcinoma (n = 776), LVI status was available for 750. LVI was defined as the presence of tumor cells within an endothelium-lined space. RESULTS: LVI was present in 36.4% (273 of 750) overall, involving 26% (151 of 581) and 72% (122 of 169) of node-negative and node-positive patients, respectively. Prevalence of LVI increased with higher pathologic stage (9.0%, 23%, 60%, and 78%, for T1, T2, T3, and T4, respectively; P < .001). Using multivariate Cox regression analyses including age, stage, grade, and number of pelvic lymph nodes removed, LVI was an independent predictor of local (HR = 2.03, P = .049), distant (HR = 2.60, P = .0011), and overall (HR = 2.02, P = .0003) recurrence in node-negative patients. LVI was an independent predictor of overall (HR = 1.84, P = .0002) and cause-specific (HR = 2.07, P = .0012) survival in node-negative patients. LVI maintained its independent predictor status in competing risks regression models (P = .013), where other-cause mortality was considered as a competing risk. LVI was not a predictor of recurrence or survival in node-positive patients. CONCLUSION: LVI is an independent predictor of recurrence and decreased cause-specific and overall survival in patients who undergo cystectomy for invasive bladder cancer and are node-negative. These patients represent a high risk group that may benefit from integrated therapy with cystectomy and perioperative systemic chemotherapy. (+info)
Age and comorbidity impact surgical therapy in older bladder carcinoma patients: a population-based study.
(79/407)
BACKGROUND: Bladder carcinoma often occurs in older patients who also may have other comorbid conditions that could influence the administration of surgical therapy. The current study was conducted to describe the distribution of comorbid conditions in patients with bladder carcinoma and ascertain whether these conditions, as grouped by the American Society of Anesthesiologists physical status classification, affected the choice of surgical therapy. METHODS: The authors examined six population-based cancer registries from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program in 1992. A total of 820 individuals age 55 years and older was found. A random sample of newly diagnosed bladder carcinoma patients were stratified according to registry, age group (ages 55-64 yrs, ages 65-74 yrs, and age 75 yrs and older), and gender. Data regarding comorbid conditions were abstracted from the medical records and merged with routinely collected cancer registry data. The main outcome measures were the prevalence and distribution of comorbid conditions, American Society of Anesthesiologists physical status classification, and the receipt of cystectomy in patients with muscle invasion. RESULTS: Hypertension, chronic pulmonary disease, arthritis, and heart disease were found to affect at least 15% of the study population. Approximately 38% of patients were current or former smokers. Greater than 90% of patients with superficial disease were treated with transurethral resection alone. Among those patients with muscle invasion, only 55% of those ages 55-59 years underwent cystectomy; this percentage dropped to 4% in patients age 85 years and older. Among patients with an American Society of Anesthesiologists physical status classification of 0-2, the cystectomy rate ranged from 53% in those ages 55-59 years to 9% in those age 85 years and older. CONCLUSIONS: There were no significant treatment differences noted with regard to age among patients with superficial disease. Among those patients with muscle invasion, those age 75 years and older were less likely to undergo radical cystectomy (14%) compared with patients ages 55-64 years (48%) and those ages 65-74 years (43%). Patient age may contribute to treatment decisions in patients with muscle-invasive disease, even when comorbidity is taken into account. (+info)
Laparoscopic assisted radical cystoprostatectomy with Y-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples through a 5 cm Pfannensteil incision.
(80/407)
INTRODUCTION: We performed a laparoscopic radical cystoprostatectomy followed by constructing a Y-shaped reservoir extra-corporeally with titanium staples through a 5-cm muscle-splitting Pfannenstiel incision. SURGICAL TECHNIQUE: Upon completion of the extirpative part of the operation, the surgical specimen was entrapped and removed intact through a 5-cm Pfannenstiel incision. Through the extraction incision, the distal ileum was identified and a 40 cm segment isolated. With the aid of the laparoscope, the ureters were brought outside the abdominal cavity and freshened and spatulated for approximately 1.5-cm. Bilateral double J ureteral stents were then inserted up to the renal pelvis and the ureters were directly anastomosed to the open ends of the limbs of the neobladder. Following this, the isolated intestinal segment was arranged in a Y shape with two central segments of 14 cm and two limbs of 6 cm. The two central segments were brought together and detubularized, with two sequential firings of 80 x 3.5 mm and 60 x 3.5 mm non-absorbable mechanical stapler (Multifire GIA--US Surgical) inserted through an opening made at the lowest point of the neobladder on its anti-mesenteric border. The neobladder was reinserted inside the abdominal cavity and anastomosed to the urethra with intracorporeal laparoscopic free-hand suturing. CONCLUSION: Although this procedure is feasible and the preliminary results encouraging, continued surveillance is necessary to determine the lithiasis-inducing potential of these titanium staples within the urinary tract. (+info)