Orthotopic Ileal Neobladder Reconstruction for Bladder Cancer: Is Adjuvant Chemotherapy Safe?

ABSTRACT Objective: We examined our database of patients undergoing radical cystectomy (RC) with orthotopic neobladder (NB) to determine whether adjuvant chemotherapy in this group is safe. Materials and Methods: We performed a retrospective analysis of patients who underwent radical cystectomy and urinary diversion between 1992 and 2004. Relevant clinical and therapeutic data were entered into a database. High-risk bladder cancer patients who underwent NB were identified. They were stratified into 2 groups, those who received adjuvant chemotherapy and those who did not. The incidence of complications between the 2 groups was analyzed and compared. Results: Over the 12-year period, 136 patients underwent RC and NB construction for bladder cancer. Of these, 83 patients were at high risk for recurrence. Nineteen patients received adjuvant chemotherapy and 64 did not. The complication rate in the adjuvant chemotherapy group was 53% and it was 23% in those who did not receive chemotherapy. There were no perioperative or treatment related death. There were 2 patients with grade 4 toxicity in the adjuvant chemotherapy group. There was a statistical difference between these two groups with regard to the incidence of complications. However, none of these complications was life-threatening, required only conservative treatment and caused no long-term disability. Conclusions: Adjuvant chemotherapy is a safe treatment for patients undergoing RC and NB substitution. Hence, the option of orthotopic NB should not be denied in selected bladder cancer patients with high risk for recurrent disease

To treat or not to treat with testosterone replacement therapy: a contemporary review of management of late-onset hypogonadism and critical issues related to prostate cancer

Over the last 10 years there has been a dramatic increase in the number of patients identified and treated with testosterone replacement therapy (TRT) for late-onset hypogonadism (LOH). By virtue of age, race, and family history, many of these patients are concurrently at risk for harboring indolent prostate cancer. Other men are at increased risk for prostate cancer as a result of an elevated serum PSA level or having had a prior prostate biopsy showing prostatic intraepithelial neoplasia (PIN) or atypical small acinar proliferation (ASAP). The clinician is often challenged with the decision whether to initiate TRT in these patients. This review presents a contemporary overview of the rationale for TRT, as well as the relationship between testosterone (endogenous and exogenous) and premalignant and malignant lesions of the prostate. We will discuss preliminary data from several recent series demonstrating that TRT may be safely administered in select patients with certain premalignant and bona fide malignant tumors of the prostate. In the absence of a large randomized clinical trial with long-term outcome data evaluating TRT, we hope that this overview will provide clinicians with an evidence-based approach to managing these anxiety-provoking - and often frustrating - clinical scenarios

Reconstruction of the Male Genitalia After Skin Cancer Surgery

Penile cancer is relatively uncommon in most industrialized nations, with an overall incidence of 1–2 cases per 100,000 males [1]. Human Papilloma Virus (HPV) accounts for approximately 30% of cases [2]. Phimosis and lichen sclerosis are additional risk factors for the development of this disease [3]. Traditionally, partial and radical penectomy have been the primary surgical modalities used to manage the primary tumor in men presenting with squamous cell carcinoma of the penis.This can be quite debilitating for the patient, as one would expect. As demonstrated within the cases of this chapter, there are a number of alternative organ-preserving, cosmetically-acceptable surgical approaches that can be deployed which may similarly provide oncological control. For the majority of patients presenting with T1 and T2 tumors, we believe that these surgical approaches should be utilized more often

An unusual complication during inflatable penile prosthesis implantation

Bladder injury during inflatable penile prosthesis implantation is a rare complication. Previous pelvic surgery or radiation can predispose to this unusual complication. We describe a case where the inflatable penile prosthesis reservoir was implanted into the urinary bladder

Genitourinary sarcoidosis: An essential review for the practicing clinician

Introduction: Sarcoidosis is a multisystem disease that commonly involves the lungs, but may also present with extrapulmonary manifestations. Genitourinary (GU) tract involvement has been traditionally thought to be rare, but that view may underestimate the true prevalence of the disease due to the often, silent presentation thereof. Methods: The literature pertaining to sarcoidosis from the general systemic point of view, etiology and therapy and with regard to specific organs was reviewed by identifying key words in a PubMed search. That material with special relevance to the Indian experience was emphasized. Results: There are a number of isolated case reports in the literature describing symptomatic and asymptomatic GU tract sarcoidosis. The world literature associated with the generalized syndrome was reviewed and summarized. Specific aspects of GU involvement are presented for each organ of the GU tract. Conclusions: It is critical for the practicing clinician to have a working knowledge of the clinical manifestations of this disease as it involves the GU tract, as well as to be able to distinguish it from tuberculosis and the various malignancies that affect this organ system

Contemporary Revision Penile Prosthesis Surgery Is Not Associated with a High Risk of Implant Colonization or Infection: A Single-Surgeon Series

Revision penile prosthesis surgery has traditionally been associated with a greater risk of postoperative infection than primary implant placement. This has been attributed to the high prevalence of asymptomatic bacteria found surrounding the implant at the time of revision surgery. To validate whether contemporary revision surgery remains associated with a high risk of asymptomatic colonization and postoperative infection. A comprehensive, prospective database consisting of consecutive patients undergoing primary and revision penile prosthesis surgery at our center was analyzed. The infection risk in primary and revision implant surgery was compared. The prevalence of asymptomatic implant colonization during revision surgery, and whether this was associated with clinical infection was evaluated. The spectrum of bacterial species causing infection in this contemporary single-surgeon series was described. One hundred seventeen primary and 72 revision implant recipients were studied. Infection developed in four (3.4%) patients undergoing primary implants, two (4.3%) patients undergoing removal and replacement for mechanical malfunction, and three (12%) patients undergoing rerouting for extrusion (P=0.26). Intraoperative cultures were positive in 5 (9.8%) of 51 revision patients, none of whom developed infections. Organisms causing infection included Staphylococcus aureus and Enterobacter aerogenes. Unexpectedly, an adjuvant, alcohol-based skin prep in our last 83 patients reduced the infection risk to 1.2%. In our series, the infection risk associated with revision of malfunctioning devices was no greater than primary implant placement. Rerouting was associated with a higher infection risk, likely due to technical factors, and not implant colonization. Less than 10% of our revision implants were colonized, and this had no bearing on the development of a postoperative infection. S. epidermidis was not the most common organism implicated in device infections. Finally, our experience with an adjuvant, alcohol-based skin prep warrants further randomized prospective evaluation. Kava BR, Kanagarajah P, and Ayyathurai R. Contemporary revision penile prosthesis surgery is not associated with a high risk of implant colonization or infection: A single-surgeon series

Efficacy and patient satisfaction associated with penile prosthesis revision surgery

Complications that arise after placement of a penile prosthesis may result in the need for revision surgery. Few contemporary penile prosthesis series have focused solely on describing the efficacy and patient satisfaction associated with penile prosthesis revision surgery. To determine the overall success of penile prosthesis revision surgery in providing the patient with a functional implant. Device efficacy and patient satisfaction with penile prosthesis revision surgery will be assessed using psychometrically validated instruments. The erectile function (EF) and satisfaction domains of the International Index of Erectile Function (IIEF) were used to quantify the overall efficacy and patient satisfaction with revision surgery. Data were derived from a prospective database of consecutive patients undergoing penile prosthesis revision surgery performed by a single surgeon (B.R.K.). Eleven patients filled out the IIEF prior to surgery and 26 completed it following surgery. Thirty-nine consecutive patients underwent 55 revision procedures related to a prior penile prosthesis. Thirty-four patients (87%) have a functional implant with a median follow-up of 6.5 months (range 1-42 months). Significant improvements in the overall IIEF, EF domain, and satisfaction domain were seen in those patients studied prior to and following revision surgery. The total IIEF, EF domain, and satisfaction domain of the IIEF for the group of 26 responders were 60.7 +/- 19.3, 26.6 +/- 8.7, and 15.7 +/- 5.6, respectively. Patients with fibrotic corporal bodies scored significantly lower on the EF and satisfaction domains than did any other group. Penile prosthesis revision surgery is highly successful in providing men with a functional implant. The prostheses function well and patients are satisfied with their devices. Further study of those men with corporal fibrosis is warranted in order to determine the factors needed to improve their overall satisfaction with revision surgery