Outcomes of surgical treatment for upper urinary tract transitional cell carcinoma: Comparison of retroperitoneoscopic and open nephroureterectomy

<p>Abstract</p> <p>Objectives</p> <p>To determine the surgical and oncologic outcomes in patients who underwent retroperitoneoscopic nephroureterectomy (RNU) in comparison to standard open nephroureterectomy (ONU) for upper urinary tract transitional cell carcinoma (TCC).</p> <p>Patients and methods</p> <p>From April 2001 to January 2007, 60 total nephroureterectomy were performed for upper tract TCC at Siriraj Hospital. Of the 60 patients, thirty-one were treated with RNU and open bladder cuff excision, and twenty-nine with ONU. Our data were reviewed and analyzed retrospectively. The recorded data included sex, age, history of bladder cancer, type of surgery, tumor characteristics, postoperative course, disease recurrence and progression.</p> <p>Results</p> <p>The mean operative time was longer in the RNU group than in the ONU group (258.8 versus 190.6 min; p = 0. < 001). On the other hand, the mean blood loss and the dose of parenteral analgesia (morphine sulphate) were lower in the RNU group (289.3 versus 313.7 ml and 2.05 versus 6.72 mg; p = 0.868 and p = 0.018, respectively). There were two complications in each group. No significant difference in p stage and grade in both-groups (p = 0.951, p = 0.077). One patient with RNU had lymph node involvement, three in ONU. Mean follow up was 26.4 months (range 3–72) for RNU and 27.9 months (range 3–63) for ONU. No port metastasis occurred during follow up in RNU group. Tumor recurrence developed in 11 patients (bladder recurrence in 9 patients, local recurrence in 2 patients) in the RNU group and 14 patients (bladder recurrence in 13 patients, local recurrence in 1 patient) in the ONU group. No significant difference was detected in the tumor recurrence rate between the two procedures (p = 0.2716). Distant metastases developed in 3 patients (9.7%) after RNU and 2 patients (6.9%) after ONU. The 2 year disease specific survival rate after RNU and ONU was 86.3% and 92.5%, respectively (p = 0.8227).</p> <p>Conclusion</p> <p>Retroperitoneoscopic nephroureterectomy is less invasive than open surgery and is an oncological feasible operation. Thus, the results of our study supported the continued development of laparoscopic technique in the management of upper tract TCC.</p

Treatment of Penile Incarceration : A Case Report (String Method)

Cases of penile incarceration with constrictive band are occasionally seen in the emergency room, and treatment is to remove the constrictive band.      We report a case of penile incarceration in a 50-year-old man, the penis was encircled by a metallic nut. This paper describes a simple method to deal with such an emergency in which no special skill is required and no immediate or long term morbidity related to the treatment

Bladder Perforation From Capsaicin Infusion : A Case Report

We reported a 36-year-old patient, with a spinal cord lesion who had bladder perforation during an infusion of 400 mls of Capsaicin (1mMol in 30% alcohol) for treatment of detrusor hyperreflexia. Under spinal anesthesia during the procedure he was restless and complained of chest discomfort. The operation was therefore terminated and a cystogram was carried out. Cystography showed extraperitoneal leakage of contrast media. He was treated conservatively and had an uneventful post-operative period. To prevent this complication, we therefore recommend an infusion volume of Capsaicin of between half to two-thirds of the patients bladder capacity together with pressure monitoring during the procedure

Percutaneous Nephrolithotomy vs Open Pyelolithotomy for Renal Pelvis Calculi

Objective : To compare the stone free rate and morbidity of percutaneous nephrolithotomy (PCNL) and open pyelolithotomy for a single renal pelvis stone. Patients and methods : A retrospective study was performed by reviewing case records of patients who underwent stone removal surgery between August 1994 and March 1999. The inclusion criteria was a single renal pelvis stone which was not smaller than 3 cm2 in surface area. Patients in the open pyelolithotomy group who had concurrent nephrotomies were excluded. There were a total of 46 patients of which 25 had undergone PCNL and 21 had undergone pyelolithotomy. Both groups were compared in terms of age, sex, stone surface area, haematocrit, blood urea nitrogen, serum creatinine, operative time, complications, stone free rate, adjunctive procedures, doses of postoperative analgesic injection, length of hospital stay, and time to return to normal work. Statistical analysis was performed by Chi-square test and t-test. Results : Preoperative status of the two groups were similar. The operative time was comparable between the two groups. The stone free rate of the PCNL group and the pyelolithotomy group were 92% and 95% respectively which was not statistically different. Five patients in the PCNL group needed ancillary procedures while only one patient in pyelolithotomy group did. Overall complications of the PCNL group and the pyelolithotomy group were 28.6% and 28% respectively which were comparable. Severe bleeding due to arterio-venous fistula occurred in 2 patients of the PCNL group. However, the complication could be managed successfully by selective embolisation. Disruption of uretero-pelvic junction occurred in one patient of the pyelolithotomy group and was repaired successfully. The number of doses of postoperative pethidine injection to lessen pain was lower in the PCNL group when compared with the pyelolithotomy group (mean 0.96 dose vs 1.95 doses, p<0.003). Length of hospital stay was comparable between the two groups. Time to return to normal work was shorter in the PCNL group when compared with the pyelolithotomy group (mean 13.7 days vs 36.3 days, p<0.001). Conclusions : PCNL is a safe and effective method to treat renal pelvis stones compared to open pyelolithotomy and offers less postoperative discomfort and shorter recovery period

Results of Chimney Modification Technique in Ureterointestinal Anastomosis of Hautmann Ileal Neobladder in Bladder Cancer

To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis. Methods: Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency. Results: At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis. Conclusion: New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy

Outcomes of Radical Prostatectomy in Thai Men with Prostate Cancer

ObjectiveRadical prostatectomy remains the standard treatment for early prostate cancer. Few data in the literature are from South East Asia. This study was conducted to evaluate the outcome of radical prostatectomy in Thai men.MethodsA total of 151 patients with prostate cancer underwent radical prostatectomy at Siriraj Hospital, Bangkok, between 1994 and 2003. Clinical staging, preoperative prostate-specific antigen (PSA) and Gleason score were evaluated with pathological stage and margin status. Follow-up PSA monitoring and survival were analysed.ResultsOf 121 patients with clinical localized disease, 79 (65.3%), 40 (33.1%) and two (1.6%) had localized, locally advanced and metastatic disease, respectively, on pathology. The chance of localized disease with a preoperative PSA of 10 ng/mL or less, more than 10-50 ng/mL and more than 50 ng/mL was 75.5%, 50% and 12.5%, respectively (all p < 0.001). The chance of localized disease with a Gleason score of 2-4, 5-7 and 8-10 was 85%, 55.1% and 20.8%, respectively (all p < 0.02). Mean follow-up was 30 months. Among 140 evaluable patients, 51 (36.4%) had adjuvant therapy and 136 (97.1%) had undetectable PSA without clinical progression. The cumulative PSA progression-free survival among patients with pathological T1N0, T2N0 and T3N0 disease was 0.83 at 82 months, 0.48 at 85 months and 0.31 at 57 months, respectively.ConclusionRadical prostatectomy in Thai men shows excellent results. The trend is the same as in Western series. The chance of organ-confined disease and free margin was high in patients with clinical T2 or less, PSA less than 10 ng/mL and low Gleason score. PSA progression-free survival was high in patients with organ-confined disease

Surgical Treatment of Renal Cell Carcinoma with Inferior Vena Cava Thrombus: Using Liver Mobilization Technique to Avoid Cardiopulmonary Bypass

To evaluate the results of surgical treatment of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus and describe the use of a transabdominal approach with liver mobilization to avoid cardiopulmonary bypass (CPB). METHODS: From February 2002 to January 2006, 109 patients with RCC were surgically treated at Siriraj Hospital. Twelve patients had an IVC thrombus, infrahepatic (level I), retrohepatic (level II), suprahepatic (level III) and intra-atrial (level IV) in one, two, eight and one patient, respectively. Patients' characteristics, pathological features, survival and morbidity were evaluated. RESULTS: Mean age was 58 years (range, 37–74 years). CPB was used in one patient with level IV thrombus. All patients (92%) with level I–III IVC thrombi underwent successful removal by transabdominal approach without any form of bypass. Mean operative time was 302 minutes (range, 195–420 minutes). The mortality rate was 16% (2 of 12) with sepsis and pulmonary embolism. One patient had colonic injury requiring primary repair. At the mean follow-up of 17 months (range, 3–35 months), of 10 patients, one died due to distant metastases, two were lost to follow-up and seven (60%) were still alive. Five patients (42%) were disease-free at the last follow-up. CONCLUSION: These results support the aggressive surgical removal of RCC with IVC thrombus as the initial treatment. Most of the thrombi can be approached and safely controlled by a transabdominal approach without any form of bypass. Tumour thrombus removal provides a high survival chance and offers improvement in quality of life