Retroperitoneal staging lymphadenectomy in stage I nonseminomatous germ cell tumours of the testis

The treatment of testicular germ cell tumours has been a constant interest to our department, comprising 268 cases over the last two decades. Alongside the spectacular progresses of specific, highly effective combination chemotherapy and retroperitoneal lymphnode surgery which have dramatically improved life expectancy and cancer free rates even in advanced abdominal or metastatic disease, the treatment and follow-up protocols for stage I nonseminomatous germ cell testicular tumours (NSGCTT) are still a question of debate. The option of "wait and see" or primary specific chemotherapy require a rigorous and wealthy healthcare system, i.e. important social costs; moreover, chemotherapy associates well-known toxic effects. These comments should also take into account the risk of CAT retroperitoneal understaging in these patients. Under this circumstances the authors propose the evaluation of the retroperitoneal lymphadenectomy (RPLA) in its modified fashion as the primary therapeutic approach in stage I NSGCTT, considering the accuracy of pathologic staging (chemotherapy becomes unnecessary) and the preservation of antegrade ejaculation (anejaculation being the major draw-back for the total bilateral RPLA). Another pro is its curative role in cases of occult abdominal disease. The main sequences of the modified RPLA are presented and commented, defining the rational ablation limits which assure a "nerve sparing" technique without oncologic rebate. in a precarious healthcare system, the modified RPLA might well be considered the primary option in the management of stage I NSGCTT for its oncologic staging and therapeutic merits, with low social costs and practically no morpho-functional sequelae

Management of a Case of Colovesical Fistula with Fecaluria as First Sign

Introduction. Fecaluria and pneumaturia are the patognomonic signs of an abnormal communication between the bladder and the intestinal tract. Therefore, when a history of digestive signs, symptoms or digestive diseases is missing, this borderline pathology leads the patients in the care of urologists. From diagnosis to treatment the management of these cases can be difficult and challenging. Materials and Methods. A 48 year old patient, without any significant medical history, presented to the emergency room for fecaluria, pneumaturia and an episode of haematuria. He had no prior digestive symptoms. The contrast enhanced abdominal and pelvic CT scan revealed a pelvic mass involving the sigmoid colon and the dome and the posterior wall of the bladder. The cystoscopy objectifies a tumor mass involving the right postero-lateral bladder wall, with extravasation of faeces. A biopsy was taken and the frozen section found mainly uncertain inflammatory type tissue. A colonoscopy couldn’t be done because of an impassable obstacle at 15 cm from the anus. Together with general surgeons we decided for en bloc resection of the tumor with partial cystectomy, right ureterocystoneostomy and rectosigmoid resection with mechanic end to end anastomosis. Results. The postoperative period was uneventful. The histopathological examination revealed an abscessed sigmoid diverticulum with vesico-sigmoid fistula and perilesional inflammatory tissue. Two years after the surgery the patient is asymptomatic with a normal function of the right kidney and restored bladder capacity. Conclusions. Being a borderline pathology, patients with fecaluria and pneumaturia and lack of digestive symptoms are referred and managed by the urologists. Despite extensive investigations, even when preoperative biopsies reveal inflammatory tissue the patients should be treated as oncologic cases. A close cooperation with general surgeons for en bloc multiorgan resection within oncologic safety margins is mandatory

Orthotopic substitution cystoplasty in female patients after anterior pelvectomy for infiltrative bladder tumour

Introduction: Hubner's studies have established: the continuity of the bladder with urethra is no t a compulsory condition for the urethral closing mechanism. Colleselli shows that the preservation of the musculature of 2/3 out of inferior part of the urethra with its innervation is important for fem ale continence. Stenzl's pathological studies identify the group of female patients to whom the substitution cystoplasty could be performed. Materials and Methods: This type of substitution cystoplasty has been used on 4 female patients (from a cohort of 51). In 3 cases we used the detubularized sigmoid colon and in 1 case the detubularized ileum - Studer's technique for female patients with bladder tumours pT3NoMoU - G1-3*. Results: The postoperative course was uneventfull. The female patients have been continent day and night. Their neobladder capacity ranged between 350 - 500 cc. Conclusions: Female orthotopic substitution cystoplasty on selected cases is feasible

Substitution cystoplasty with detubularized ileum

Introduction: The major advantage of the continent urinary reservoirs is an improving of the quality of life and of the corporal image in the radical cystectomy patients. Materials and methods: A segment of about 30 - 35 cm is isolated configurated in a "U " form and detubularized. A suture is made between the two arms of the "U " and an intestinal plate is obtained. After the partial closing of the anterior segment with 3-0 PDS, anastomoses is practised to the urethra on a 20 Ch catheter with 6 points of 3-0 Vicryl. The ureters are implanted according to the modified Le Due Carney technique and the pouch is closed. Results: At the Urologic Clinic of "Fundeni" Hospital, 108 substitution cystoplasty have been performed. The studying group is represented by 51 cystoplasties. Carney II technique have been used in 10 cases. The evolution of the patients has been without major complications, with a very good diurnal and nocturnal continence. Conclusions: The relative facile and rapidly performing, with a small rate of complications and a good social and professional integration of the patient, all together make this type of urinary diversion to be into the attention of urologists who are practising the substitution cystoplasty

Orthotopic bladder replacement - our experience on 93 cases

Purpose: Orthotopic urinary tract reconstruction has become a standard surgery technique. Reservoir anastomoses to the urethra enables the patient to empty his bladder by micturition, avoiding the catheters use or external appliance. Materials and Methods: Between 1992 - 2001, 93 patients underwent radical cystectomy and orthotopic bladder replacement. All the patients have had bladder tumors, stage pT, - pT3 (1pT4) N0M0. 7 patients were NĂ (2 Nr 5 N2), 84 patients have had TCC, 3SCC, 3 fibrosarcomas, 1 adenocarcinoma, 2 cases of defunctionalized bladder. Patients' age is ranged between 38 - 74 years (71 males, 4 females). Follow-up between 7 and 126 months. Bladder replacement consisted in 55 cases with detubularized ileum (Carney, Studer, others) and 38 cases with detubularized sigmoid bowel (Reddy). Results: Postoperative early complications: urinary leakage (7), urinary fistula (1), ileal fistula (3), stercoral fistula (1), acute pyelonephrites (1), small bowel occlusion (1). Late complications: regional recurrence (7), metastasis (5) post-irradiation rectitis (1), acute pyelonephrites (2), ureter-neobladder strictures (2), neobladder urethral stenosis (3), pulmonary embolism (1), gastro-intestinal bleeding. 16patients died, 1 patient is lost of follow-up, Diurnal continence is very good 97,5%. Night continence is 65%. Urodynamic findings: mean bladder capacity 300 cc (ranged between 250 - 400 cc), mean intravesical pressure at maximum cystometric capacity was 51 cmH20 (40-60 cmH20), urethral profile - mean pressure 40 cmH20 (35-45 cmH20). Conclusions: These findings confirm that the orthotopic bladder replacement may be considered the choice method for urinary diversion after radical cystectomy. Our patients' continence rate is excellent and guarantees a good quality of life

Radical cystectomy (anterior exenteration) in female patients

Introduction: Radical cystectomy or anterior exenteration, is the treatment of choice for infiltrative bladder tumours in female patients. Radical cystectomy consists in ileo-pelvic lymphodissection + extirpation of: a), urinary bladder + urethra, b). uterus, ovary, uterine tubes, c). anterior vaginal wall. Materials and Methods: From the radical 1.200 cystectomies performed between 1975-1998, to women, 164 anterior pelvectomies have been made. The female patient in a dorsal decubitus position with the elevator located under the ombilicus. After checking the bladder lesions, liver, ileopelvic and para-aortic adenopathies, the peritoneum is incised at the level of the iliac vessels and the urethers are dissected up to the juxta-vesical level, where are divided. The ligature / cross-sectioning of the lombo-ovarian ligaments and round ligament is practised. The ileo-pelvin lymphodissection is practised. The incision of the recto-vaginal peritoneum is followed by the decollation of vagina from the rectum. The ligature of the vascular pedicles and cross-sectioning, follows. The posterior vaginal wall is transversally incised. Anteriorely the pubo-vesical ligaments and the dorsal vein of the clitoris are ligated and cross-sectioned. Laterally, the lateral walls of the vagina are incised. The urethra is isolated and divided. The operation is ending by the suture of the vaginal anterior wall. Results and Conclusions: Female radical cystectomy may be performed with an acceptable low rate of morbidity and mortality. The operation is the election procedure for multifocal cancer and / or infiltrative in the urinary bladder

Orthotopic bladder substitution with detubularized sigmoid colon

Introduction: The surgeons who performs substitution cystoplasty should know different techniques utilising the small bowell and sigmoid colon, depending of the local anatomic situation. Materials and methods: A sigmoid colon segment of about 25 cm is isolated. The colic continuity is restored. The isolated segment is put under a "U " shape, it is detubularized and the arms of the "U" are sutured each to the other. The reservoir is anastomosed to the urethra. The urether implantation is performing according to Le Due Carney modified technique and the pouch is closed. Results: From a cohort of 51 patients, this type of cystoplasty have been performed to 23 cases (4 partial detubulized, 19 total detubulized). The postoperative evolution was a good one, continence was relatively good, there were no phenomena of vesico - uretheral reflux. All the patients have had daily continence. 7 patients are incontinent during night time. Conclusions: The sigmoid colon represents a technical variant for bladder substitution to be retained due to its pelvic position, a good vascularization, to easy restoring of the colic continuity, to the urodynamic qualities of the sigmoid bowell, etc

Studer’s orthotopic bladder substitution

Introduction: The continent urinary reservoirs connected to the urethra have known in the last decade a formidable development. A variant of these ones is the cystoplasty of Studer type. Materials and Methods: About 60 cm of ileum is isolated and the small intestine is restored. The isolated intestinal segment is put under a “J" form, so that 22 A 22 cm should become the urinary reservoir and about 17 cm will be the part of the intestine in which the urethers are implanted. The declive portion is made under "U" form and is detubulized on a portion as long as about 44 cm. The arms of the “U" form are sutured each other with 3 PDS and so an intestinal plate is obtained which is perpendicularly double-fold plicatured on the first suture. The reservoir is closed, a lateral stoma of about 1 cm is practised which is anastomozed to the urethra on a 20 Ch catheter, after the ureteral implanting on 6 Ch splints and the closing of the intestinal segment will be made. Results: In a group of 51 patients this type of cystoplasty has been used in 15 cases. Conclusions: The postoperative course was uneventfull. In 3 cases the patients have had nocturnal incontinence. All of the 15 patients are continent all day long