Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En Bloc Resection

Background Colorectal cancers that adhere to the urinary bladder require en bloc partial or total cystectomy to achieve negative tumor margins. Methods This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer. Results Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54%, with a mean follow-up of 7.6 (range 5–12) years. Five-year survival for margin negative patients was 72% (26/36) and 27% (4/15) for node negative and positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in five, with ten patients requiring urinary diversion. Conclusions En bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node negative tumors is good. Bladder reconstruction is achievable in most patients.     

Long-term results of necessarily extensive colectomies for cancer. A retrospective study of 41 cases]

In the present study, we try to discuss the results of the "en bloc" surgical resection of the extensive cancer of the colon which infiltrates one or more of the neighboring organs. Data from 41 patients who underwent this kind of operation from 1970 to 1988 were reviewed. The localisation, currently seen of this cancer, was the sigmoid colon and the number of the infiltrated neighboring organs varied from 1 to 3. The small intestine and the urinary tract were the most frequently infiltrated organs. The classification of Dukes was used: 14 cases were on stage B and 27 on stage C. The operative mortality was 9.7% and the morbidity was 38%. The survival rate at 5 years was calculated with the Kaplan-Meier method. It was 48% with a significant difference between stage B (91%) and stage C (25%). These results were similar to those of the authors found in the literature in the past ten years. They justify these extended resections.     

半导体激光联合吉西他滨膀胱灌注治疗非肌层浸润性膀胱肿瘤

目的 探讨经尿道半导体激光膀胱肿瘤整块切除术联合吉西他滨膀胱灌注化疗治疗非肌层浸润性膀胱肿瘤的手术方法并评估其安全性和有效性.方法 2014年7月至2015年7月采用经尿道半导体激光膀胱肿瘤整块切除术治疗非肌层浸润性膀胱肿瘤患者62例,术后定期行吉西他滨膀胱灌注化疗.记录手术时间、术中出血情况、手术并发症、膀胱持续冲洗时间、留置尿管时间、术后住院天数及术后复发情况等.结果 手术平均时间为(30.5±12.8)min,术中出血少,均未出现闭孔神经反射、膀胱穿孔、水中毒、尿外渗、继发性出血等并发症,术后平均膀胱冲洗时间为(6.15 ±2.33)h,术后平均留置尿管时间为(7.33±1.54)d,术后平均住院时间为(8.21±1.26)d.术后随访6～18个月,3例异位复发.结论 经尿道半导体激光膀胱肿瘤整块切除术联合吉西他滨膀胱灌注治疗非肌层浸润性膀胱肿瘤的方法安全有效,并且该术式能够提供肿瘤准确分级、分期信息,值得临床推广应用.     

Reconstruction of urinary tract combined with surgical management of locally advanced non-urological cancer involving the genitourinary organs

INTRODUCTION: The objective of this study was to review our experience with urinary reconstruction in patients undergoing surgical management for locally advanced pelvic cancer, and to evaluate the role of urologists in these procedures. MATERIALS AND METHODS: This study included a total of 37 patients undergoing some type of urinary reconstruction due to invasion of the urological organs by locally advanced pelvic cancers, including 17 rectal cancers, 9 cervical cancers, 4 sigmoid cancers, 4 retroperitoneal sarcomas, 2 ovarian cancers and 1 appendiceal cancer. Among these 37, 18 were recurrent cancers following initial surgery for primary tumors. The clinical outcomes of these approaches were retrospectively analyzed. RESULTS: Of the 37 patients, 9 underwent cystectomy (group A) with the following urinary diversions: ileal neobladder in 3, ileal conduit in 5 and colon conduit in 1, and 12 underwent partial cystectomy (group B), among whom 11 received additional urinary reconstruction as follows: bladder flap repair in 5, psoas hitch in 2, ileal ureter in 2, bladder augmentation in 1 and ureteroureterostomy in 1, while the remaining 16 (group C), in whom complete bladder preservation was possible, underwent the following types of urinary reconstruction: bladder flap repair in 6, psoas hitch in 3, en bloc removal of the rectum with prostate in 3, ileal ureter in 2, and ureteroureterostomy in 2. There were 10 early urological complications, including leakage of urine in 7 and acute pyelonephritis in 3. As a late urological complication, hydronephrosis was observed in 8 patients, but ureteral stent was not required in any of these 8. There were no significant differences in the incidence of postoperative complications, the status of surgical margin and the survival among groups A-C. CONCLUSION: Our experience with extended surgical management of non-urological pelvic cancer with reconstruction of the urinary tract suggests that the urological portion of this procedure can be performed with acceptable morbidity, and that the role of the urological surgeon during this procedure is potentially important.     

Operative treatment of Crohn''s ileocolitis complicated by ileosigmoid and ileovesical fistulae.

Ileovesical and ileosigmoid fistulae were found to coexist in 22 patients with Crohn's ileocolitis. Persistent or recurrent urinary tract infection was a complaint in all cases, and 11 patients reported pneumaturia and/or fecaluria. Thus, bladder involvement was either suspected or clinically apparent in each patient. The cystogram was the best confirmatory test for the ileovesical fistula (positive in 9 of 22 patients). The coexistence of the sigmoid fistula was best diagnosed on intestinal radiographs (positive in 9 of 22 patients); there were no clinical signs of its presence. The coexistence of ileosigmoid and ileovesical fistulae was the sole indication for operation in two patients. In all others, a combination of factors required surgical therapy. An ileocolonic resection with primary intestinal anastomosis was performed in 16 patients and exteriorization was performed in six patients. The sigmoid defect was closed primarily in 16 patients and required wedge resection in the other six patients. The bladder defect was sparingly excised and closed with absorbable sutures. All patients recuperated without anastomotic leaks, bladder leaks, or persistent cystitis. This experience indicates that coexisting ileosigmoid and ileovesical fistulae may add complexity to an ileocolonic resection for Crohn's disease, but is not a difficult management problem for the gastrointestinal surgeon.     

Treatment methods as a prognostic factor in eight patients with urachal carcinoma

Between 1960 and 1982, 8 patients with urachal carcinoma underwent segmental resection of the bladder or en bloc resection, and their five-year survival rate was 50%. One patient each with well, moderate and poorly differentiated adenocarcinoma and one patient with transitional cell carcinoma, died of cancer from 6 months to 2 years and 2 months after operation (mean duration: 1 year and 3 months). The patient with well differentiated adenocarcinoma underwent en bloc resection and was recognized to have peritoneal involvement of the tumor at the operation. The remaining three patients were diagnosed to have tumors confined to their bladder and urachal remnant and were treated with segmental resection of the bladder. Two patients each, with well and moderately differentiated carcinoma confined to their bladder and urachal remnant, were treated with en bloc resection and have been surviving from 8 years and 5 months to 24 years and 10 months (mean duration: 13 years and 7 months) postoperatively as of Dec. 1987. Therefore, patients with well and moderately differentiated adenocarcinomas confined to the bladder and the urachal remnant could be expected to survive longer by en bloc resection.     

Bladder-sparing surgery in locally advanced nonurological pelvic malignancy

INTRODUCTION: The urinary bladder is commonly involved in pelvic malignancy. The incidence of apparent extension into adjacent organs in locally advanced colorectal malignancy is 5-12%. It is not known with other pelvic malignancy. No guidelines are available for its management. Often a dilemma exists between cystectomy and a bladder-sparing procedure. We studied the validity of bladder-sparing surgery (BSS) in locally advanced nonurological pelvic malignancy. METHODS: Hospital records of patients who underwent BSS along with other surgeries (abdomino-perineal resection, anterior resection, anterior exenteration, debulking surgery and total pelvic exenteration) from January 1992 to May 2003 were reviewed. RESULTS: BSS was done in 15 patients. 10 had locally advanced colorectal malignancy, 3 with soft tissue masses of the lateral pelvic wall, 1 had ovarian malignancy and the other had residual mass following radiotherapy and chemotherapy of cancer cervix. In those with locally advanced colorectal malignancy, symptoms suggestive of lower urinary tract involvement were present in 8 (80%). Urine examination and ultrasonography was not helpful in suggesting bladder involvement, unlike CT scan of abdomen and pelvis. Preoperative cystoscopy showed endoscopic evidence of bladder involvement in 7 (87.5%). Bladder was involved supratrigonally in 7. Partial cystectomy was done in 9 patients. The left ureter was involved in 6 patients, and they required ureteric reimplantation. Palliative transurethral resection was done in 1 patient with tumor infiltration at the bladder neck and prostate. 50% patients had bothersome lower urinary tract symptoms at 1 year. One patient died in the immediate postoperative period due to a nonurological cause. Overall 3-year survival rate was 40%. CONCLUSION: Unlike primary bladder cancers these lesions are not multifocal and hence en block conservative bladder-sparing surgery can be offered. Preoperative CT scan or MRI can predict lower urinary tract involvement and help in decision-making by both surgeon and patient. The ultimate decision for bladder sparing is based on intraoperative findings. Sparing the bladder might provide better quality of life by avoiding urinary diversion without altering survival.     

Concomitant urethral triplication, bladder, and colon duplication

The concomitant presence of urethral triplication and caudal duplication is extremely rare with no previous reported cases. We report a case of urethral triplication associated with bladder, sigmoid, and rectum duplication. The patient was initially referred with a history of fecaluria and recurrent urinary tract infection. Physical examination revealed 2 meatal opening on the glans penis. Further investigation revealed three distinct urinary streams, two terminating on the glans penis, and one in the rectum in voiding cystourethrography and retrograde urethrography. Computed tomography demonstrated the bladder divided into two compartments by a complete sagittal septum. The patient was managed by the excision of the rectal ending urethra and removal of the bladder sagittal septum during which, two sigmoidal and rectal segments (the right one filled with fecal) were revealed. The right sigmoid and rectum was resected. The two ventral urethras were kept intact. The postoperative course was uneventful. At his 4 month readmission for colostomy closure, the patient reported good urethral voiding with no complication and recurrence of urinary tract infection and the colostomy was closed with no major complication.     

Surgical management of primary and metastatic sarcoma of the mobile spine

OBJECT: Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series. METHODS: A retrospective review of patients undergoing resection for sarcomas of the mobile spine between 1993 and 2005 was undertaken. Sarcomas were classified by histology study results and as either primary or metastatic. Details of the surgical approach, levels of involvement, and operative complications were recorded. Outcome measures included neurological function, palliation of pain, local recurrence, and overall survival. RESULTS: Eighty patients underwent 110 resections of either primary or metastatic sarcomas of the mobile spine. Twenty-nine lesions were primary sarcomas (36%) and 51 were metastatic sarcomas (64%). Intralesional resections were performed in 98 surgeries (89%) and en bloc resections were performed in 12 (11%). Median survival from surgery for all patients was 20.6 months. Median survival for patients with a primary sarcoma of the spine was 40.2 months and was 17.3 months for patients with a metastatic sarcoma. Predictors of improved survival included a chondrosarcoma histological type and a better preoperative functional status, whereas osteosarcoma and a high-grade tumor were negative influences on survival. Multivariate analysis showed that only a high-grade tumor was an independent predictor of shorter overall survival. American Spinal Injury Association scale grades were maintained or improved in 97% of patients postoperatively, and there was a significant decrease in pain scores postoperatively. No significant differences in survival or local recurrence rates between intralesional or en bloc resections for either primary or metastatic spine sarcomas were found. CONCLUSIONS: Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.     

继发于结直肠的膀胱转移性腺癌的诊断和治疗

目的:探讨继发于结直肠的膀胱转移性腺癌的临床特点,提高对此病的诊治水平。方法:总结2004年6月~2012年3月我们共收治的11例继发于结直肠的膀胱转移性腺癌的诊治结果。原发癌包括:直肠癌6例,乙状结肠癌4例,降结肠、乙状结肠及直肠多发癌1例。其中8例原发癌术后出现膀胱转移时间为6~50个月,平均20个月;3例同时发现原发病变及膀胱转移病变。结果:10例患者接受随访,1例失访,随访时间为1~42个月,平均18.7个月。死于全身多发转移6例,从发现膀胱转移癌到死亡间隔时间为6~28个月,平均17.2个月,其余4例均仍在随访中。结论:继发于结直肠的膀胱转移性腺癌少见,预后差。早期诊断困难,免疫组化有助于鉴别原发性膀胱腺癌和继发于结直肠的膀胱转移性腺癌。     

Surgical treatment of T3 lung cancer invading the chest wall

Lung tumors invading the chest wall are classed as belonging to the T3 group and are considered potentially resectable. Their management, however, is controversial, and extrapleural resection, when possible, is preferred to en bloc resection which is regarded as a far more invasive and dangerous operation. Five year survival rates for completely resected cases range in the literature from 25 to 35%, but survival rates are much worse if lymph node metastases are present. These poor outcomes have prompted the development of combined surgical approaches: preoperative radiation therapy, with or without chemotherapy, has been used with an improvement in resectability rates, but only modest results in terms of median survival; in a number of case series, increased operative morbidity and mortality have been reported with this approach. The present report relates to 122 patients treated by en bloc (20 cases) or extrapleural (102 cases) resection, 31 of whom also received neoadjuvant treatment. The operative mortality was 4.6%. Median survival was 17 months after en bloc resection and 19 months after extrapleural resection. Though no statistically significant difference was found, extrapleural resection would appear to yield better results than the en bloc procedure.     

Primary adenocarcinoma of the appendix invading the urinary bladder

We report a case of adenocarcinoma of the appendix invading the urinary bladder in a 75-year-old man. Although cystoscopic examination and computed tomography suggested a primary or secondary bladder tumor, repeated transurethral bladder biopsy could not confirm the neoplasm. At operation a primary neoplasm of the appendix invading the bladder was discovered and en bloc resection of the urinary bladder with the adherent cecum followed by an ileocolonic anastomosis and ureterocutaneostomy was performed. The patient died of carcinoma 13 months later.     

UROLOGICAL COMPLICATIONS FOLLOWING ABDOMINOPERINEAL EXCISION OF THE RECTUM FOR CARCINOMA

A retrospective study was made of 122 patients who had an abdominoperineal excision (APE) of the rectum for carcinoma at Concord Hospital between 1971 and 1979. Fifty-two percent of patients suffered one or more significant urological complications. These included urinary tract infection (32%), operative trauma to the urinary tract (8.5%) and temporary or permanent bladder dysfunction in 35% of patients. Acute urinary retention, when temporary, was managed by simple measures. Chronic retention, incontinence and some episodes of acute retention were due to a neurogenic bladder. These patients were difficult to treat. It is recommended that urodynamic studies be used to assess these patients who develop a neurogenic bladder before any treatment is instituted. This is relevant especially in those patients in whom a transurethral resection of either the bladder neck or prostate is contemplated.     

Malacoplakia: a 25-year experience with a review of the literature

Our experience with 9 cases of genitourinary malacoplakia is reviewed. The bladder was involved in 4 patients, ureter in 2, prostate in 1, testis in 1 and a combination of prostate, bladder, rectum and pelvic adnexae in 1. The female-to-male ratio was 2:1. Escherichia coli was present in 7 of 8 available urine cultures. Of 9 patients 2 had associated immunocompromised conditions. A variety of therapeutic approaches were chosen, depending mainly on location and extent of disease. These varying combinations of medical and surgical therapies produced resolution of disease in 8 of 9 patients. Generally, upper tract involvement requires surgical intervention, while most cases of lower tract involvement can be managed with antibiotics and endoscopic resection. Rare cases of extensive lower tract malacoplakia may require extirpation for cure.     

En bloc resection of an ethmoid carcinoma involving the orbit and medial wall of the cavernous sinus.

The involvement of the cavernous sinus by malignant tumors has limited their surgical treatment. We report here a successful en bloc resection of an invasive ethmoid carcinoma involving the cavernous sinus in a 46-year-old man. To prepare for surgery on this patient, a cadaver study was performed to investigate the feasibility of en bloc cavernous sinus resection and reconstruction. The preoperative evaluation, operative approach, and postoperative management are presented.     

泌尿系统子宫内膜异位症11例报告并文献复习

目的:探讨泌尿系统子宫内膜异位症的临床特征.方法:报告11例泌尿系统子宫内膜异位症患者的临床资料.11例均行开放手术治疗,术后育龄期患者服用达那唑者或米非司酮者时间1年.结果:将异位内膜组织均完全切除,所有患者随访2个月～2年,1例(9.1%)复发患者服用达那唑效果良好,3例肾积水患者积水明显减轻.结论:子宫手术时应重视对周围组织的保护,泌尿系子宫内膜异位症一经诊断后应及时彻底治疗.     

Giant diverticulum of the sigmoid colon with perforation. Report of a case

We present a case of perforated giant diverticulum of the sigmoid colon. This condition is extremely rare and only a few cases have so far been reported in the literature. Our case involved a 55-year old woman. Diagnosis was easy with barium enema and CT scan examination. Laparotomy revealed a giant diverticulum of the sigmoid colon compressing adjacent structures with signs of inflammation. An en bloc resection of the sigmoid colon, ovary and fallopian tube was performed with primary colon-rectal anastomosis.The post-operative course was uneventful.     

不同术式对肾盂输尿管癌术后再发膀胱癌的影响(附94例报告)

目的：探讨肾盂输尿管癌的最佳手术方式及预防术后再发膀胱癌的有效措施。方法;对94例采用不同术式治疗肾盂输尿管癌患者术后再发膀胱癌的临床资料进行总结。结果：单发肾盂或输尿管行肾盂输尿管切除术（未切除壁间断输尿管及管口周围部分膀胱）术后膀胱再发率为54．5％（6／11）,明显高于肾盂输尿管膀胱部分切除术（23．5％,12／51）和改良膀胱粘膜袖套状切除法肾盂输尿管膀胱部分切除术（33．3％,3／9）,差别有显著性意义（P＜0．05）;后二者比较差别无显著性意义（P＞0．05）。肾盂输尿管癌术后再发时间短,多位于病侧管口周围。肾盂输尿管多器官癌行肾盂输尿管膀胱部分切除术后膀胱癌再发率为72．2％（13／18）,与改良膀胱粘膜袖套状切除法肾盂输尿管膀胱部分切除术60％（3／5）比较,差别无显著性意义（P＞0．05）。结论：改良膀胱粘膜袖套状切除法可防止瘤细胞种植,是一良好的治疗方法。彻底切除病侧管口周围部分膀胱壁是预防术后再发膀胱癌的关键。     

Multivisceral operations for carcinoma of the upper stomach and cardia

In this study are noted technical problems regarding "en bloc" multiple organ resections and the anatomic and functional reconstruction for carcinoma of the upper stomach and cardia. From 1997 to 2002, a total of 264 patients with cancers of the stomach were operated in the service. 75 patients presented cancers localized at the proximal stomach and cardia (97.33% adenocc.). The rate of resectability was 27.77% (27 pt.). Types of operations in this series were: standard esophagogastrectomy in 7 patients; total gastrectomy with regional lymphadenectomy in 9 patients; 11 patients underwent "en bloc" multiple organ resection, with the removal of the stomach, partial or total esophagectomy and, occasionally, ablation of the spleen, pancreas, left hepatectomy, resection of the diaphragm and an extensive lymphadenectomy. Surgical mortality for the complex multivisceral resections was noted in 3 patients (8.88%). The global 5 years survival in the service is poor: 15.9%.     

Long‐term outcome of giant cell tumors of bone around the knee treated by en bloc resection of tumor and reconstruction with prosthesis

Objective: To study the long‐term outcomes and complications of giant cell tumors around the knee treated with en bloc resection and reconstruction with prosthesis. Methods: From January 1991 to March 2005, 19 patients (11 men, 8 women, average age 35.4 years) were treated in our hospital with en bloc resection and reconstruction with domestic prosthesis (15 hinge knee and 4 rotating‐hinge knee). The distal femur was involved in 12 and the proximal tibia in 7 cases. Nine tumors were primary and 10 recurrent. All cases were Campanacci grade III. The affected limb functions were evaluated by the Musculoskeletal Tumor Society scoring system. Results: All patients underwent operation successfully with no complications. The mean follow‐up time was 128.9 months (60 to 216 months). Apart from one patient who underwent amputation because of wound infection two years after reoperation, the range of knee motion of 18 patients was 30°–110°. The mean functional score of the affected limb was 22.7 (15 to 27 points). The length of the lower extremities was equal in nine cases; the affected limb was 2–9 cm shorter in the other ten cases. Prosthesis fracture and loosening developed in one, prosthesis aseptic loosening in three, and delayed deep infection and prosthesis loosening in two cases. The prosthesis loosening rate was 31.6%. One patient developed a proximal femur fracture. Conclusion: En bloc resection and reconstruction with prosthesis is a feasible method for treating giant cell tumor of bone around the knee. Complications related to the prosthesis, mainly prosthesis loosening and limb shortening, increase gradually with longer survival time.