Recurrence and survival following laparoscopic radical nephroureterectomy with various forms of bladder cuff control

PURPOSE: We document recurrence and survival following laparoscopic radical nephroureterectomy (LNUX) for upper tract transitional cell carcinoma (TCC) using primarily 2 methods of managing the bladder cuff. MATERIALS AND METHODS: The records of 60 patients undergoing LNUX at our institution for upper tract TCC were reviewed retrospectively. En bloc excision of the bladder cuff was primarily performed transvesically by our described cystoscopic secured detachment and ligation method (CDL) or extravesically using a laparoscopic stapling device (LS). RESULTS: Median followup was 23 months (range 1 to 45). Recurrence developed in 27%, 7% and 12% of cases in the bladder at a median of 5 months, retroperitoneum at 8 months and distant sites at 8 months, respectively. Compared to the novel CDL technique LS resulted in a higher positive margin rate (p = 0.046). Overall survival correlated with bladder recurrence (p = 0.003), upper tract TCC stage (p = 0.01) and method of bladder cuff control when comparing CDL vs LS (p = 0.04). Freedom from recurrent upper tract disease was related to pathological stage (p = 0.015) and bladder cuff excision method (p = 0.02). CONCLUSIONS: These data underscore the aggressive nature of high stage, high grade upper tract TCC and validate the importance of complete excision of the distal ureter and bladder cuff during LNUX. In patients without coexisting bladder tumor the CDL method, which allows formal bladder cuff excision in a secured manner akin to that of established open surgical principles, appears oncologically valid.     

UPPER TRACT RECURRENCES FOLLOWING RADICAL CYSTECTOMY: AN ANALYSIS OF PROGNOSTIC FACTORS, RECURRENCE PATTERN AND STAGE AT PRESENTATION

PURPOSE: We study the incidence and pattern of upper tract recurrences following radical cystectomy for bladder cancer, and analyze the prognostic factors. MATERIALS AND METHODS: A retrospective study was performed on 529 patients who underwent radical cystectomy and urinary diversion at Memorial Sloan-Kettering Cancer Center between July 1989 and June 1997. Data related to upper tract recurrence were analyzed. RESULTS: Of the 529 patients 16 (3%) had upper tract recurrence. Median followup was 16.9 months for the entire group and 49.1 months for patients with upper tract recurrence, with a median time to recurrence of 37.2 months. Of 12 upper tract recurrences 7 (58%) were locally advanced at surgery (p3a or greater with or without lymph node metastasis) and 5 of 16 patients with recurrence (31.3%) had bilateral tumors (2 synchronous and 3 metachronous). Overall survival from the time of diagnosis of upper tract recurrence after radical cystectomy was poor, with a median of 10 months (confidence interval 1 to 19). CONCLUSIONS: The incidence of upper tract recurrence following radical cystectomy is low (3%). However, the incidence of bilateral tumors (31.3%) and locally advanced stage at the time of operation (58%) is higher than expected for upper tract tumors in the general population. Survival of patients with upper tract recurrence is poor, with a median of 10 months.     

Multivariate analysis of clinical parameters of synchronous primary superficial bladder cancer and upper urinary tract tumor

PURPOSE: We determined the incidence and characteristic of synchronous upper urinary tract tumors (UUTTs) in patients with primary superficial bladder carcinoma and evaluated the characteristics of bladder tumors related to UUTTs. MATERIALS AND METHODS: We performed a retrospective study of 1,529 patients with primary superficial bladder carcinoma who underwent initial examination of the upper urinary tract with excretory urography. Data were analyzed by multivariate analysis using logistic regression. Variables evaluated and related to the incidence of UUTT were multiplicity, carcinoma in situ, bladder tumor size, localization of tumor in the bladder, and tumor grade and stage. RESULTS: A total of 28 patients (1.8%) had simultaneous bladder tumor and UUTT. UUTTs showed no preferred location and 17.9% were multiple. Of UUTTs 46% were invasive and almost 87% were grade 2 or 3. The only significant variable related to UUTT was bladder tumor in the trigone (RR 5.8, 95% IC 2.18 to 15.9, p <0.0005). Of 147 tumors located in the trigone 11 (7.5%) were associated with UUTT, corresponding to 41% of the UUTTs first diagnosed. If multiplicity and tumors in the trigone (551 cases) had been considered, 66.7% of tumors would have been diagnosed. CONCLUSIONS: Synchronous UUTT and superficial bladder tumor are uncommon but 46% are invasive. Considering the possible examination of the upper urinary tract only in patients with tumor in the trigone or with multiple bladder tumors 41.4% or 69% of UUTTs, respectively, would have been diagnosed. Patients with tumor in the trigone are at almost 6-fold higher risk for a synchronous tumor in the upper urinary tract.     

Intermediate followup of hand assisted laparoscopic nephroureterectomy for urothelial carcinoma: factors associated with outcomes

PURPOSE: We report our experience with hand assisted laparoscopic (HALS) nephroureterectomy and describe the associations of preoperative, operative and pathological factors with outcome. MATERIALS AND METHODS: HALS nephroureterectomy was performed in 54 consecutive patients using modified transurethral resection of the ureteral orifice (TURUO) or a 1 port transvesical endoscopic cuff technique for the distal ureter in all except 8. Data were collected prospectively and retrospectively, and followup was distinguished for bladder, contralateral upper tract and nonurothelial (local recurrence and distant metastases) sites. RESULTS: The endoscopic cuff was associated with significantly shorter mean operative time than the transurethral resection of the ureteral orifice method (234 vs 295 minutes, p = 0.002) but the comparison was confounded by the effect of experience. With 28% of patients having stage II or greater tumors and 49% having high grade bladder disease, contralateral upper tract and nonurothelial recurrences developed in 55%, 11% and 25% of evaluable patients at a median followup of 25.1, 24.4 and 24.9 months, respectively, in those without recurrence. At a median followup of 25.0 months cancer specific survival was 94%, 86% and 80% at 1 to 3 years, respectively. Three-year cancer specific survival was 100% in patents with grade 1 or 2, or stage 0 or I tumors but only 57% and 36% in patients with grade 3 and stage II or IV tumors, respectively. CONCLUSIONS: HALS nephroureterectomy is associated with 3-year outcomes that are strongly associated with stage and grade. We prefer the endoscopic cuff method for the distal ureter because it is performed after nephrectomy, does not require patient repositioning and is expedient.     

Serum anti-p53 antibodies and p53 protein status in the sera and tumors from bladder cancer patients

OBJECTIVES: The purpose of this study was to evaluate the association between the serum anti-p53 antibodies (Abs) status and the p53 protein status in the sera and tumors as well as clinical or pathological parameters in bladder cancer patients retrospectively. METHODS: Serum samples from 100 patients with bladder cancer were assayed for anti-p53 Abs and p53 protein by enzyme-linked immunosorbent assay (ELISA). A monoclonal antibody DO7 was used for immunohistochemical staining of tumor p53 protein. RESULTS: Prevalences of serum anti-p53 Abs, serum p53 protein and tumor p53 protein were 12, 1 and 63%, respectively. There was a significant correlation between serum anti-p53 Abs status and factors including tumor stage, tumor grade, and tumor p53 protein status. In the univariate analysis, tumor stage, tumor grade, serum anti-p53 Abs status, and tumor p53 protein status were significantly associated with an increased risk of death. Multivariate analysis showed that tumor stage was the only independent prognostic factor among the factors examined. CONCLUSIONS: The present study suggests that serum anti-p53 Abs had a limited value as a tumor marker in bladder cancer patients. Further studies to elucidate the mechanism of anti-p53 Abs production will be necessary for a better understanding of the immune status in bladder cancer patients.     

Upper urinary tract tumors after primary superficial bladder tumors: prognostic factors and risk groups

PURPOSE: We evaluated the prognostic factors of primary superficial bladder cancer that may predict a metachronous upper urinary tract tumor. We also determined whether the incidence of upper urinary tract disease varies according to risk group based on primary superficial bladder tumor classification. MATERIALS AND METHODS: We studied disease evolution in a cohort of 1,529 patients with a primary superficial bladder tumor. To determine the prognostic factors of upper urinary tract cancer we performed multivariate analysis using Cox regression. Independent variables were grade, T stage, multiplicity, tumor size, carcinoma in situ association, previous or synchronous upper urinary tract tumor and intravesical instillation. We also performed the chi-square test and Kaplan-Meier survival analysis to assess the variable incidence of upper urinary tract tumors according to primary superficial bladder tumor risk group classification. RESULTS: The incidence of upper urinary tract cancer was 2.6%. The only factor prognostic for an upper urinary tract tumor was multiplicity (relative risk 2.7, 95% confidence interval [CI] 1.06 to 6.84). All patients with an upper urinary tract tumor had a previously recurrent primary superficial bladder tumor. In the low, intermediate and high risk groups the incidence of upper urinary tract cancer was 0.6% (relative risk 1), 1.8% (relative risk 3.1, 95% CI 0.4 to 23.9) and 4.1% (relative risk 8.3, 95% CI 1.1 to 61.6), respectively (chi-square and log rank tests p = 0.007 and p <0.05, respectively). CONCLUSIONS: A higher risk of upper urinary tract cancer must be expected in cases of multiple primary superficial bladder tumors. This finding supports the multicentricity theory of transitional cell carcinoma. Primary superficial bladder tumor classification by risk group is also useful for predicting the various risks of metachronous upper urinary tract cancer.     

A comparison of the pathology of transitional cell carcinoma of the bladder and upper urinary tract

OBJECTIVE: To clarify the histopathological patterns of upper and lower urinary tract transitional cell carcinomas (TCCs), as previous reports suggest that upper urinary tract TCCs have a greater tendency towards high-grade disease than bladder TCCs, of which most are low-grade and low-stage tumours. PATIENTS AND METHODS: All patients presenting with TCC of bladder or upper urinary tract between February 1991 and December 2001 at one institution were identified. Further patient information was obtained from the hospital database and case-note review. RESULTS: In all, 164 patients with upper urinary tract TCC and 2197 with bladder TCC were identified. There was a correlation between grade and stage of both upper urinary tract and bladder TCCs. 35% of the upper tract TCCs were classified as grade 2 and 44% as grade 3, while for bladder TCCs, 31% of lesions were classified as grade 2 and 35% as grade 3 (P = 0.003). Of the upper urinary tract lesions 33% were stage pT2-T4, compared with only 20% of bladder TCCs (P = 0.001). CONCLUSIONS: Upper urinary tract TCC is a higher grade and stage disease than bladder cancer, a finding that emphasizes the need for aggressive treatment of upper urinary tract TCC. If endourological management of upper urinary tract TCC is considered, histopathological determination of tumour grade before treatment is essential.     

Recurrence of bladder tumors following surgery for transitional cell carcinoma of the upper urinary tract.

A retrospective analysis of 53 patients with an upper urinary tract (UUT) transitional cell carcinoma, which was treated surgically, was performed in relation to the development of a subsequent bladder tumor. In 19 of the 53 patients (35.8%) bladder tumors developed following surgery of a UUT tumor. The simultaneous occurrence of a bladder tumor and more than two tumors in the UUT had a significant influence on the rate of bladder tumor recurrence. On the other hand, location, mode of growth, grade, stage and vascular invasion of the UUT tumor, and history of bladder tumors did not seem to be related to the frequency of subsequent bladder tumors. These findings suggest that the diversity of UUT tumors at the time of diagnosis is an important factor in bladder tumor recurrence. Therefore, clinical and pathological examinations should be carefully performed in patients with UUT tumors.     

Behavior of urothelial carcinoma with respect to anatomical location

PURPOSE: Urothelial carcinoma is a disease of the entire urothelium. Recent molecular insights suggest that the biology of some upper urinary tract and bladder urothelial carcinoma differ. These differences may affect tumor phenotype. Observational studies conflict as to the significance of anatomical location on the behavior of urothelial carcinoma. We compared the biological outcome in a large series of urothelial carcinoma with respect to anatomical location. MATERIALS AND METHODS: We analyzed urothelial carcinoma in 425 patients treated at 4 centers according to stage and anatomical location, including the bladder in 275, the ureter in 67 and the renal pelvis in 79. Relapse surveillance was performed for a median of 46 months (range 2 to 216). A separate invasive bladder urothelial carcinoma population was also included to pathologically balance upper and lower tract urothelial carcinoma cases to allow behavioral comparisons. RESULTS: As a whole, upper urinary tract urothelial carcinoma is more invasive and worse differentiated than bladder cancer (chi-square test p<0.0001 and 0.015, respectively). In pathologically matched cohorts recurrence to less aggressive disease, progression to more advanced disease and death occurred in 37%, 40% and 44% of patients with bladder urothelial carcinoma, and in 41%, 44% and 43% of those with upper urinary tract urothelial carcinoma, respectively. Multivariate analysis revealed that tumor stage and grade (Cox p=0.0001 and 0.012, respectively) but not location were associated with behavior. CONCLUSIONS: Urothelial carcinoma behaves identically in the upper and lower urinary tracts when stage and grade are considered. The majority of tumors relapse within 5 years of excision. The current move to minimally invasive/nephron sparing techniques for urothelial carcinoma of the upper urinary tract appears safe. Care could be analogous to that for bladder urothelial carcinoma.     

Distinct microsatellite alterations in upper urinary tract tumors and subsequent bladder tumors

PURPOSE: Although synchronous and/or metachronous tumor development is common in urothelial cancer, genetic and biological differences in upper urinary tract and bladder tumors are unclear. We compared the genetic alteration pattern in multifocal disease in patients with upper urinary tract and subsequent bladder tumors, and those with recurrent bladder tumor. MATERIALS AND METHODS: Using 21 microsatellite markers on the 8 chromosomal arms 2q, 4p, 4q, 8p, 9p, 9q, 11p and 17p we analyzed 34 tumors from 15 patients with upper urinary tract and subsequent bladder disease, and 70 tumors from 22 with recurrent bladder disease. RESULTS: Judging from the patterns of genetic alterations multifocal tumors were considered to have derived from an identical progenitor cell in 7 of 13 evaluable patients (54%) with upper urinary tract and subsequent bladder tumors, and 16 of 19 (84%) who were evaluable with recurrent bladder tumor. These data confirm the view that seeding or intraepithelial spread is a major mechanism for the multifocal development of urothelial cancer in general. However, a discordant microsatellite alteration pattern in multifocal tumors was observed in 6 of 7 patients (86%) with upper urinary tract and subsequent bladder lesions but in 2 of 16 (13%) with recurrent bladder cancer (p <0.005). CONCLUSIONS: Our results imply that upper urinary tract neoplasms may be genetically more unstable than bladder neoplasms. The implantation of tumor cells from upper urinary tract to bladder may involve additional and diverse genetic alterations. Furthermore, a considerable number of multifocal upper urinary tract and subsequent bladder lesions may arise independently via field cancerization mechanism. Our study indicates that the factors contributing to multifocal development are different in the 2 groups.     

Conservative elective treatment of upper urinary tract tumors: a multivariate analysis of prognostic factors for recurrence and progression

PURPOSE: We evaluate the safety and efficacy of conservative elective treatment of upper urinary tract tumors, and determine predictive factors for recurrence and progression to optimize indications of this type of treatment. MATERIALS AND METHODS: Since 1984 we have performed a prospective study of conservative treatment of single, low grade and stage, less than 3 cm. upper tract tumors. The study includes 54 patients with a normal contralateral kidney who had been followed for more than 36 months. Open conservative surgery was performed in 31 cases and endourological surgery in 23. Minimum followup was 36 months, maximum 210 and mean 84.8. Univariate and multivariate analyses of recurrence and progression were performed in relation to age, sex, association with a bladder tumor, bladder tumor stage and grade, sequence of bladder tumor in relation to upper urinary tract tumor, number of previous bladder tumor recurrences, association with bladder carcinoma in situ, upper urinary tract tumor grade, stage, location, size and therapy, and upper urinary tract cytology. RESULTS: Of the 54 patients 19 (35%) had recurrence, which was bilateral recurrence in 4, and progression occurred in 9 (16%). At the end of analysis 44 (62.9%) patients were disease-free and alive at a mean time of 92.88 months, 13 (24%) died disease-free at a mean of 72.7 months and 7 (12.9%) died of disease at a mean of 97.85 months. Cause specific mortality occurred in 7 (12.9% cases). Among the 54 initially conservatively treated units 42 (77.7%) kidneys were ultimately preserved. On univariate and multivariate analysis tumor location in the renal pelvis and association with a previous multi-recurrent bladder tumor were variables significantly related to recurrence and progression, as well as bilateral recurrence. CONCLUSIONS: Conservative treatment is an optional approach for select upper urinary tract tumors. The strongest risk factors for recurrence and progression were association with a previous multi-recurrent bladder tumor and tumor location in the renal pelvis but these conditions were also the strongest risk factors for bilateral recurrence. Conservative treatment can also be recommended in these cases but only with compliant patients and close followup.     

The study on cell surface antigens in epithelial tumor of the upper urinary tract: ABH-isoantigen and Thomsen-Friedenreich antigen

ABH-isoantigen (ABH-Ag) and Thomsen-Friedenreich antigen (T-Ag) were investigated by the Avidin-Biotin-Peroxidase Complex (ABC) method on 47 patients with epithelial tumor of the upper urinary tract (all patients underwent nephroureterectomy including the cuff of the bladder; 30 patients were diagnosed as transitional cell carcinoma of renal pelvis and 17 ureteral organs). The correlations between ABC expression for ABH-Ag and T-Ag with histological grade, stage and prognosis (5 year survival rate) were studied. A correlation was observed between grade (p less than 0.05) and deletion of the antigenicity of ABH-Ag, but no correlation was evident with stage and prognosis. A high correlation was evident, however, between grade (p less than 0.01), stage (p less than 0.01) and prognosis (p less than 0.01) and deletion of the antigenicity of T-Ag. The analysis of ABC expression for ABH-Ag and T-Ag may therefore be valuable for predicting the malignant potential in transitional cell carcinoma of the upper urinary tract. T-Ag determination in particular may provide a useful prognostic probe should it find clinical application.     

Different treatment strategies for end stage renal disease in patients with transitional cell carcinoma

PURPOSE: Transitional cell carcinoma is the most common urinary tract cancer in Taiwanese patients on dialysis. It is a unique finding compared within Western countries. Due to this geographic difference and a higher recurrence rate a more extensive operation and aggressive followup protocols should be refined for these patients on dialysis. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients with transitional cell carcinoma who had end stage renal disease and underwent hemodialysis. Records were reviewed for hemodialysis duration, initial tumor location, tumor grade, stage, operative method, operative complication and final surgical status. Tumor grade and stage was determined by the WHO and proposed Jewett systems. Six patient groups were classified according to final surgical status for comparative analysis. RESULTS: A total of 30 patients were included in this study. Painless gross hematuria and urethral bloody discharge were the most common complaints. Tumor in 25 of the 30 cases was high grade and all were early stage. Of the patients 11 (36.7%) had undergone bilateral nephroureterectomy and radical cystectomy in as a 1 or multiple step procedure. Six patients (20%) had undergone bilateral nephroureterectomy at 1 or 2 sequential operations. Seven of the 13 patients (53.8%) in whom low urinary tract transitional cell carcinoma was initially treated with transurethral resection unfortunately had recurrent transitional cell carcinoma of the upper urinary tract. Ten of the 14 patients (71.4%) with upper urinary tract transitional cell carcinoma who underwent nephroureterectomy and bladder cuff excision had subsequent transitional cell carcinoma within the bladder. CONCLUSIONS: Patients with transitional cell carcinoma on dialysis had a higher recurrence rate in the upper urinary tract than patients not on dialysis. Most cases were at an early stage but with high grade tumor behavior. In 11 patients (36.7%) total exenteration of the urinary tract except the urethra was eventually done. The final bilateral nephroureterectomy rate was 56.7%. Since the rate of total exenteration and bilateral nephrectomy was abnormally high at such a short followup, 1-step bilateral nephroureterectomy and radical cystectomy are a recommended treatment for patients with transitional cell carcinoma on dialysis.     

核转录因子 κ B、P53在膀胱癌组织中的表达及其与临床病理特征的关系

目的:探讨核转录因子κB(NF-κB)、P53蛋白在膀胱尿路上皮癌组织中的表达及其与患者临床特征及术后复发的关系。方法:选择2014年2月—2017年1月成都市郫都区人民医院确诊并手术的膀胱移行上皮癌患者48例、同期手术治疗的非膀胱癌患者16例,采用免疫组织化学SP法检测膀胱癌组织、癌旁组织及非膀胱癌患者正常尿路黏膜组织中NF-κB和P53蛋白的表达水平。探讨NF-κB和P53蛋白阳性表达与患者临床特征包括年龄、性别、病理分级、临床分期、淋巴结转移及术后复发情况的关系。结果:膀胱尿路上皮癌组织、癌旁组织和正常尿路黏膜组织中NF-κB蛋白阳性表达率分别为52.5%(30/48)、16.7%(8/48)和6.3%(1/16);P53蛋白阳性表达率分别为72.9%(35/48)、45.8%(22/48)和12.5%(2/16),癌组织>癌旁组织>正常尿路黏膜组织(P<0.05);NF-κB阳性表达与膀胱尿路上皮癌患者肿瘤病理分级存在相关性,高级别膀胱尿路上皮癌(G2/G3)组织中NF-κB阳性率显著高于低级别(G1)肿瘤组织(P<0.05);P53阳性表达与膀胱尿路上皮癌患者肿瘤分期存在相关性,T2-3期患者阳性率显著高于Tis-1期(P<0.05);NF-κB表达阳性和阴性患者的中位无疾病进展生存时间(DFS)分别为8.9个月和30.1个月,阳性组复发风险显著高于阴性组(P<0.05);P53表达阳性和阴性患者的DFS分别为9.2个月和28.6个月,阳性组复发风险显著高于阴性组(P<0.05)。结论:与正常膀胱黏膜比较,膀胱尿路上皮癌患者NF-κB、P53蛋白表达水平显著上调,并与患者肿瘤分级和分期有关,可作为膀胱尿路上皮癌术后复发预测的分子标志物。     

Reevaluation of serum p53 antibody as a tumor marker in colorectal cancer patients

Purpose

We reevaluated the serum p53 antibody (S-p53Ab) ELISA kit, which was approved as a tumor marker of colon cancer in the Japanese Health Insurance System in 2007.

Methods

S-p53Ab was measured as a tumor marker in 154 colorectal cancer patients, and the results were categorized by clinical and pathological variables. We then compared the positive frequency of S-p53Ab, carcinoembryonic antigen (CEA), and carbohydrate 19-9 (CA19-9).

Results

S-p53Ab was positive in 33.1% of the colorectal cancer patients. The positive rate was significantly higher in patients with lymph nodes metastasis (P?=?0.025) and lymphatic invasion (P?=?0.023). In patients with stage I colorectal cancer, the positive rate of S-p53Ab (23.7%) was significantly higher than that of CEA (5.3%) or CA19-9 (7.9%).

Conclusion

The approved kit for S-p53Ab testing was found to be an effective tumor marker of colorectal cancer. The positive rate of S-p53Ab was significantly higher in patients with cancer involvement of the lymphoid tissues. The positive rate of S-p53Ab was higher than that of CEA and CA19-9 in patients with stage I colorectal cancer, suggesting that the S-p53Ab is a useful tumor marker for patients with early-stage disease.     

Urethral tumor recurrence following cystectomy and urinary diversion: clinical and pathological characteristics in 768 male patients

PURPOSE: We evaluated the incidence and risks of urethral recurrence following radical cystectomy and urinary diversion in men with transitional cell carcinoma of the bladder. MATERIAL AND METHODS: Clinical and pathological results were evaluated in 768 consecutive male patients undergoing radical cystectomy with intent to cure for bladder cancer with a median followup 13 years, including 397 (51%) who underwent orthotopic urinary diversion with a median followup of 10 years and 371 (49%) who underwent cutaneous urinary diversion with a median followup of 19 years. Demographically and clinically these 2 groups were well matched with the only exception being longer median followup in the cutaneous group (p <0.001). Urethral recurrence was analyzed by univariate and multivariable analysis according to carcinoma in situ, tumor multifocality, pathological characteristics (tumor grade, stage and subgroup), the presence and extent of prostate tumor involvement (superficial vs stromal invasion) and the form of urinary diversion (cutaneous vs orthotopic). RESULTS: A total of 45 patients (6%) had urethral recurrence at a median of 2 years (range 0.2 to 13.6), including 16 (4%) with an orthotopic and 29 (8%) with a cutaneous form of urinary diversion. Carcinoma in situ and tumor multifocality were not significantly associated with an increased risk of urethral recurrence (p = 0.07 and 0.06, respectively). The presence of any (superficial and/or stromal invasion) prostatic tumor involvement was identified in 129 patients (17%). Prostate tumor involvement was associated with a significantly increased risk of urethral recurrence (p = 0.01). The estimated 5-year chance of urethral recurrence was 5% without any prostate involvement, increasing to 12% and 18% with superficial and invasive prostate involvement, respectively. Patients undergoing orthotopic diversion demonstrated a significantly lower risk of urethral recurrence compared with those undergoing cutaneous urinary diversion (p = 0.02). Patients without any prostate tumor involvement and orthotopic diversion (lowest risk group) demonstrated an estimated 4% year chance of urethral recurrence compared with a 24% chance in those with invasive prostate involvement undergoing cutaneous diversion (highest risk group). On multivariate analysis any prostate involvement (superficial and/or invasive) and urinary diversion form remained independent and significant predictors of urethral recurrence (p = 0.035 and 0.01, respectively). CONCLUSIONS: At long-term followup urethral tumor recurrence occurs in approximately 7% of men following cystectomy for bladder transitional cell carcinoma. Involvement of the prostate with tumor and the form of urinary diversion were significant and independent risk factors for urethral tumor recurrence. Patients undergoing orthotopic diversion have a lower incidence of urethral recurrence compared with those undergoing cutaneous diversion. Although prostate tumor involvement is a risk factor for urethral recurrence, it should not preclude orthotopic diversion, provided that intraoperative frozen section analysis of the urethral margin is without evidence of tumor.     

Pressure flow analysis may aid in identifying women with outflow obstruction

PURPOSE: We refined recently developed pressure flow cutoff values for female bladder outlet obstruction and applied these values in a consecutive group of women undergoing urodynamic testing for various lower urinary tract symptoms. MATERIALS AND METHODS: A total of 87 women with clinical obstruction determined by history and presenting complaint were enrolled in our prospective evaluation of pressure flow studies. We identified 3 groups of participants according to the suspected cause of obstruction, including prolapse in 33, previous incontinence surgery in 25, and no likely source of obstruction identified from history and physical examination only in 29. An additional 124 patients presenting for evaluation of stress urinary incontinence served as controls. Optimal cutoff values for determining obstruction were developed using receiver operating characteristic curves. To determine the prevalence of bladder outlet obstruction these values were prospectively applied to 106 women undergoing urodynamics for various voiding complaints. RESULTS: In controls the average maximum flow rate was 23 cc per second and average detrusor pressure was 21.9 cm. water, whereas the corresponding values in those with clinical obstruction were 10.7 cc per second and 40.8 cm. water (p <0.001). No differences were noted in the various obstruction groups. Receiver operating characteristics analysis revealed that cutoff values of 11 cc per second or less and 21 cm. water or more optimized the selection of patients with bladder outlet obstruction. Using these values we noted a bladder outlet obstruction prevalence of 20% in a consecutive cohort of women undergoing urodynamic studies at our center. CONCLUSIONS: We propose cutoff pressure flow values for identifying women with bladder outlet obstruction although they should be used only in conjunction with the overall clinical situation. Neither pressure flow data only nor clinical symptoms alone may be sufficient for diagnosing obstruction in women.     

Superficial transitional cell carcinoma of the ureteral orifice: Higher risk of developing subsequent upper urinary tract tumors

AIM: Reports specifically addressing transitional cell carcinoma (TCC) of the ureteral orifice are scarce. This paper presents our experiences of such tumors, including the characteristics of the disease and the incidence of subsequent upper urinary tract recurrence. METHODS: This study included 572 new cases of TCC of the urinary bladder diagnosed in our institute during a period of 5 years. Thirty-one (5.4%) patients had superficial tumors involving ureteral orifices. All 31 patients underwent transurethral resection of the bladder tumors, including the involved ureteral orifices. After the surgery, patients received regular follow up with cystourethroscopy, urine cytology and periodic intravenous pyelography (IVP). Ureterorenoscopy was performed in cases of suspicious IVP or urine cytology findings. RESULTS: Thirty-one patients with superficial tumors involving the ureteral orifice were followed up for 5-8 years or until death. The pathological stage was Ta in 16 cases and T1 in 15 cases. Bladder tumor recurrence was noted in three (18.8%) of the pTa patients and in seven (46.7%) of the pT1 patients. Subsequent upper urinary tract tumors developed in four (12.9%) patients between 33 and 67 months (mean: 33.5) after the first transurethral resection. All four cases of upper tract recurrence had pT1 primary bladder tumor, which recurred for 1-3 times (mean 1.8) before upper tract recurrence. None of these patients had ureteral stenting after bladder tumor resection. Three of four patients with upper tract recurrence had single lower ureteral tumor, while the remaining one patient had multiple tumors. Patients with subsequent upper urinary tract tumors underwent nephroureterectomy and bladder cuff excision. One died of the disease; the other three cases were free of the disease after the therapy. CONCLUSIONS: Patients with primary superficial bladder transitional cell carcinoma involving the ureteral orifice have a higher risk of developing subsequent upper urinary tract tumors, particularly for pT1 primary bladder tumors. Frequent and close follow up is recommended.     

The outcome of patients on dialysis with upper urinary tract transitional cell carcinoma

PURPOSE: Transitional cell carcinoma is the most common upper urinary tract cancer in Taiwanese patients on dialysis. It is a unique finding compared with Western countries. Unfortunately, the long-term outcomes of patients with upper urinary tract transitional cell carcinoma on dialysis are largely unknown. This study presents clinical outcome of patients on dialysis with upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients with upper urinary tract transitional cell carcinoma who had end stage renal disease and underwent dialysis. Traditional prognostic factors including age, sex, tumor grade, stage and tumor location were analyzed with respect to disease recurrence and survival. RESULTS: A total of 73 patients were included in this study. The major complaints were painless gross hematuria and urethral bloody discharge. Disease relapsed in 40 (54.8%) patients at average time of 15 months (2 to 92). Univariate analysis failed to identify significant prognostic factors for recurrence. The average duration between primary and contralateral metachronous upper urinary tract transitional cell carcinoma recurrence was 36 months (range 5 to 96). Patients on dialysis with upper urinary tract transitional cell carcinoma who had previous or concurrent bladder tumor, or who had a history of recurrent bladder tumor, had high contralateral upper urinary tract transitional cell carcinoma recurrence. (p = 0.038) The statistically significant prognostic factor for disease-free survival was pT stage (p = 0.041). CONCLUSIONS: Patients on dialysis with painless gross hematuria or bloody urethral discharge must undergo detail urinary system evaluation. Since patients with upper urinary tract transitional cell carcinoma on dialysis have a high recurrence rate and metachronous or even multiple, early synchronous tumor characteristics that may be missed by imaging, total urinary tract exenteration is a recommended therapeutic option.     

Risk factors for the development of bladder cancer after upper tract urothelial cancer

OBJECTIVES: To determine the clinical and pathologic risk factors for initial intravesical recurrence in patients with primary renal pelvic and/or ureteral cancer and to examine the progression in the bladder in patients having high risk factors for intravesical recurrence. METHODS: This study included 69 patients with renal pelvic and/or ureteral cancer. We excluded patients with distant metastases, those with a short period of follow-up, and those having a previous history or concomitance of bladder cancer. The exclusion criteria were chosen to avoid contamination by patients with a poor prognosis who might die of the primary cancer before bladder cancer development. Multivariate analysis by Cox's proportional hazards model was used to determine what clinical and pathologic variables significantly affected the initial intravesical recurrence of cancer. We also studied the stage progression of cancer that recurred in the bladder. RESULTS: Initial intravesical recurrence of the cancer was found in 22 patients during a median follow-up period of 53 months (range 12 to 225). The intravesical disease-free rate after upper tract urothelial cancer was 65% (rate of disease recurrence in bladder 35%) at 5 years by the Kaplan-Meier method. The extent (multifocality) of the upper urinary cancer (P = 0.0038) and pathologic stage (P = 0.0409) independently influenced intravesical recurrence. Age, sex, adjuvant chemotherapy, configuration of the primary tumor, primary cancer size, and pathologic grade did not affect recurrence. The rate of stage progression also was not influenced by the extent of the disease in the upper urinary tract. CONCLUSIONS: The extent and pathologic stage of cancer in the upper urinary tract were significant and independent factors for initial intravesical recurrence of cancer. However, no difference was found in clinical outcome in terms of stage progression between patients having high risk factors for intravesical recurrence and those without them.