膀胱癌原位新膀胱术后远期并发症观察

目的了解膀胱癌原位新膀胱术后远期并发症的发生情况并进行分析。方法对于昆明医科大学第二附属医院泌尿外科接受膀胱癌膀胱全切+原位新膀胱术的88例患者进行随访。了解其术后远期并发症发生情况,并进行总结分析。结果术后随访期间共发生肾积水12例(13.6%),肾功能不全9例(10.2%),新膀胱尿道吻合口狭窄12例(13.6%),复发转移13例(14.8%),死亡14例(15.9%),肿瘤相关死亡率8%。尿失禁21例(23.9%),术后尿失禁发生率与性别、年龄无相关性;随访期在1年内与随访期超过1年者尿失禁发生率无统计学差异;60岁以上组与60岁以下组死亡率无统计学差异。3年存活率90.5%(38/42),5年存活率70%(14/20)。结论膀胱癌原位新膀胱术后远期效果理想,肿瘤相关死亡率较低,肾功能衰竭是重要的患者死亡原因,术后尿失禁的发生与性别年龄无相关性,尿失禁发生率在术后1年内达到稳定,在随访期内患者死亡率与年龄无明显相关性。     

Salvage prostate cryoablation for recurrent localized prostate cancer after radiotherapy

Salvage prostate cryoablation (SCA) for recurrent localized prostate cancer after radiotherapy has been studied in Western countries for more than a decade. We present our experience of SCA in a Taiwanese medical center. We performed four cases of SCA for recurrent localized prostate cancer after radiotherapy. The data recorded included age, cancer stage, prostate-specific antigen (PSA) level, Gleason score, prostate volume and patient outcome. The median follow-up period was 17 months. All cases were biopsy-proven to have residual cancer before cryoablation. After SCA, 25% of the patients reached undetectable PSA levels, 50% showed response but did not reach undetectable levels, and 25% showed no decrease in PSA. The median recurrence-free duration after SCA was 18 months in the patients who experienced a decrease in PSA. ADT was initiated after SCA for the patient who did not show any response, and bone metastasis was later diagnosed in that patient. Most patients experienced obstructive voiding problems after SCA, which improved over time. SCA is a safe salvage option for prostate cancer patients with local recurrence after RT. The preliminary results are encouraging. More extensive imagery to exclude extra-glandular disease is warranted before SCA. A longer follow-up period and larger sample size are necessary to delineate the benefits more conclusively.     

Quality of life after external beam radiotherapy for localized prostate cancer: Comparison with other modalities

In external beam radiotherapy for localized prostate cancer, acute toxicities are typically transient and mild. These symptoms will disappear within 4–8 weeks after external beam radiotherapy. Some patients might suffer from proctitis with bloody stools as late rectal toxicity. Therefore, it has been shown that external beam radiotherapy has a more pronounced negative impact on bowel function compared with other treatment modalities. However, the recent development of modern beam delivery techniques, including intensity‐modulated radiotherapy, allows us not only to deliver higher doses to the prostate, but also to decrease the doses to the critical organs, resulting in the maintenance of patients’ quality of life within satisfactory levels. Patients’ quality of life after external beam radiotherapy is also strongly related to the total dose, fractionation regimens, dose parameters of the critical organs and treatment plan quality, with a trade‐off between the radicality of external beam radiotherapy and potentially increased toxicity. Radiation oncologists should choose treatment parameters carefully to achieve a reasonable balance between a good oncological outcome and the patient's quality of life.     

保留性功能全膀胱切除原位回肠新膀胱术(附19例报告)

目的探讨保留勃起和射精功能的全膀胱切除术对浸润性膀胱癌的疗效。方法收集2000年1月～2006年6月膀胱移行细胞癌19例，男性，平均年龄50.9岁，为保留性功能，改善控尿，行改良根治性全膀胱切除原位回肠新膀胱术，保留精囊、输精管、双侧神经血管束及大部分前列腺包膜，随访观察手术效果和生活质量。结果术后病理报告T2aN0M013例，T2bN0M06例。平均随访39个月（6～78个月），死亡率0，均未发现局部及远处转移;平均手术时间5h，平均出血400ml;白天控尿率100%（19/19），夜间尿失禁10.5%（2/19）;全部患者均保留勃起及逆行射精功能，IIEF-5平均22分;新膀胱储尿囊容量350～480ml，充盈压13～25cmH2O，残余尿量10～60ml。结论对有选择的病例采用保留性功能的全膀胱切除-原位回肠新膀胱术可以更好的保留阴茎勃起射精及控尿功能。     

腹腔镜下膀胱癌根治术36例报告

目的探讨腹腔镜下全膀胱切除术治疗膀胱癌的手术方法和临床效果。方法36例患者,男性28例,女性8例;年龄56～75岁。36例病理证实为浸润性膀胱移行细胞癌Ⅱ～Ⅲ级,TNM分期：T2N2M0 22例,T3aN0M0 10例,T3bN0M0 4例。行腹腔镜下膀胱癌根治术,其中25例行原位乙状结肠代膀胱术,11例输尿管造口术,观察手术时间、术中出血量、术后肠道功能恢复、术后并发症及手术效果。站杲手术时间5～10h,术中失血200-1000mL,术后约72h肠道功能恢复,术后2周拔输尿管导管,术后3周拔尿管后腹压排尿正常,术后3个月IVU未见。肾积水,未出现腹腔并发症。结论腹腔镜下全膀胱切除术具有微创、出血少、恢复快等特点,随着技术的进步,该术式将成为治疗浸润性膀胱癌的较好方法之一。     

Salvage radiotherapy for biochemical recurrence after radical prostatectomy

OBJECTIVE: To evaluate the clinical outcome of salvage radiotherapy (RT) for biochemical recurrence after radical prostatectomy (RP) at our institution. PATIENTS AND METHODS: Between March 1999 and January 2004, 37 patients had salvage RT for prostate-specific antigen (PSA) failure after RP, including eight who had had neoadjuvant hormone therapy. After surgery, PSA was measured with ultrasensitive immunoassays. In all patients RT was delivered to the prostatic bed at a total dose of 60 Gy with a four-field box technique. RESULTS: The median (range) PSA level before salvage RT was 0.146 (0.06-3.216) ng/mL and RT was started at a PSA level of <0.5 ng/mL in 34 of the 37 patients (92%). With a median follow-up of 31.9 (0-69.8), months, 11 patients (30%) had disease progression after RT and the 3- and 5-year progression-free probability was 74% and 54%, respectively. Univariate analysis showed that clinical and pathological tumour stages and PSA level before RT (>0.15 vs < or = 0.15 ng/mL) were significant predictors of disease progression. There were no late adverse events related to RT. CONCLUSION: Salvage RT for biochemical failure after RP at a low PSA level, using ultrasensitive immunoassays for monitoring, is a reasonably effective treatment. A relatively low radiation dose (60 Gy) seems to be effective.     

Upper urinary tract recurrence following radical cystectomy for bladder cancer

AIM: The objective of this study was to analyze the clinicopathological features of upper urinary tract recurrence following radical cystectomy for bladder cancer. METHODS: Between 1995 and 2003, 583 patients underwent radical cystectomy and urinary diversion for bladder cancer at the authors' institution and the related hospitals. A retrospective review of patient records was carried out to evaluate characteristics of patients who underwent upper urinary tract recurrence after radical cystectomy. RESULTS: During the observation period (median, 41.5 months), 12 (2.1%) of the 583 patients had upper urinary tract recurrence. Of the 12 patients with upper urinary tract recurrence, there were multiple tumors in eight at the initial diagnosis of bladder cancer, and eight received transurethral resections two or more times before radical cystectomy. The median time to diagnosis of an upper urinary tract cancer after radical cystectomy was 29.5 months. When upper urinary tract recurrence was detected, five patients had metastatic diseases simultaneously, and two had bilateral upper urinary tract cancers. The cancer-specific survival in patients with upper urinary tract recurrence was significantly poorer than that in those without upper urinary tract recurrence. In addition, eight of the 12 patients (66.7%) died of disease progression within 3 years after the diagnosis of upper urinary tract cancer. CONCLUSIONS: These findings suggest that despite the low incidence of upper urinary tract recurrence following radical cystectomy, the prognosis of such patients was markedly poorer compared with that of those without upper urinary tract recurrence. Accordingly, intensive therapies should be considered when upper urinary tract recurrence is detected after radical cystectomy.     

Salvage permanent perineal radioactive‐seed implantation for treating recurrence of localized prostate adenocarcinoma after external beam radiotherapy

OBJECTIVE

To assess our experience with salvage permanent perineal radioactive‐seed implantation (SPPI) as a possible therapeutic option for recurrent prostate adenocarcinoma, as salvage therapies for recurrences after definitive external beam radiotherapy (EBRT) for localized adenocarcinoma of the prostate are associated with significant morbidity and biochemical failure.

PATIENTS AND METHODS

We retrospectively analysed on patients who had SPPI for localized recurrent prostate adenocarcinoma from 1996 to 2007 after primary treatment with EBRT. Excluded were patients who had other primary treatment or had no follow‐up. Primary outcomes were time to biochemical relapse‐free survival, using the Phoenix definition of a prostate‐specific antigen (PSA) nadir +2 ng/mL, and cancer‐specific survival. Secondary outcomes were the International Prostate Symptom Score (IPSS), the International Index of Erectile Function‐5 score (IIEF‐5), and complications based on Common Terminology Criteria for Adverse Events (version 3).

RESULTS

In all, 37 patients had SPPI during this period; after applying inclusion and exclusion criteria, 24 remained for analysis. At the time of salvage therapy, the median time to the diagnosis of local recurrence was 49 months, the median PSA level was 3.36 ng/mL, the median PSA doubling time was 20 months, and all patients were clinically re‐staged at ≤T2 with negative transrectal ultrasonography and/or magnetic resonance spectroscopy. The original Gleason score was ≤6 in nine patients, 7 in eight and ≥8 in three (not recorded in two). The median follow‐up after SPPI was 30 months; the cancer‐free survival was 96% (one death) and biochemical relapse‐free survival was 88% (three patients). The PSA level was higher than the levels before SPPI at 3 months in all three failures, but lower in all 21 patients considered relapse‐free. Complications included one urethral stricture, one grade 3 rectal haemorrhage and five grade 2 gross haematuria that resolved with conservative management. Insufficient data were available to assess the IPSS or IIEF‐5 scores.

CONCLUSION

With a short‐term follow‐up SPPI appears to provide excellent prostate cancer control with an acceptable rate of complications for patients with local recurrence of prostate cancer after EBRT. An extended follow‐up is necessary to determine the long‐term durability and safety of SPPI.     

Radical cystectomy for primary bladder malignancy: a 10 year review

BACKGROUND: Radical cystectomy is universally accepted as the definitive treatment for muscle invasive bladder cancer and preventing stage progression in high-risk groups. There are few recent reviews outside of major international centres. We compared our institution's results with published literature. METHODS: Records of 50 consecutive patients treated with radical cystectomy for biopsy-proven bladder carcinoma between 1995 and 2005 were reviewed. RESULTS: The mean age was 70 years and 76% were male. Median follow up was 38 months (1-111 months). Twenty-three patients (46%) had known history of superficial transitional cell carcinoma and 12 patients (24%) had undergone previously intravesical therapy. Transitional cell carcinomas accounted for 94% of cases and most (76%) were poorly differentiated. Twenty-four (48%) had disease at pT3 stage or higher. Regional lymph nodes were involved in 35%. Twenty-three patients (46%) developed recurrence and over half (12 patients) recurred within 12 months. Both lymph node involvement and recurrence were associated with higher pT stage (P < 0.001). All patients with recurrent disease were dead within a year (median 103 days). Median hospital stay was 19 days and there was one postoperative death (2%). Five-year disease-free and overall survival were 42 and 34% respectively. CONCLUSION: Survival following curative resection for primary bladder malignancy is at best modest. Our overall proportion of higher stage disease contributed to earlier recurrence and lower survival rates. Our postoperative morbidity and mortality rates as well as length of stay are acceptable compared with major international units.     

选择性心理干预对膀胱全切加原位回肠代膀胱术患者情绪的影响

目的 观察选择性心理干预对行原位回肠代膀胱术患者情绪的影响.方法 将67例行膀胱全切加原位回肠代膀胱术患者按入院时间分为对照组(34例)和观察组(33例),两组患者均予常规护理,观察组在此基础上进行选择性心理干预,包括认知行为教育、体育锻炼、音乐治疗和情绪管理等.结果 两组干预后SAS、SDS评分比较,差异有统计学意义(均P＜0.01).结论 选择性心理干预注重心理干预个性化的特点,可降低原位回肠代膀胱术患者的焦虑抑郁情绪.     

膀胱癌合并上尿路积水患者行根治术的预后分析

目的 探讨术前合并上尿路积水对根治性膀胱切除患者预后的影响.方法 回顾性分析从2003年1月至2010年5月期间126例行根治性膀胱切除术患者的资料,上尿路积水39例(31.0%),单因素分析上尿路积水对膀胱癌患者术后无复发生存率的影响,多因素分析上尿路积水、病理T分期和盆腔淋巴结转移情况等因素对膀胱癌根治术患者术后预...     

Presentation, location and overall survival of pelvic recurrence after radical cystectomy for transitional cell carcinoma of the bladder

OBJECTIVES

To evaluate the presentation, location and overall survival of pelvic recurrence after radical cystectomy (RC) for transitional cell carcinoma (TCC) of the bladder.

PATIENTS AND METHODS

We reviewed a consecutive series of 130 patients who had a limited bilateral pelvic lymph node dissection (PLND) and RC between 1987 and 2000, and who later developed pelvic recurrence. All patients were staged N0M0 before RC and no patient received neoadjuvant radio/chemotherapy. The boundaries of the limited PLND were the pelvic side‐wall between the genitofemoral and obturator nerves, and the bifurcation of iliac vessels to the circumflex iliac vein. Pelvic recurrence was defined as a radiographic soft‐tissue density of ≥2 cm below the bifurcation of the aorta. Kaplan‐Meier and Cox proportional hazards analyses were used to determine if imaging or symptomatic presentation, age, pT stage, and pN status were predictive of overall survival.

RESULTS

The median (range) time from RC to pelvic recurrence was 7.3 (1.2–55.4) months. No patients had concomitant distant metastasis. Of the patients, 61.5% were diagnosed with pelvic recurrence because of symptoms, and 38.5% by surveillance computed tomography (CT). Of the 130 patients, 128 died, with a median survival from the time of pelvic recurrence of 4.9 (0.1–129.3) months. The median overall survival time for pelvic recurrence diagnosed with CT was 21.6 months, vs 10.6 months for symptomatic presentations (P < 0.001). In the uni‐ and multivariate models, type of presentation (CT vs symptomatic) and pT stage were predictors of overall survival, while age and pN status were not.

CONCLUSION

The prognosis of patients with pelvic recurrence after RC for TCC is poor even with subsequent therapy, emphasizing the need for optimum local control at the time of initial treatment.     

Upper urinary tract recurrence after radical cystectomy for bladder cancer: incidence and risk factors

Objectives: To examine the incidence of and the risk factors for upper urinary tract recurrence in patients undergoing a radical cystectomy for bladder cancer, and to examine the clinical course of patients harboring upper urinary tract recurrence. Methods: This retrospective study included 362 patients who underwent radical cystectomy for bladder cancer. Patients with a history of upper urinary tract recurrence and concomitant upper urinary tract recurrence at cystectomy were excluded. Results: After a median follow up of 48 months (range 0–214) after radical cystectomy, 11 patients (3.0%) developed upper urinary tract recurrence. The median time to upper urinary tract recurrence was 48.4 months (range 11.6–78.6). The overall probability of upper urinary tract recurrence was 3.3% at 5 years. The median overall survival period after upper urinary tract recurrence was 23.5 months (range 4.3–53.9), with a better overall survival for patients who received a radical operation than for those who did not (38.6 months vs 11.9 months, respectively; P = 0.03). At multivariable analysis, the presence of carcinoma in situ (P < 0.01) and invasion of the urethra (P = 0.02) were independent risk factors for upper urinary tract recurrence. The 5‐year upper urinary tract recurrence was significantly higher for patients positive for either of these risk factors than for those without risk factors (12.0% vs 0.9%, respectively; P < 0.001). Conclusions: This study shows that the presence of carcinoma in situ and cancer invading the urethra are risk factors for upper urinary tract recurrence. Close follow up is needed for early detection of upper urinary tract recurrence in patients at higher risk.