Clinical study of transitional cell carcinoma of the prostate associated with bladder transitional cell carcinoma

BACKGROUND: Transitional cell carcinoma of the prostate in patients with bladder cancer appears to influence the prognosis and affects the decision about therapeutic modality. Therefore, it is important to characterize transitional cell carcinoma associated with bladder cancer. METHODS: From April 1980 to December 1998, 81 male patients underwent total cystoprostatectomies for transitional cell carcinoma of the bladder. The 81 cystoprostatectomy specimens were examined to clarify the characteristics of prostatic involvement by transitional cell carcinoma. The extent, origin, mode of spread and risk factor of prostatic involvement as well as the prognosis were investigated. In 13 of 15 patients with prostatic involvement the prostate was examined by sequential step sections. RESULTS: Prostatic involvement was observed in 15 of 81 patients (18.5%). Prostatic urethral involvement, invasion to prostatic duct/acinus, prostatic stromal invasion and extraprostatic extension and/or seminal vesicle involvement were recognized in 12 (80%), 14 (93.3%), six (40%), and five (33.3%) of the 15 patients, respectively. Twelve of the 15 patients (80%) with prostatic involvement had papillary or non-papillary tumors (i.e. carcinoma in situ) both in the prostatic urethra and prostatic duct. In 10 of these 12 patients (88.3%), there was contiguity between prostatic urethral and ductal tumors. Seven of the 23 patients (30.4%) with carcinoma in situ of the bladder showed prostatic involvement, which increased to 50% in the presence of carcinoma in situ of the trigone or bladder neck. CONCLUSIONS: Eighty per cent of the patients with prostatic involvement showed papillary or non-papillary tumors both in the prostatic urethra and prostatic duct. There was a high level of contiguity between both tumors. Patients with carcinoma in situ of the trigone or bladder neck revealed significantly higher incidence of prostatic involvement.     

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.     

Transitional cell carcinoma in an ectopic ureter

We experienced an 82-year-old man with transitional cell carcinoma in an ectopic ureter draining into the prostatic urethra. Carcinoma arising from an ectopic ureter is very rare and a differential diagnosis is difficult. To our knowledge, our case is the third male case reported in the literature.     

Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: a critical appraisal

Two of the mini‐reviews in this issue evaluate the laparoscopic approach to urology; one critically appraising laparoscopic nephroureterectomy for upper tract TCC, and the other looking back on the first 10 years of laparoscopic pyeloplasty. They are also a testament to the relationship which has developed between the effects of British urologists in becoming experts in this area, and the outstanding help and supervision given by Inderbir Gill and his team at the Cleveland Clinic. The financial backing for this venture came from the British Urological Foundation, which enthusiastically supports the concept of this preceptorship at the Cleveland Clinic.     

腹腔镜治疗上尿路移行细胞癌合并膀胱前列腺疾病

目的探讨腹腔镜治疗上尿路移行细胞癌合并膀胱前列腺疾病的临床效果。方法腹腔镜行肾输尿管全长、膀胱袖状切除和膀胱疾病处理及前列腺摘除术共10例。结果10例手术全部成功,术后无并发症,效果良好。随访3个月~3年未见局部复发和远处转移。结论该法不仅具有腹腔镜创伤小、恢复快的优点,且处理合并症简单,适合治疗上尿路移行细胞癌合并膀胱前列腺疾病。     

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: results of a Belgian retrospective multicentre survey

OBJECTIVES: To evaluate the technical and oncologic feasibility of laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma. METHODS: A retrospective survey of 100 patients, treated with laparoscopic nephroureterectomy in 10 Belgian centres, was performed. Most procedures were performed transperitoneally. The distal ureter was managed by open surgery in 55 patients and laparoscopically in 45 patients. The mean follow-up was 20 mo. RESULTS: Mean operation time was 192 min and mean blood loss 234 ml. The conversion rate was 7%. Important postoperative complications were seen in 9%. Pathologic staging was pTa in 31 patients, pT1 in 23, pT2 in 12, pT3 in 33, and pT4 in 1, concomittant pTis in 3. Pathologic grade was G1 in 24 patients, G2 in 28, and G3 in 48. Negative surgical margins were obtained in all but one patient. Twenty-five patients developed progressive disease (24%) at a mean postoperative time of 9 mo (local recurrence in 8%, metastases in 11%, both in 5%). Progression was 0% for pTa, 17% for pT1, 17% for pT2, 51% for pT3, and 100% for pT4. Cancer-specific survival was 100% for pTa, 86% for pT1, 100% for pT2, 77% for pT3, and 0% for pT4. CONCLUSION: Laparoscopic nephroureterectomy appears to be a technically and oncologically feasible operation. To prevent tumour seeding, one should avoid opening the urinary tract and should extract the specimen with an intact organ bag. The high local recurrence rate in this study probably reflects the high percentage of high-grade and high-stage tumours in this study.     

经尿道输尿管口及周围膀胱壁加肾输尿管切除治疗肾盂移行细胞癌

目的探讨治疗肾盂移行细胞癌的新方法及疗效。方法总结2003年1月至2006年3月收治的12例患者的临床资料。病例均采用经尿道输尿管口及周围膀胱壁袖套状切除加腰部斜切口肾输尿管全切术。合并膀胱肿瘤及腺性膀胱炎者同期行汽化电切处理（TUEVBt）。术后1周拔除导尿管开始膀胱灌注化疗。半年一次膀胱镜检。结果全部病例均一期愈合,无出血、感染、漏尿等并发症发生。病理证实均为肾盂移行细胞癌Ⅰ-Ⅲ级。1例术后9个月膀胱肿瘤复发行TUEVBt。现患者均健在。结论该法操作简单,疗效好,创伤小,并发症少,恢复快,可同时处理膀胱其他疾患,是治疗肾盂移行细胞癌的良好术式。     

后腹腔镜联合膀胱电切镜对上尿路移行细胞癌根治性治疗的安全性研究

目的探讨后腹腔镜联合膀胱电切镜对肾盂、中上段输尿管移行细胞癌根治性治疗的手术及肿瘤学安全性。方法回顾性分析肾盂、中上段输尿管移行细胞癌患者58例临床资料,后腹腔镜联合膀胱电切镜肾输尿管全长切除组（A组）41例,开放肾输尿管切除组（B组）17例。对其手术效果、并发症及术后肿瘤复发情况进行对比。结果A组和B组手术出血量（98．4和165mL）、术后住院天数（7．1和8．0d）、术后应用止痛药时间（1．2和3．1d）比较,A组优于B组（P〈0．05）;两组手术时间（150和110min）、术后留置尿管时间（6．2和3．5d）比较,A组长于B组（P〈0．05）。A组1例因电切输尿管口出血,中转开放手术。A、B两组并发症发生率（7．3％和11．8％）及肿瘤复发率（14．6％,23．5％）差异均无统计学意义（P均〉O．05）。结论联合尿道电切镜、后腹腔镜肾输尿管切除术与开放手术相比,出血少、术后恢复快、并发症少,未增加术后肿瘤的复发。     

Conservative management in selected patients with upper tract urothelial carcinoma compares favourably with early radical surgery

OBJECTIVE

To compare the outcomes of patients treated for upper tract urothelial carcinoma with either immediate nephroureterectomy (NU) or initial endoscopic management.

PATIENTS AND METHODS

The treatments of 108 patients (120 renal units) at the authors’ institution were retrospectively reviewed and divided into two groups, i.e. those who received immediate NU and those who had conservative initial therapy, which included renal units solely treated with endoscopy with or without delayed NU. Overall and disease‐specific survival (DSS) were compared between the treatment groups.

RESULTS

There were 48 low‐grade tumours, of which 27 (56%) were managed conservatively and 21 (44%) by immediate NU. Seven patients treated conservatively had stage or grade progression and had delayed NU. The mean (sd ) DSS at 5 years in patients with low‐grade disease was equally good for conservative treatment and immediate NU, at 86.2 (9.1)% vs 87.4 (8.4)% (P = 0.909). There were 68 high‐grade tumours, of which 12 (18%) patients had conservative management and 56 (82%) had immediate NU. Among the former, seven of 12 had a solitary kidney and three had bilateral disease. In patients managed endoscopically, four of 30 (13%) required delayed NU. The DSS for the conservative and immediate NU groups were 68.6 (18.6)% vs 75.0 (8.1)% (P = 0.528).

CONCLUSION

Management with a conservative approach in selected patients provides comparable outcomes to immediate NU in patients with low‐grade disease.     

Laparoscopic management of a transitional cell carcinoma arising in a right ectopic ureter

Ectopic ureter is a rare abnormality, so presenting a transitional cell carcinoma (TCC) arising from an ectopic ureter is extremely rare. We report here a case of a man with an invasive transitional cell carcinoma arising from a right ectopic ureter and managed by laparoscopy. To our knowledge, this is the fourth case described in the literature, and the second case of a TCC arising in a right ectopic ureter.     

Common sheath reimplantation with ureteral plication: A useful technique for the management of ectopic ureterocele

BACKGROUND: When salvaging the upper pole kidney in duplex ectopic ureterocele, primary bladder level surgery with common sheath ureteral reimplantation has the definite advantage of allowing the reconstruction of the entire collecting system through a single lower abdominal incision. However, there are several complications associated with a common sheath reimplantation in a child with a very dilated upper pole ureter, such as vesicoureteral reflux or ureterovesical stenosis. METHODS/RESULTS: To avoid these complications, ureteral plication over the common ureteral sheath in two children with duplex ectopic ureterocele was used. Postoperatively, neither child showed reflux or recurrent urinary tract infection and both showed a marked improvement of the upper pole collecting system. CONCLUSION: This technique allows for a simple and definitive reconstruction in cases of duplex ectopic ureterocele, particularly with dilated upper pole ureter.     

Surgical management for upper urinary tract transitional cell carcinoma (UUT‐TCC): a systematic review

What's known on the subject? and What does the study add? Upper urinary tract transitional cell carcinoma (UUT‐TCC) is an aggressive disease. The mainstay in the treatment of UUT‐TCC is surgical intervention, with oncological control the primary objective. UUT‐TCCs have been conventionally treated with radical nephroureterectomy (NU). This procedure involves removal of the kidney, ureter and ipsilateral excision of a bladder cuff. Whilst open NU has traditionally been the approach used, laparoscopic NU (LNU) is now an increasingly popular and established approach for UUT‐TCC. It is argued that LNU reduces postoperative morbidity without compromising oncological efficacy. With technological evolution, robotic NU has now been attempted in some centres as well. In addition, several techniques have been described to manage the bladder cuff with no agreement as to the most efficacious approach. In a further attempt to reduce morbidity and safeguard nephrons, there have been advocates of a number of nephron‐sparing techniques, e.g. ureteroscopic management, percutaneous approaches, and distal ureterectomy. These approaches obviously raise concern on oncological efficacy with requirement for more stringent long‐term surveillance protocols. This study comprehensively reviews and summarises the evidence comparing various surgical techniques in the management of UUT‐TCC. The review additionally evaluates and critically appraises the quality of evidence available, which currently informs practice.

• ? Surgical management of upper urinary tract transitional cell carcinoma (UUT‐TCC) has significantly changed over the past two decades. Data for several new surgical techniques, including nephron‐sparing surgery (NSS), is emerging.
• ? The study systematically reviewed the literature comparing (randomised and observational studies) surgical and oncological outcomes for various surgical techniques
• ? MEDLINE, EMBASE, Cochrane Library, CINAHL, British Nursing Index, AMED, LILACS, Web of Science, Scopus, Biosis, TRIP, Biomed Central, Dissertation Abstracts, ISI proceedings, and PubMed were searched to identify suitable studies. Data were extracted from each identified paper independently by two reviewers (B.R. and B.S.) and cross checked by a senior member of the team.
• ? The data analysis was performed using the Cochrane software Review manager version 5. Comparable data from each study was combined in a meta‐analysis where possible. For dichotomous data, odds ratios with 95% confidence intervals (CIs) were estimated based on the fixed‐effects model and according to an intention‐to‐treat analysis. If the data available were deemed not suitable for a meta‐analysis it was described in a narrative fashion.
• ? One randomised control trial (RCT) and 19 observational studies comparing open nephroureterectomy (ONU) and laparoscopic NU (LNU) were identified. The RCT reported the LNU group to have statistically significantly less blood loss (104 vs 430 mL, P < 0.001) and mean time to discharge (2.30 vs 3.65 days, P < 0.001) than the ONU group. At a median follow‐up of 44 months, the overall 5‐year cancer‐specific survival (CSS; 89.9 vs 79.8%) and 5‐year metastasis‐free survival rates (77.4 vs 72.5%) for the ONU were better than for LNU, respectively, although not statistically significant.
• ? A meta‐analysis of the observational studies favoured LNU group for lower urinary recurrence (P < 0.001) and distant metastasis. The meta‐analyses for local recurrence for the two groups were comparable.
• ? One retrospective study comparing ONU with a percutaneous approach for grade 2 disease reported no significant differences in CSS rates (53.8 vs 53.3 months).
• ? Three retrospective studies compared NSS and radical NU, and reported no significant differences in overall CSS and recurrence‐free survival between the two approaches.
• ? Five retrospective studies compared various techniques of en bloc excision of the lower ureter. No technique was reported to be better (operative and oncological) than any other.
• ? This review concludes that there is a paucity of good quality evidence for the various surgical approaches for UUT‐TCC. The techniques have been assessed and reported in many retrospective single‐centre studies favouring LNU for better perioperative outcomes and comparable oncological safety. The reported observational studies data is further supported by one RCT.

     

Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: comparison of laparoscopic and open surgery

OBJECTIVES: We made a comparative study of laparoscopic nephroureterectomy (LNU) and standard open surgery (ONU) for upper urinary tract transitional cell carcinoma. METHODS AND METHODS: From July 2000 to February 2005, 49 patients underwent total nephroureterectomy for upper tract transitional cell carcinoma at Osaka University Medical Hospital. Of the 49 patients, twenty-five were treated with LNU, and twenty-four with ONU. Each group of cases was reviewed with respect to operative time, complications and postoperative convalescence. RESULTS: The average operative time of the LNU and ONU group was 305.9 min (range 190-480) and 271.2 min (range 135-480) respectively, and the average blood loss was 321.5 ml (80-1370) and 557.7 ml (range 100-1730), respectively. The average time until ambulation after LNU and ONU was 2.2 days (range 1-3) and 4.0 days (range 3-5), respectively. No major postoperative complications were observed in either group. CONCLUSION: ONU still represents the gold standard for the management of upper tract transitional cell carcinoma; however, for low stage cases, LNU offers the advantages of minimally invasive surgery.     

A one-port pneumovesicum method in en bloc laparoscopic nephroureterectomy with bladder cuff resection is feasible and safe for upper tract transitional cell carcinoma

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To introduce a modified method for managing the distal ureter in laparoscopic nephroureterectomy (LNU) for upper tract transitional cell carcinoma (TCC) and to evaluate the feasibility and safety of this method.

PATIENTS AND METHODS

? Six consecutive patients underwent LNU using a one‐port pneumovesicum method for pathologically confirmed upper tract TCC. ? Each patient was placed on the operating table in the lithotomy position and the pneumovesicum method was applied with CO₂ insufflation. Dissection was performed circumferentially through the entire detrusor muscle to disconnect the ureter from the bladder wall. A 10‐mm trocar was placed into the bladder above the pubic bone. The distal ureter was occluded using a Hem‐o‐lok clip and pushed out of the bladder. Laparoscopic nephroureterectomy was then performed with the patient in the lateral position. ? After surgery, all six patients received systemic chemotherapy and follow‐up.

RESULTS

? All procedures were performed successfully. ? The median (range) operating time for the complete procedure was 105 (85–140) min, and the median (range) estimated blood loss was 125 (60–230) mL. ? Seven days after surgery, each patient underwent cystography, which confirmed no extravasation of urine. ? None of the patients developed bladder tumour recurrence or metastatic disease during follow‐up.

CONCLUSIONS

? The one‐port pneumovesicum method in LNU, which is applied to manage the distal ureter and bladder cuff, is technically feasible and safe. ? The method simplifies management of the distal ureter, reduces the invasiveness of the procedure and improves cosmesis.     

Possibility of spontaneous seeding of transitional cell carcinoma of the ureter in renal tubules: Another mechanism of transitional cell carcinoma dissemination

Cancer cell seeding inside the urinary tract always has been considered one possible mechanism of the multicentric origin of transitional cell carcinoma (TCC). However, there is still no direct clinical evidence to prove that the natural seeding of TCC is a real event. To our knowledge, we report the first case of spontaneous seeding of TCC of the ureter in the renal tubules of a hydronephrotic kidney. The TCC nature of the intratubular tumor cells has been confirmed by the morphological appearance of them after hematoxylin and eosin staining and positive p53 immunohistochemical staining.     

腹腔镜肾输尿管全长切除术及膀胱袖状切除术治疗上尿路移行细胞癌

目的:评价腹腔镜经腹腔径路行肾输尿管全长切除术及膀胱袖状切除术治疗上尿路移行细胞癌的有效性及安全性。方法:对6例上尿路移行细胞癌患者行腹腔镜经腹腔径路肾切除术,经同侧下腹斜切口、袖状切除输尿管并完整取出标本。结果:6例手术均获成功,无中转开放手术,手术时间200～320min,平均250min,术中出血100～300ml,均未输血,住院8～12d,平均9d,术后常规膀胱灌注丝裂霉素,随访2～14个月,均无复发或转移。结论:腹腔镜肾输尿管全长切除术是治疗上尿路移行细胞癌安全有效的微创手术,具有痛苦小、康复快等优点。     

Endourological management of upper tract transitional cell carcinoma

In this Issue, there are four mini‐reviews, three of which relate to cancer of the genitourinary system. In the first of these the endourological management of upper tract TCC is described by authors from the Mayo Clinic who have a long‐term experience in this area. The second and third of the mini‐reviews concern prostate cancer, but in different ways. The authors from Sacramento write about the use of the artificial urinary sphincter for post‐prostatectomy incontinence. Obviously this includes surgery for benign disease also, but the main emphasis is on its use after radical prostatectomy for prostate cancer. The other article is about the use of ErbB receptors as possible therapeutic targets, from the University of Leicester. Finally in this section, authors from Kingston, Ontario, have written a mini‐review on hypogonadism and erectile dysfunction, relating pathophysiology to treatment and outcomes.