Getting under the hood of the volume-outcome relationship for radical cystectomy

PURPOSE: Hospital and surgeon volumes independently explain variations in outcomes for a host of surgical procedures. However, the mediators of the volume effect remain unclear. We assessed whether differences among hospitals could explain some or all of the volume effect on short-term outcomes after cystectomy for bladder cancer. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample a 20% sampling of hospital discharges in the United States and the American Hospital Association file we applied International Classification of Diseased, 9th revision, clinical modification procedure codes to identify 1,847 patients who underwent cystectomy for bladder cancer in 2003. Multivariable mixed models were fit to quantify the differences in measures of hospital structure (capacity, staffing and health services) by hospital volume. Separate models were fit to determine the impact of accounting for these differences on the volume-outcome relationship. RESULTS: There were substantial differences in hospital structure according to radical cystectomy volume, including those characterizing capacity, staffing levels and the breadth of available health services. For example, 40.7% of low and 87.8% of high volume hospitals for radical cystectomy offered open heart surgery (OR 10.4, 95% CI 1.3-85.3). After adjusting for case mix patients treated at low volume centers were 3.2 times (95% CI 0.8-13.4) more likely to die postoperatively. Accounting for differences in hospital structure attenuated the volume effect by 59% (OR 1.9, 95% CI 0.4-8.6). CONCLUSIONS: Measurable differences in the availability and breadth of consultative, diagnostic and ancillary services may at least partially explain the association between procedure volume and short-term cystectomy outcomes.     

T1G3期膀胱肿瘤经尿道二次电切的临床疗效分析

目的探讨二次经尿道膀胱肿瘤电切术（TURBT）治疗T1G3期膀胱肿瘤患者的临床疗效。方法回顾分析2005年1月至2011年12月在我院初次行TURBT治疗病理诊断为T1G3期膀胱肿瘤、并规律进行丝裂霉素膀胱灌注的49例患者资料。其中行二次TURBT治疗的患者19例（观察组）,未行二次电切的患者30例（对照组）。观察两组间肿瘤复发率差异、残余肿瘤存在与否,以及肿瘤病理分期、分级的变化。结果二次电切后发现5例（26．3％）有残余肿瘤,3例（15．9％）有肿瘤分期的升高,其中1例改行根治性膀胱切除术。随访8～18个月（平均15个月）,观察组有3例（15．9％）肿瘤复发,对照组13例（43．3％）肿瘤复发。结论二次TURBT可切除残存肿瘤,更准确了解肿瘤分期情况,是确定患者是否应行根治性膀胱切除的重要依据,并可明显降低肿瘤的复发与进展。     

Complications of intravesical therapy for urothelial cancer of the bladder

PURPOSE: Intravesical therapy is an integral part of treatment in patients with superficial urothelial carcinoma of the bladder. The American Urological Association and European Association of Urology guidelines on bladder cancer incorporate it for the treatment of superficial bladder cancer. Given the extensive use of intravesical immunotherapy and chemotherapy, it is essential for the practicing urologist to be aware of the local and systemic side effects of these therapies. MATERIALS AND METHODS: We reviewed the literature on intravesical immunotherapy and chemotherapy with particular emphasis on side effects, complications and their management. A Medline search of the English language literature for the last 25 years was done on Entrez PubMed and all relevant articles were studied in full. All side effects and complications were studied and their management was reviewed. RESULTS: Intravesical therapy for transitional cell carcinoma of the bladder is generally safe. There is a high incidence of local, usually self-limiting, relatively minor side effects and infrequent, potentially severe local and systemic side effects. Most side effects are avoidable. CONCLUSIONS: Although intravesical therapy is generally safe, local and systemic side effects occur and it is important to be aware of them. Identifying complications early, preventing them when possible and managing them efficiently are critical. Most complications are preventable. Knowing the risks and benefits of chemotherapeutic and immunotherapeutic agents may decrease the short-term and long-term toxicity of these agents. Adherence to guidelines may prevent inappropriate use, which can lead to unnecessary complications, resulting in bladder dysfunction and even cystectomy.     

Results of umbilicoplasty for bladder exstrophy

PURPOSE: The umbilicus is an important aesthetic landmark and its absence or deformity may be associated with poor self-image. In patients born with bladder exstrophy the umbilicus is attached to the upper margin of the bladder and reconstructive surgery often removes the navel. The umbilicus marks the waistline and serves to complete the harmony of the curved lines above and below the waist. We present our experience with children born with exstrophic anomalies during the last 2 decades. MATERIALS AND METHODS: Our database included 61 children born with classic bladder and 8 born with cloacal exstrophy treated between 1980 and 1998. We performed primary reconstruction in 35 children, while 34 children and young adults were referred for secondary surgical repair, including bladder augmentation, continent diversion, genitoplasty and so forth. Neoumbilicoplasty was done in all of the former and in 30 of the 34 latter cases. Early in the series a V-shaped flap was raised and buried subcutaneously. The flap eventually became a tube around the cystotomy tube and the cicatrix formed the umbilical dimple. This method necessitated packing with iodoform gauze for 4 weeks with weekly dressing. The technique evolved into a tubularized U-shaped flap. A rubber tube was placed indwelling as a stent to maintain inward projection of the neoumbilicus. RESULTS: In 66 of the 69 cases the early results of umbilicoplasty were described by the surgeon as excellent or satisfactory. In 3 cases the neoumbilicus appeared flat, lost depth and was described as unsatisfactory. Long-term followup of more than 1 year was available in 48 patients, of whom 2 underwent umbilical repositioning for an off center or low umbilicus and 3 underwent repeat umbilicoplasty for a flat umbilicus that had lost depth. The best cosmetic results were achieved in patients with a relatively thick layer of subcutaneous fat, whereas cosmesis was suboptimal in thin children. Nevertheless, the patients and parents were generally pleased with the umbilical appearance even when the surgeon was not. CONCLUSIONS: Although the navel is a functionless depressed scar, it represents an important and pleasing landmark. Umbilical construction should be attempted early during functional closure or urinary diversion.     

Comparison of two-port and four-port irradiation in the bladder preservation therapy for locally invasive bladder cancer

AIM: To ascertain therapeutic effectiveness and adverse reactions with radiochemotherapy for locally invasive bladder cancer, comparison was made between two-port and four-port irradiation with intravenous cisplatin administration. METHODS: In 86 patients who were diagnosed with locally invasive bladder cancer on the basis of imaging and biopsy findings, transurethral tumor resection was carried out initially to minimize tumor volume, and then radiochemotherapy was done. From 1985 to 1997, bilateral two-port irradiation was carried out, and after 1998, four-port irradiation was done. In regards to chemotherapy, cisplatin was administered intravenously. Therapeutic effects were assessed 1 month after the end of therapy. RESULTS: Fifty-five patients underwent two-port irradiation; complete response (CR) was achieved in 26 and partial response (PR) in 29 patients. Thirty-one patients underwent four-port irradiation; CR was achieved in 20 patients and PR in 11 patients. The cause-specific 5-year survival rate did not differ significantly between two-port and four-port irradiation (74%vs 79%), but there was a significant difference of survival between CR and PR patients. In the two-port irradiation group, 5-year bladder preservation rate was 89% in CR patients and 52% in PR patients. In the four-port irradiation group, 5-year bladder preservation rate was 90% in CR patients and 46% in PR patients. Of the various adverse reactions, no significant differences in leukopenia, thrombocytopenia or bladder symptoms were observed between two-port and four-port irradiation, but the incidence and severity of loss of appetite, nausea and/or vomiting, diarrhea and dermatitis were significantly greater for two-port irradiation. CONCLUSION: Radiochemotherapy are considered to be modest effective in the bladder preservation therapy for locally invasive bladder cancer. The four-port irradiation shows less adverse reactions than two-port irradiation.     

Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era

PURPOSE: We studied the effect of radical cystectomy for transitional cell carcinoma of the bladder on survival and failure patterns when the 2 surgical standards cystectomy and neobladder were combined, when possible. MATERIALS AND METHODS: A consecutive series of patients undergoing radical cystectomy with pelvic lymph node dissection for transitional cell carcinoma of the bladder with curative intent was analyzed. Patients with neoadjuvant radiotherapy/chemotherapy were excluded. Pathological characteristics based on the 2002 TNM system, recurrence-free/overall survival and metastatic patterns were determined. RESULTS: A total of 788 patients with a mean age +/- SD of 65 +/- 10 years and a mean followup of 53.5 months who underwent surgery between 1986 and 2003 were analyzed. A neobladder was constructed in 75.4% of patients. Ten-year recurrence-free and overall survival rates were 59.1% and 44.9%, respectively. Positive lymph nodes were present in 143 patients (18%). The rate of recurrence-free survival at 5 years was 82.5% for pT2a pN0, 61.9% for pT2b and pT3a pN0, and 53.1% for pT3b pN0 disease. Local and distant failure rates were 4% and 9.5% for organ confined tumors, 15.9% and 19.2% for nonorgan confined tumors, and 20.4% and 45.1% in patients with positive lymph nodes, respectively. CONCLUSIONS: In patients with organ confined, lymph node negative transitional cell carcinoma excellent survival data can be achieved as long as the tumor is limited to the inner half of the detrusor. These data on a large group of patients support early aggressive surgical management for invasive bladder cancer. The results of this surgery only series may serve as a reference for other treatment modalities for bladder cancer.     

经尿道膀胱颈内切开术治疗女性膀胱颈梗阻的疗效观察

目的:评估经尿道膀胱颈内切开术治疗女性原发性膀胱颈梗阻(PBNO)的长期疗效。方法:56例女性患者通过排泄性膀胱尿道造影及尿动力学检查确诊为PBNO,在膀胱颈上选取2点及10点位置,所有患者行经尿道膀胱颈内切开术。结果:术后随访6~72个月(平均26.2个月)。56例接受手术的患者中47例(83.9%)术后恢复良好,未见严重并发症。随访过程中,平均国际前列腺症状评分(IPSS)由21.2降至7.6(P<0.05),生活质量评分(QOL)由4.2降至2.3(P<0.05),最大尿流率(Q_max)由8.63ml/s增至17.36ml/s(P<0.05),残余尿量(PVR)由106.32ml降至21.46ml(P<0.05),最大尿流率时逼尿肌压力(Pdet at Q_max)由68.42cmH_2O降至19.86cmH_2O(1cmH_2O=0.098kPa,P<0.05)。术后出现的并发症有血尿、二次行膀胱颈内切开术、压力性尿失禁、尿道狭窄。所有这些并发症按Clavien分类评估为Ⅲa级。3例(5.3%)术后出现出血,经延长尿管留置时间、膀胱冲洗治愈,均未输血治疗;4例(7.1%)出现压力性尿失禁,行经阴道无张力尿道中段吊带术后恢复;4例(7.1%)出现尿道狭窄,间断尿道扩张后好转。结论:PBNO不常见,排泄性膀胱尿道造影及尿动力学检查可确诊,通过经尿道膀胱颈内切开术治疗安全有效。在膀胱颈的2点和10点方向仔细地、足够深度地行颈内切开可以保证手术的成功。     

Interconnections of the upper ventral rami of the human sacral plexus: A reappraisal for dorsal rhizotomy in neurostimulation operations

The extension of a dorsal rhizotomy in bladder stimulation patients is partly determined by connections between the ventral rami of the second, third, and fourth sacral spinal nerves. The literature is inconclusive on interconnections of these ventral rami in the human sacral plexus. The sacral plexuses of ten human cadavers were dissected in this gross anatomy study. In nine cases a branch connecting the ventral rami of the second and third sacral spinal nerves was found. Electron microscopy demonstrated the presence of thick myelinated fibers in this branch. In the male plexuses this branch formed the only link between the second sacral spinal segment and the pelvic plexus. The ventral ramus of the second sacral nerve always contributed to the pudendal nerve, whereas involvement of the ventral rami of the first and third sacral nerves differed individually and intersexually.     

两种膀胱扩大术治疗神经源性膀胱比较分析

目的:比较膀胱自扩大术和回肠膀胱扩大术治疗神经源性膀胱的临床效果。方法:回顾分析膀胱自扩大术10例,回肠膀胱扩大术13例患者临床资料,对两种术式的手术方法,手术前后患者膀胱容量,肾功能以及临床症状进行比较。结果:膀胱自扩大术和回肠膀胱扩大术的患者术后平均安全膀胱容量显著增多,分别为(178.2±31.8)vs(420.7±54.9)ml,(115.9±19.5)vs(517.4±48.3)ml(P<0.05),顺应性明显改善。前者尿失禁消失8例,明显改善1例;术后血清肌酐水平恢复正常6例,明显下降2例,肾积水明显缓解或消失,未发现膀胱输尿管反流现象;后者尿失禁消失9例,明显改善2例,血清肌酐水平6例恢复正常,1例明显下降,肾积水情况均较术前明显缓解或消失,膀胱输尿管反流消失;术后3例出现尿路感染;1例轻微漏尿;1例出现腹泻;3例出现肠梗阻;2例出现膀胱结石,均对症处理后好转。结论:膀胱自扩大术较为简单、安全,但其适应证把握应慎重。回肠膀胱扩大术是治疗神经源性膀胱有效的手术方式,其适应证相对广,但并发症较多。     

The limits of bacillus Calmette-Guerin for carcinoma in situ of the bladder

PURPOSE: Historically carcinoma in situ of the bladder has been treated with radical cystectomy based on the aggressive and potentially invasive nature of this disease. The introduction in the late 1970s of intravesical bacillus Calmette-Guerin (BCG) has made this therapy the gold standard in the management of carcinoma in situ. Cases that are refractory or resistant to BCG therapy are a management dilemma with various available treatment options. MATERIALS AND METHODS: A comprehensive literature review of the current management of carcinoma in situ of the bladder was performed using MEDLINE, a review of current urology journals and abstracts from recent urology meetings. Data focused on BCG resistant carcinoma in situ of the bladder and current approaches in use for refractory disease. RESULTS: Complete and durable response rates have been reported in more than 70% of patients with carcinoma in situ who are treated with intravesical BCG. To our knowledge the optimal therapeutic regimen has not been established, although extended periods of treatment beyond the originally described 6-week course have not been shown to improve complete response rates. Prolonged administration of BCG is associated with adverse side effects. Various prognostic indicators of recurrence and progression exist that may identify a subset of cases unlikely to respond favorably to a conservative approach, including carcinoma in situ with associated stage T1 bladder lesions, diffuse and multifocal carcinoma in situ, multiple recurrences with intravesical therapy and extravesical involvement. Current molecular markers may also predict the response of carcinoma in situ to therapy. Treatment options available for BCG refractory carcinoma in situ of the bladder include intravesical chemotherapy, combined immuno-chemotherapy and radical cystectomy. Intravesical valrubicin and oral bropirimine have been shown to induce a complete response rate of 21% to 50%, although data on long-term followup are forthcoming. Radical cystectomy remains effective therapy for aggressive carcinoma in situ of the bladder. CONCLUSIONS: The current management of carcinoma in situ of the bladder is ill defined due to the variable natural history and unpredictable response of this disease to therapy. Controversy exists as to the optimal treatment of carcinoma in situ of the bladder since different forms of carcinoma in situ may exist that complicate therapeutic decisions for appropriate therapy. Some tumor characteristics are associated with more aggressive behavior and may be predictive of treatment outcome.     

经尿道2μm激光膀胱部分切除术治疗膀胱尿路上皮癌组织病理学分析

Objective To observe the histopathologic characteristics of 2 micron continuous wave laser transurethral partial cystectomy for the treatment of bladder tumor. Methods A total of 54 patients with 65 bladder tumors underwent 2 micron laser via transurethral by caudal or surface anesthesia from October 2007 to December 2008. It included 41 male and 13 female cases, and the age ranged from 27 to 81 years old with a mean of (66.2±12.4) years old. The operation evaporated and exsected the wall of urinary bladder, including tumor, submucosa and all muscular layers. Specimens were sent for pathology examination. The histomorpholagic changes of raw surfaces were observed 1 week, 1 month, 3 months, 6 months and 1 year postoperation by cystoscopic and pathologic examinations. Results All the patients tolerated in the operation. Clinical stages of the tumor: T1 for 42 cases, T2 for 12 cases. All cases were followed-up for 1 to 14 months, with a mean of 8. 5 months. Tumor recurrences were found in 2 cases, no one had recurrence in situ. The tumor, submucosa and all muscular layem can be resected completely by 2 micron continuous wave laser transurethral partial cystectomy. Pathologic staging can be judged correctly.The umbilication raw surface were infiltrated by fibrous connective tissue and chronic inflammatory cells 1 week postoperation. The umbilication changed shallow and transitional epithelial cells began to cover it 1 month postoperation. The umbilication dispeared and transitional epithelial cells cover the raw surface 3 months postoperation. There was no difference between the raw surface and normal bladder mucosa.Conclusions 2 micron continuous wave laser for the treatment of bladder tumor can get the same clinical result as partial cystectomy. The pathologic staging can be judged correctly by the specimens.     

Variability in the performance of nuclear matrix protein 22 for the detection of bladder cancer

PURPOSE: We assessed variability in the diagnostic performance of NMP22 for detecting recurrence and progression in patients with Ta, T1, and/or CIS transitional cell carcinoma of the bladder in a large international cohort. MATERIALS AND METHODS: NMP22 voided urine levels were measured in 2,871 patients who underwent office cystoscopy for monitoring previous stage Ta, T1 and/or CIS transitional cell carcinoma at 12 participating institutions. RESULTS: Patient characteristics varied considerably among institutions. Overall 1,045 patients (36.4%) had recurrent transitional cell carcinoma (range across institutions 13.6% to 54.3%). Median NMP22 was 5.5 U/ml (range across institutions 2.5 to 18.8). Of the patients 33.5% had grade III tumors (range across institutions 20.6% to 54.0%) and 22.4% had muscle invasive tumors (range across institutions 3.2% to 38.2%). Area under the ROC curve for bladder TCC detection was 0.735 (95% CI 0.715 to 0.755, range across institutions 0.676 to 0.889). The manufacturer recommended cutoff of 10 U/ml detected 57% of cases with a 19% false-positive rate. AUC for grade III and stage T2 or greater disease was 0.806 (95% CI 0.780 to 831) and 0.864 (95% CI 0.839 to 0.890), respectively. For each NMP22 cutoff NMP22 had higher sensitivity for detecting grade III and stage T2 or greater bladder transitional cell carcinoma than for detecting any cancer. No optimal cutoffs for detecting any or aggressive bladder transitional cell carcinoma could be derived based on NMP22 values. CONCLUSIONS: There is a substantial degree of heterogeneity in the diagnostic performance of NMP22 applied to populations from different institutions. There is no clearly defined NMP22 cutoff but there is a continuum of risk for recurrence and progression.     

膀胱自扩大术治疗高反射性神经原性膀胱

目的探讨膀胱自扩大手术治疗高反射性神经原性膀胱的方法及疗效。方法6例患者,男5例,女1例,年龄5～36岁,平均28岁。尿动力学检查显示6例均为膀胱反射亢进,逼尿肌括约肌协同失调。病程5～10年,平均6年。对6例患者的手术方法,手术前后膀胱容量,肾功能以及临床症状进行回顾分析。结果手术时间100～180min,平均120min。安全膀胱容量术前(182±52)ml,术后3个月(315±65)ml,术后10个月(420±105)ml,手术前后比较差异有统计学意义(P<0.01)。术后导尿间歇平均4h(3～5h),术前5例尿失禁患者尿失禁消失4例,1例经口服抗胆碱药物后症状明显改善。术前4例肾功能异常者3例恢复正常,1例改善。结论膀胱自扩大术结合清洁间歇自家导尿治疗高反射性小容量膀胱是一种简便,可靠的方法。     

经电切镜外鞘输尿管镜下钬激光碎石治疗膀胱结石

目的探讨经电切镜外鞘输尿管镜下钬激光碎石治疗膀胱结石的疗效。方法回顾性分析36例膀胱结石患者,其中单纯膀胱结石11例,合并前列腺增生17例,膀胱颈纤维化2例,尿道外口息肉1例,膀胱感染4例,经尿道前列腺电切术后1例,采用经电切镜外鞘置入输尿管镜下钬激光碎石。结果 36例均一次性击碎清除结石,无膀胱穿孔、大出血、尿道狭窄等并发症。结论经电切镜外鞘输尿管镜下钬激光碎石治疗膀胱结石,具有创伤小、操作简单、手术时间短、并发症少等优点,是一种安全、有效的方法 。     

经尿道膀胱颈电切术治疗慢性前列腺炎合并膀胱颈梗阻

目的探讨经尿道膀胱颈电切术治疗慢性前列腺炎合并膀胱颈梗阻的临床效果。方法经尿道膀胱颈部电切术治疗慢性前列腺炎合并膀胱颈梗阻23例,并进行术前术后临床症状和尿流动力学检查及对比。结果所有患者术后排尿通畅,效果满意。随访1～3个月,最大尿流率由（10．78±1．35）mL／s上升至（21．30±0．63）mL／s,差异有统计学意义（P〈0．05）;前列腺液及精液检查正常。结论对于慢性前列腺炎合并膀胱颈梗阻患者经药物治疗无效后,可选用经尿道膀胱颈部电切术治疗膀胱颈梗阻。