Oncological outcome after radical cystectomy and orthotopic bladder substitution in women

Aim

The pathological outcome after radical cystectomy and orthotopic bladder substitution in women and the possibility of genital sparing are studied in a prospective way.

Methods

Between January 1995 and June 2003, 180 women with bladder cancer (mean age 50.6 years) underwent orthotopic neobladder reconstruction. Histopathologic assessment of the cystectomy specimens was performed. Involvement of the internal genitalia by primary or secondary cancer was evaluated by preoperative CT or MRI. Histopathological evaluation of these organs was made in the cystectomy specimens.

Results

Mean follow-up was 57 months. At follow-up, isolated urethral recurrence developed in two patients. Local pelvic recurrence developed in 30 patients, distant metastasis in 14 and both in nine. Uterine infiltration, which was suspected by preoperative CT, was confirmed by definitive histopathology after radical cystectomy in only two cases; otherwise there were no primary or secondary malignancies of the internal genitalia. Isolated recurrence of bladder cancer in the vaginal remnant during follow-up after cystectomy was not noted in any woman.

Conclusions

The rate of urethral recurrence and oncological failure after orthotopic bladder substitution in women is low and acceptable and thus justifies the continued performance of this type of diversion. Proper selection of cases is mandatory. In women with absence of malignant involvement of the internal genitalia on preoperative imaging, the risk of secondary malignant involvement of these organs in cystectomy specimens is very low. Therefore, preservation of the uninvolved gynecologic organs during radical cystectomy in premenopausal women with unifocal, organ-confined tumor above the bladder base, is justified.     

The S-shaped orthotopic ileal neobladder substitute incorporating a new seromuscular antireflux technique (split ileal end) in a series of 50 patients

Objective

The purpose of this study was to assess the function of our new technique, complications, continence, voiding patterns in those patients with the clinical evaluation of the S-shaped orthotopic ileal neobladder substitute incorporating a new antireflux technique.

Patients and methods

Between April 2002 and November 2006, 50 patients (44 men and 6 women) underwent radical cystectomy and S-shaped ileal neobladder reconstruction with our new antireflux technique (split seromuscular). The mean age of male patients was 58 years (45–71 years). The mean age of female patients was 50 years (45–55 years). In all patients an S-shaped ileal pouch was constructed incorporating the new antireflux technique. This antireflux has not yet been described in the literature before. All procedures are performed by the same surgeons and the mean follow-up was 30 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), and as diversion-related and diversion-unrelated. Continence and voiding patterns were also evaluated.

Results

There is no reflux in all patients except one. Early complications occurred in 8 patients. The most common early diversion-related complication was urinary leakage in 3 patients. No patients sustained an early diversion-related complication attributed to the new antireflux technique. Late complications occurred in 6 patients. Overall, 39 patients voided to completion without needing catheterization. A total of 7 patients required some form of clean intermittent catheterization to empty the new bladder completely including 5 of 44 men (12.5%) and 2 of 6 women (33.3%).

Conclusions

The functional results with this pouch incorporating the new antireflux technique were efficient. Our S-shaped pouch has reduced the length of intestine (37 cm) that minimized the metabolic and malabsorption complications. Moreover it is simple.     

Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series

Aim

In this study, we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center.

Minimum incision endoscopic radical cystectomy in patients with malignant tumors of the urinary bladder: Clinical and oncological outcomes at a single institution

Aims

The objectives of this study were to investigate the clinical and oncological outcomes of patients with malignant tumors of the urinary bladder undergoing minimum incision endoscopic radical cystectomy (MIE-RC).

Methods

Between August 2005 and June 2011, 130 consecutive patients at Hirosaki University Hospital underwent MIE-RC and bilateral lymphadenectomy for malignant tumors of the urinary bladder. We retrospectively studied all 130 patients. MIE-RC was performed through a 7-cm suprapubic midline incision. A 30° laparoscope was conveniently positioned on the head side of the patients, for precise observation and monitoring.

Results

The median operative time for all procedures, including MIE-RC, bilateral pelvic lymphadenectomy and urinary diversion was 266 min. The median estimated blood loss was 1260 mL. None of the patients had positive surgical margins. The post-operative median follow-up period was 32.8 months. The 5-year overall and disease-free survival rates were 91.6% and 87.0%, respectively.

Conclusions

Our experience with MIE-RC appears to be favorable with acceptable operative and oncological outcomes.     

Limb-salvage reconstruction with MUTARS hemipelvic endoprosthesis: A prospective multicenter study

Background

Limb-sparing surgery with hemipelvic megaprosthetic replacement is often limited by the high rate of associated complications. The aim of this evaluation was to assess clinical and oncological findings with respect to type, treatment and outcome of post-operative complications.

Methods

First results of 40 patients treated with individual MUTARS^® hemipelvic endoprostheses were evaluated in a prospective multicenter study.

Results

The mean follow-up period of the 27 male and 13 female patients was 24 months (range 1–61). The diagnosis was, in 29 cases, a primary bone or soft tissue sarcoma, in 11 patients, a metastasis. Clinical evaluation showed a mean Enneking score of 50% (range 10–70%). The oncological outcome revealed 25 patients (62.5%) alive with no evidence of disease. Seventeen of them had a primary tumour, eight a metastatic malignancy. Seven patients (17.5%) had died of their disease and eight (20%) were still alive but had developed a metastases and/or had had a recurrence of the primary tumour. The one- and two-year overall survival rate of the patients was 89% (± 0.10) and 81% (± 0.19), respectively. Post-operative complications occurred in 75% of the patients, predominantly wound-related disorders. The rate of implant revision was 22.5% with three septic and six aseptic cases of implant loosening. The estimated three-year-survival rate of the implant was 61.4% [CI95%: 0.36;0.87].

Conclusions

Periacetabular endoprosthetic replacement showed an acceptable functional and oncological outcome but had a high complication rate owing, predominantly, to infection. The indication for hemipelvic prosthesis in patients with a metastatic disease must be considered seriously.     

Health related quality of life after radical cystectomy: Comparison of ileal conduit to continent orthotopic neobladder

Aims

To compare health related quality of life (HRQOL) between patients with two different types of urinary diversion, ileal conduit and orthotopic neobladder, and between them and an age-matched population of healthy subjects.

Materials and methods

Eighty eight patients treated with radical cystectomy for bladder cancer at our institutions between 2002 and 2007 were contacted for this survey. All of them had a follow-up of more than 12 months after surgery and were recurrence free. The SF-36 questionnaire was provided to each patient during a follow-up visit at outpatient clinics. Overall, 79 patients (90%) returned the questionnaire and were included in this analysis. They were divided into two groups: group 1 comprised 44 patients with an ileal conduit diversion, and group 2 included 35 patients with a neobladder. As a control, normative values of an age-matched healthy Italian population were considered.

Results

No significant difference was found in scale scores between the neobladder and ileal conduit groups. Scale scores for role-physical functioning, social functioning and role-emotional functioning in both the neobladder and ileal conduit groups were significantly below the Italian population norm. Patients with a neobladder 65 years old or older (n = 18) had significantly lower scores for role-physical functioning and role-emotional functioning than those younger than 65 years (n = 17; p < 0.05).

Conclusion

Few differences between ileal conduit and orthotopic bladder substitution have been detected. Thus, the assumption that continent reconstruction provides better HRQOL than ileal conduit diversion cannot be supported. Patient education and active participation in treatment decisions seem to be the key to postoperative satisfaction.     

Abdominosacral resection: Long-term outcome in 86 patients with locally advanced or locally recurrent rectal cancer

Aims

The purpose of this study is to evaluate the outcome of abdominosacral resections (ASR) in patients with locally advanced or recurrent rectal cancer.

Methods

From 1994 until 2012 patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) underwent a curative ASR and were enrolled in a database. The postoperative complication rates, predictive factors on oncological outcome and survival rates were registered.

Results

Seventy-two patients with LRRC (mean age 63; 44 male, 28 female) and 14 patients with LARC (mean age 65; 6 male, 8 female) underwent ASR. R0 resection was achieved in 37 patients with LRRC and 11 patients with LARC. Twenty-seven patients underwent an R1 resection (3 in the LARC group). Eight patients had an R2 resection, compared to no patients in the LARC group. In respectively 26 and 1 patients of the LRRC and LARC groups a grade 3 or 4 complication occurred and the 30-days mortality rate was respectively 3% and 7%. The 5-years overall survival was 28% and 24% respectively.

Conclusion

En bloc radical resection remains the primary goal in the treatment of dorsally located (recurrent) rectal cancer. After thorough patient selection, ASR is a safe procedure to perform, shows acceptable morbidity rates and leads to a good oncological outcome.     

Outcomes after limb sparing resection in primary malignant pelvic tumors

Aim

To evaluate morbidity, oncologic results and functional outcome in patients with malignant tumors of pelvis treated with limb sparing resection.

Methods

Between March 2002 and November 2010, 106 cases of non metastatic malignant pelvic tumors were treated with limb sparing resections of pelvis. Diagnosis included chondrosarcoma (65), Ewing's sarcoma (25), osteogenic sarcoma (10), synovial sarcoma (3) and malignant fibrous histiocytoma, high grade sarcoma, epitheloid hemangiothelioma (1 each). Three patients had intralesional surgery because of erroneous pre-operative diagnosis of benign tumor and were excluded from final analysis. Remaining 103 patients underwent limb sparing resections with intent to achieve tumor free margins. In 1 case, an intraoperative cardiac event lead to the surgery being abandoned. Reconstruction was done in 2 of 38 cases that did not include resection of acetabulum. For 64 resections involving acetabulum various reconstruction modalities were used.

Results

Surgical margins were involved in 20 patients. Forty five patients had complications. 91 patients were available for follow up. Follow up of survivors ranged from 24 to 122 months (mean 55 months).Twenty one patients (23%) had local recurrence. Sixty patients are currently alive, 46 being continuously disease free. Overall survival was 67% at 5 years. Patients in whom acetabulum was retained had better function (mean MSTS score 27) compared to patients in whom acetabulum was resected (mean MSTS score 22).

Conclusions

Though complex and challenging, limb sparing surgery in non metastatic malignant tumors is oncologically safe and has better functional outcomes than after an amputation surgery.     

Preoperative sexual function in women with rectal cancer

Background

Even though sexual dysfunction has been reported after rectal cancer treatment, information on preoperative sexual function is scarce, particularly in female patients.

Aims

To describe preoperative sexual function in women with rectal cancer, and to analyse potential sources of bias.

Methods

The Female Sexual Function Index (FSFI) was administered to women with newly diagnosed non-metastatic rectal cancer, irrespective of whether they were sexually active or not. FSFI total and domain scores were calculated for women with complete responses to the corresponding items. Data were compared for those who did and did not complete all the FSFI domains, and for women in the study cohort, and those who were eligible for inclusion but not included.

Results

Sexual inactivity was common. Mean FSFI total score was low (16.4 ± 10.6 SD) among the women who completed all six FSFI domains. The proportion of women who had a partner was higher in this group compared with those who did not complete all the domains (49 of 57 vs 7 of 25, p < 0.001). Eighty-two of the 157 women eligible for inclusion were included. Included women were younger (p = 0.002) and had less co-morbidity than those who were not included (p = 0.025).

Conclusions

The low FSFI total score indicates sexual dysfunction. However, the use of FSFI in both women who are and who are not sexually active complicates interpretation of the data and may result in an information bias hampering internal validity. External validity may be limited by selection bias.     

Total laparoscopic radical hysterectomy and pelvic lymphadenectomy in patients with Ib1 stage cervical cancer: Analysis of surgical and oncological outcome

Aim

To evaluate safety, feasibility and oncological outcome of total laparoscopic radical hysterectomy (TLRH) in patients with early invasive cervical cancer.

Methods

Data of patients with Ib1 cervical cancer who underwent TLRH were prospectively collected. Inclusion criteria were: good general condition, tumor size <3 cm, and no evidence of lymph node metastases in imaging study (MRI and/or CT and/or PET). Radical hysterectomy was performed with a PlasmaKinetic tissue management system. Adjuvant therapy was administered according to surgical risk factors.

Results

Between September 2001 and October 2007 107 patients underwent laparoscopic radical hysterectomy and pelvic lymphadenectomy. Conversion to laparotomy was necessary in 6 patients. Median number of resected pelvic lymph nodes was 26. Median blood loss was 200 ml and median duration of surgery was 305 min. Minor intraoperative complications were registered in two patients, while five patients needed a second surgery for postoperative complications. Thirteen patients had microscopic nodal metastasis. A total of 24 patients received adjuvant therapy. After a median follow-up of 30 months 11 patients had a recurrence; survival rate is 95%.

Conclusion

Total laparoscopic radical hysterectomy, in experienced hands, has to be considerate an adequate and feasible surgical technique. Considering historical data the oncological outcome can be considered comparable to patients treated with laparotomy, as the relapse rate in our population was 11% and the overall survival good.     

Open conservation partial laryngectomy for laryngeal cancer: A systematic review of English language literature

Background

Different modalities of treatment in early laryngeal cancer lead to equivalent oncological outcomes. Hence this systematic review was undertaken to synthesise the key oncological outcomes following primary open partial laryngectomy for laryngeal cancer.

Methods

A systematic review of the English literature with statistical pooling of outcomes, the main outcome measure being local control at 24 months.

Results

A total of 53 articles satisfied inclusion criteria and were included in the review. The pooled local control rate at 24 months from 5061 patients was 89.8% (95% CI 88.3–91.2), pooled overall survival was 79.7% (n = 3967; 95% CI 76.5–782.8) and pooled mean disease free survival was 84.8% (n = 2344; 95% CI 80.6–88.7). The pooled mean operative mortality, laryngectomy for function, tracheostomy decannulation and permanent gastrostomy rates were 0.7%, 1.7%, 96.3%, and 2.0%, respectively.

Conclusions

Open conservation laryngectomy is a good option in selected primary laryngeal cancers with excellent oncological outcomes.     

Prostate sparing cystectomy for bladder cancer: A two-center study

Purpose

To assess long-term functional and oncologic outcomes of prostate sparing cystectomy (PSC) as a sexuality-preserving alternative to radical cystectomy in a selected group of bladder cancer (BC) patients.

Skin sparing mastectomy and immediate breast reconstruction: A review

Aims

Skin Sparing Mastectomy (SSM) is widely practised now in major centres which manage large numbers of breast cancer but anxiety still exists over the safety of SSM both from oncological and aesthetic points of view. We aim to review literature to date in SSM and summarise and discuss the current evidence.

Methods

Studies were identified by an online search of the English language literature in the PubMed database till April 2012 followed by an extensive review of bibliographies from relevant articles.

Results

There is abundance of evidence with regards to the safety of SSM both oncologically and aesthetically especially in immediate breast reconstruction. The use of SSM technique broadens the repertoire of oncoplastic techniques and at the same time facilitates such techniques by preserving patient's native skin and anatomical landmarks.

Conclusions

SSM is a safe technique providing better cosmetic outcome without compromising oncological safety as per the current evidence. However, prospective data collection of its application in various newer types of reconstructions, and continuing long-term follow-up of current data series would be prudent to evaluate long-term outcomes.     

Lymphovascular invasion,ureteral reimplantation and prior history of urothelial carcinoma are associated with poor prognosis after partial cystectomy for muscle-invasive bladder cancer with negative pelvic lymph nodes

Purpose

To identify predictive factors underlying recurrence and survival after partial cystectomy for pelvic lymph node-negative muscle-invasive bladder cancer (MIBC) (urothelial carcinoma) and to report the results of partial cystectomy among select patients.

Methods

We retrospectively reviewed 101 cases that received partial cystectomy for MIBC (pT_2-3N₀M₀) between 2000 and 2010. The log-rank test and a Cox regression analyses were performed to identify factors that were predictive of recurrence and survival.

Results

With a median follow-up of 53.0 months (range 9–120), the 5-year overall survival (OS), cancer-specific survival (CSS) and recurrence-free survival (RFS) rates were 58%, 65% and 50%, respectively. A total of 33 patients died of bladder cancer and 52 patients survived with intact bladder.Of the 101 patients included, 55 had no recurrence, 12 had non-muscle-invasive recurrence in the bladder that was treated successfully, and 34 had recurrence with advanced disease.The multivariate analysis showed that prior history of urothelial carcinoma (PH.UC) was associated with both CSS and RFS and weakly associated with OS; lymphovascular invasion (LVI) and ureteral reimplantation (UR) were associated with OS, CSS and RFS.

Conclusions

Among patients with pelvic lymph node-negative MIBC, PH.UC and UR should be considered as contraindications for partial cystectomy, and LVI is predictive of poor outcomes after partial cystectomy. Highly selective partial cystectomy is a rational alternative to radical cystectomy for the treatment of MIBC with negative pelvic lymph nodes.     

Behaviour of ovarian tumors of low malignant potential treated with conservative surgery

Objective

Fertility-sparing surgery has been proposed for the treatment of borderline ovarian tumors. The aim of this study was to evaluate the outcome of patients submitted to cystectomy (CYS) compared with patients treated by unilateral salpingo-oophorectomy (USO) or bilateral salpingo-oophorectomy with/without total hysterectomy (radical surgery, RS).

Methods

We reviewed retrospectively the data of patients treated in 3 institutions for borderline ovarian tumors. One hundred and sixty-eight patients underwent laparoscopic or laparotomic surgical treatment from 1985 to 2006. Tumor recurrence rate, disease-free survival and site of recurrences were evaluated. Specific prognostic factors, such as stage, histology, micropapillary subtype, exophytic tumor growth, intraoperative spillage, endosalpingiosis, staging procedures, and route of surgery were analysed.

Results

Thirty-five patients underwent cystectomy, 50 unilateral salpingo-oopohorectomy, and 83 radical surgery. Twelve patients in the CYS group (34.3%), 10 in the USO group (20.0%), and 5 (6.0%) in RS group relapsed. Five-year progression-free survival (PFS) was 59.6%, 78.4%, and 93.5% in CYS, USO and RS groups, respectively. None of the relapsed patients died of disease.

Conclusions

Cystectomy is an effective surgical strategy for patients with borderline ovarian tumor. The higher risk of local relapses is not associated with a reduction in the overall survival. The procedure should be offered to young patients with bilateral tumors and to very young ones, considering the higher risk of local relapse.     

Comprehensive study of ovarian metastases in young women with peritoneal pseudomyxoma: Is a preservation of fertility possible?

Objective

To determine whether ovaries can be preserved in selected young women with peritoneal pseudomyxoma (PMP).

Background data

The traditional rule is to systematically perform a bilateral oophorectomy.

Patients and methods

A new policy was developed to preserve the ovaries when they are macroscopically normal in young women with PMP, strongly desiring a future pregnancy.

Results

Thirty-three women younger than 41 years were selected after undergoing complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for PMP. A normal ovary was preserved in 6 of them, but in 6 of the 14 women who strongly desired a future pregnancy. Subsequently, ovarian preservation was only performed in cases of grade-1 PMP. Ovarian invasion was correlated with the grade (p < 0.05) and with the extent of peritoneal disease (p < 0.01). After a median follow-up of 54 months, none of the 6 women with preserved ovaries has developed an ovarian or a peritoneal recurrence. One woman became pregnant and egg harvesting and cryopreservation were performed for 4 women with a partially normal ovary.

Conclusion

This new policy allowed ovarian preservation in 43% of the young women desiring a future pregnancy and has already resulted in one birth. It exclusively concerned low-grade PMP. Recurrence in the preserved ovary was 0% with our selection criteria.     

Outcome of intralesional curettage for low-grade chondrosarcoma of long bones

Background

Different treatment strategies for low-grade chondrosarcomas are reported in the literature with variable outcomes. The aim of this study was to assess the oncological and functional outcomes associated with intralesional curettage and cementation of the lesion as a treatment strategy.

Patients and methods

We performed a retrospective review of 39 consecutive patients with intramedullary low-grade chondrosarcoma of long bones treated by intralesional curettage and cementation at our institution between 1999 and 2005.

Results

There were 10 males and 29 females with a mean age of 55.5 years (32–82), and a mean follow-up of 5.1 years (3–8.7). Local recurrence occurred in two patients (5%) within the first two years following index surgery. Both were treated by re-curettage and cementation of the resultant defects. A second local recurrence developed a year later in one of these two patients, for which a further curettage followed by local liquid nitrogen treatment was performed. Overall, there were no cases of post-operative complications or metastases. The patients were assessed using the Musculoskeletal Tumour Society scoring system (MSTS) to determine limb function. The average score achieved was 94% (79–100%).

Conclusion

Intralesional curettage is an effective treatment strategy for low-grade intramedullary chondrosarcoma of long bones, with excellent oncological and functional results. Careful case selection with stringent clinical and radiographic follow-up is recommended.     

Prolonged portal triad clamping during liver surgery for colorectal liver metastases is associated with decreased time to hepatic tumour recurrence

Aims

The aim of this study was to evaluate the oncological outcome of portal triad clamping during hepatectomy in colorectal cancer patients.

Methods

160 patients with colorectal liver metastases underwent a partial hepatectomy with curative intent. Data were collected in a prospective database and were retrospectively analyzed for time to liver recurrence (TTLiR) and time to overall recurrence (TTR). The prognostic significance of portal triad clamping of any type and severe ischemia due to prolonged portal triad clamping was determined by Cox regression models.

Results

TTLiR was reduced after clamping of any type, although not statistically significant (p = 0.061). Severe ischemia due to prolonged portal triad clamping significantly decreased TTLiR (p = 0.022), but not TTR. Furthermore, severe ischemia independently predicted TTLiR in a multivariable analysis (p = 0.038).

Conclusions

Severe ischemia due to prolonged portal triad clamping during hepatic resection for colorectal liver metastases appears to be associated with decreased TTLiR. Further research remains necessary to determine the causative effect of prolonged vascular clamping on liver tumour recurrence.     

Conservative treatment of early stage ovarian cancer: Oncological and fertility outcomes

Background

Ovarian cancer may appear in young women during their reproductive age. As a result of late childbearing nowadays, fertility preservation has become a major issue in young women with gynecological cancer. The aim of this review is to update the current knowledge on conservative treatment and fertility preservation of women affected of early stage epithelial ovarian cancer.

Material and methods

A web-based search in Medline and CancerLit databases on conservative treatment for early stage ovarian cancer has been carried out. All relevant information has been collected and analyzed.

Results

Less than 40% of ovarian cancers are diagnosed at early stages. Conservative treatment may be considered in young patients with a relapse rate that ranges from 9% to 29%, and a 5-year survival ranging from 83% to 100%. Recurrences in the controlateral ovary has been reported to be less than 5%, with most of these patients being alive after savage treatments. Moreover, it has been reported good fertility outcomes after conservative treatment with a successful conception rate that ranges from 60% to 100%, with an abortion rate under 30% in all series reported.

Conclusions

Conservative treatment for early epithelial ovarian cancers could be a safe option for women younger than 40 years who wish to preserve their childbearing potential. We need a strict case selection such as FIGO stage I grade 1 and 2, although grade 3 cases could be considered.     

Role of robot-assisted laparoscopy in adjuvant surgery for locally advanced cervical cancer

Objective

The aim of this study was to compare the feasibility and efficacy of robot-assisted laparoscopy with traditional laparotomy and conventional laparoscopy in a series of patients with locally advanced cervical cancer managed in our two institutions.

Methods

Twenty-two patients who underwent robot-assisted laparoscopy were compared with 20 patients who underwent adjuvant surgery by laparotomy and 16 who underwent conventional laparoscopy, before the arrival of the Da Vinci surgical system.

Results

There was no significant difference between the three groups in terms of body mass index, FIGO stage, or tumor histology. The complication rate was similar in the three groups of patients, although there was a trend towards more lymphatic complications in the robot-assisted subgroup managed medically. There was no significant difference in the recurrence rate between the robot-assisted laparoscopy, conventional laparoscopy and laparotomy groups (27.3%, 29.4% and 30%, respectively).

Conclusion

Robot-assisted laparoscopy is feasible after concurrent chemoradiation and brachytherapy in cases of locally advanced cervical cancer. This new surgical approach reduces hospital stay, and seems to result in less severe complications than conventional laparotomy without modifying the oncological outcome.