Laparoscopic Partial Cystectomy for Inflammatory Myofibroblastic Tumor of the Urinary Bladder

Bladder inflammatory myofibroblastic tumor (IMT) is a rare intermediate malignancy. Muscle-invasive bladder IMT is associated with a high risk of recurrence and metastasis, and bladder-sparing treatments for this condition are still under exploration. This case aims to evaluate the therapeutic efficacy of 1470 nm diode laser transurethral en bloc resection (ERBT) followed by laparoscopic partial cystectomy in the treatment of muscle-invasive bladder IMT. A 23-year-old male patient presented with painless terminal gross hematuria and was treated at Shandong Provincial Hospital of Shandong First Medical University. Computed tomography urography (CTU) and magnetic resonance imaging (MRI) identified a large tumor on the anterior bladder wall with muscle layer invasion, measuring approximately 5.0 × 3.9 × 4.3 cm. The patient underwent 1470 nm laser ERBT, followed by laparoscopic partial cystectomy 35 days later. Pathological examination following 1470 nm laser resection confirmed the diagnosis of an IMT with malignant potential, showing anaplastic lymphoma kinase (ALK) positivity, a Ki-67 index of 20% in hotspot regions, and ALK gene rearrangement detected by fluorescence in situ hybridization (FISH). Pathology after the secondary laparoscopic partial cystectomy showed tumor invasion into the superficial muscle layer, with negative margins at the resection site. MRI and cystoscopy showed no recurrence during 1 year follow-up. This case presents a patient with a huge muscle-invasive bladder IMT who received bladder-sparing therapy through 1470 nm diode laser ERBT followed by laparoscopic partial cystectomy. During subsequent follow-ups, the patient showed good recovery with no signs of recurrence, providing a promising treatment concept for bladder-sparing therapy in muscle-invasive bladder IMT.

Urachal adenocarcinoma is rare, accounting for only 10% of adenocarcinomas of the bladder and the prognosis of urachal adenocarcinomas is poor since most cases are detected late. Since urachal adenocarcinoma is a rare disease, no effective standard treatment has yet been established. However, in recent studies, resection of carcinoma is considered the only treatment considered for non-metastatic cases. Although for large sized urachal adenocarcinoma, open surgery or laparoscopic surgery is usually considered, we have recently experienced huge urachal carcinoma by robotic surgery. We used cystoscopy and the robot to assess the cancer margins and safely perform the operation. A 71-year-old man with a medical history of hypertension and arrhythmia visited our urology department with urachal cancer detected by computed tomography (CT). CT showed a lobulated low-density mass, most likely urachal carcinoma, abutting the anterior dome of the bladder and anterior abdominal wall. We performed preoperative cystoscopy to assess the extent of the protrusion of the urachal cancer into the bladder wall and the area requiring resection during surgery. We confirmed the size and extent of the mass protruding into the anterior wall of the urinary bladder and Robot-assisted laparoscopic intracorporeal urachal mass resection and partial cystectomy using cystoscopy together was performed. After one month, the patient has no complications and no complaining symptoms complaints without any abnormal finding of follow up imaging test. Although more procedures must be performed to ensure the safety of robotic surgery as a treatment strategy for large urachal carcinomas, we confirm that robotic surgery can replace open or laparoscopic surgery for such tumors.

The purpose of this study was to investigate the effectiveness of the vascularization index (VI) obtained using color superb microvascular imaging (cSMI) technique in assessment of the anterior urinary bladder wall in pediatric patients with acute cystitis (AC). The anterior bladder wall of 157 patients (age range 13-84 months, mean 43.62 ± 17.79 months) whose clinical and laboratory findings were proven of AC and 150 healthy asymptomatic participants (age range 13-84 months, mean 43.88 ± 18.11 months) with normal laboratory values were examined using cSMI. VI measurements were performed by manually drawing the contours of the anterior bladder wall using the free region of interest with 2-dimensional cSMI VI (2DcSMIVI) mode. The quantitative 2DcSMIVI values of the symptomatic group and the asymptomatic group were compared. The correlation between the 2DcSMIVI values and the anterior bladder wall thickness (BWT) were analyzed. The mean 2DcSMIVI values of the BWT were significantly higher in symptomatic group when compared to the asymptomatic group (p<0.001). AC can be diagnosed with a 93% sensitivity, 92% specificity when 3.25% 2DcSMIVI designated as the cutoff value. There was a significant positive correlation between 2DcSMIVI values and BWT (p<0.001). Two-dimensional cSMI VI can be used effectively in children as an imaging method in the diagnosis of AC.

Adjuvant Chemo-radiation Therapy Provided Good Local Control and Survival for a Young Patient With Advanced Urachal Carcinoma: A Case Report and Literature Review.

Objective To explore the efficacy of constructing the neourethra using a bladder anterior wall for the treatment of female total urethral stricture or atresia. Methods We retrospectively reviewed 11 female patients with total urethral stricture or oblitalition, who were underwent a procedure of reconstructive neourethra using a bladder anterior wall, from January 2009 to November 2015. Of the 11 patients , urethral stricture was associated with vesicovaginal fistula and a severe hydrocolpos in the proximal vagina because of vaginal anterior strictures or atresia in four girls. The mean age was 16 years (ranging 5-48 years) in all patients. The etiology was posttraumatic urethral injuries after pelvic fracture in 9 patients, radical urethral resection because of urethral cancer in 1 patient and congenital bladder exstrophy with an absent urethra in 1 patient. All patients underwent a procedure of neourethral construction under general anesthesia. The bladder anterior wall, which was about 2.0 to 2.5 cm in width and 4.0~4.5cm in length, was separated from bladder neck to middle partion of the anterior bladder wall. The bladder flap was tubularized around a 12-14 French catheter using continuous 4-0 polyglycolic acid sutures for the mucosa and interrupted sutures of 3-0 polyglycolic acid for the muscle. The tubularized flap was then flipped caudally to the site of the original external urethral meatus to form a new urethra. 4 patients with severe stenosis or oblitalition of the distal vagina underwent a procedure of vaginoplasty at same time, including island vulvar flaps enlarging vaginoplasty in two girls and reconstructive vaginal orifice using the proximal enlargedvagina wall in other two girls. Results There were no serious complications postoperatively. The catheter was removed 3~4 weeks after the operation. 7 patients were completely continent with excellent voiding, 3 patients had stress incontinence. One patient experienced dysuria. And the urethroscopy in this case showed that the mucosal prolapse was present at the 12 to 3 o'clock position on the neck of the bladder, which caused urinary obstruction. Endoscopic resection of the prolapsed mucosa was performed. The patient could easily void without incontinence after the operation. The patients were followed up a median of 38 months, (ranging 6-72 months). 2 patients experienced dysuria 3 and 4 months after operation, separatively. Examination showed that the mucosal prolapse was present at the position on the neck of the bladder in one patient and urethral meatal stenosis in another patient. The two patients were separatively underwent a procedure of endoscopic resection of the prolapsed mucosa and meatal urethroplasty, using vulvar flap. All of them could easily void without incontinence after the operation. Of the 3 patients with stress urinary incontinence, one underwent a procedure of TVT-O one year later, and after which continence was achieved with good voiding; the other two cases were awaiting for reoperation. Four cases of postoperative vaginal fluid disappeared with unobstructed micturition. Conclusions Female neo-urethral reconstruction using the bladder anterior wall flap was a reliable technique for the management of complete urethral stricture or obliteration. Key words: Female; Bladder wall flap; Urethra; Reconstruction

Purpose: Bladder endometriosis (BE) is rare. Deep invasive endometriosis is difficult to control with medications alone; such cases need surgical treatment. Good results of laparoscopic partial cystectomy with a transurethral (TU) resectoscope by the see-through technique for patients with BE are reported. Materials and Methods: From January 2008 to February 2016, 12 cases of symptomatic BE were seen in our institution. The chief complaints of 9 cases were micturition pain during menstruation. Preoperative cystoscopy showed a bladder mass with blueberry spots. All surgeries were performed under general anesthesia. Laparoscopic surgery was performed with a fan of 4 ports in the lower abdomen. First, the uterus and bilateral ovaries were checked. Then, the TU resectoscope was inserted. When the affected bladder wall was identified, it was again observed with the laparoscopic light source off, which made it possible to observe the twilight leaking inside from the bladder. This twilight came from the light source of the TU resectoscope via the unaffected bladder wall. In contrast, the thickness of the affected wall prevented the light from inside the bladder from passing through it. We call this the “see-through technique.” The tumor was then safely dissected with both laparoscopic and TU resection procedures. Finally, the bladder was sutured by laparoscopic procedures using absorbable sterile surgical suture. The urethral catheter was removed after cystography 7 days after the operation. Results: The surgical margins of all cases were negative. There has been no recurrence of BE so far in any patients. There were no major adverse events perioperatively and the urinary symptoms improved in all cases. Conclusions: By laparoscopic partial cystectomy assisted with a TU resectoscope and see-through technique, the edge of BE could be easily and precisely identified. These procedures are effective and safe for BE surgical treatment.

Laparoscopic partial cystectomy is performed in selected patients with isolated diseases, such as bladder endometriosis, pheochromocytoma, leiomyoma, and malignant bladder tumors. Laparoscopic partial cystectomy is indicated for a solitary bladder tumor that is distant from the bladder neck, the ureteral orifices, and the trigone, to allow a resection margin of 1 to 2 cm. We report our experience with cystoscopy-assisted laparoscopic partial cystectomy. The bladder was mobilized adequately by laparoscopy. Intraoperative cystoscopy was performed Cystoscopic guidance was used for the initial cystotomy. Further excision of the bladder tumor with a safety margin of 1.5 to 2 cm was performed under laparoscopic vision. Three patients underwent cystoscopy-assisted laparoscopic partial cystectomy. Cystoscopy aided in planning a proper and adequate safety margin around the tumor as well as helped in marking the initial cystotomy. Cystoscopic assistance during laparoscopic partial cystectomy helps to properly place the initial cystotomy as well aids in planning the safety margin around the tumor. It is safe, easy, and does not add to increased operative time or morbidity.

Bladder cancer is the second most common cancer of the genitourinary tract, and its most common symptom is hematuria, either gross or microscopic. However, the differential diagnosis for hematuria is extensive1. Patients referred with hematuria in the absence of infection should have renal ultrasonography or intravenous urography, urine cytology and cystourethroscopy to distinguish between a renal or postrenal source of the bleeding1. We report the three-dimensional (3D) sonographic findings in two cases of bladder carcinoma. The first case was a 59-year-old postmenopausal woman who presented with a history of urinary frequency, nocturia and dysuria associated with gross hematuria. Transvaginal ultrasonography (TVS) revealed an ill-defined, 3.2 × 2.7-cm hypoechogenic nodule with an inner calcified ring located in the right anterior lateral aspect of the bladder, protruding into the bladder lumen. 3D scanning revealed invasion of the bladder wall (Figure 1a) and plaque-like extension of the tumor, which increased the thickness of the underlying bladder wall (Figure 1b). Doppler studies revealed increased vascularity in the periphery of the tumor mass (Figure 2). The lowest resistance index value of the tumor vessels was 0.29. Cystoscopy revealed an irregular mass protruding into the bladder cavity (Figure 3). A transurethral biopsy specimen contained malignant cells. Subsequent surgery showed a Stage IV tumor of the right anterior bladder wall. The pathological diagnosis was a poorly differentiated adenosquamous carcinoma. In Case 1, three-dimensional transvaginal ultrasound examination revealed bladder wall invasion (a) and plaque-like extension (b) of the bladder tumor. (a) Bladder wall invasion is recognized by the normal bladder wall (white arrows), which is relatively echogenic, being interrupted by hypoechogenic tumor tissue. (b) The bladder wall underlying the plaque-like extension of the tumor is 11.7 mm thick (black arrows). Doppler study in Case 1. The vascularity is increased at the periphery of the tumor mass. Cystoscopic examination in Case 1 showing an irregular mass. The second case was a 50-year-old woman who was referred to our clinic with a history of frequency, nocturia, urgency and urinary incontinence. Urinalysis revealed numerous red and white blood cells. TVS revealed a 3.2 × 3.1-cm echogenic mass located at the junction of the bladder dome and anterior bladder wall and protruding into the bladder cavity. 3D scanning revealed a tiny tumor invading the bladder wall (Figure 4). Increased vascularity was seen centrally on Doppler studies (Figure 5). Cystoscopy and transurethral biopsy revealed a malignant bladder tumor. On subsequent surgery, a Stage I adenocarcinoma was found. In Case 2, a three-dimensional transvaginal sonographic scan revealed a tiny protuberance (arrows) invading the bladder wall. In Case 2, a Doppler study revealed increased vascularity centrally within the tumor mass. Ultrasound has been reported to be useful for screening and detecting bladder tumors and is considered superior to intravenous urography for this purpose2. Dibb et al. reported varying morphological features of bladder tumors on transabdominal ultrasonography, including: a polypoid, sessile or plaque-like configuration; regular or irregular surface; calcified or uncalcified texture2. TVS with a high-resolution probe can clearly differentiate various intravesical masses such as bladder calculus3, foreign bodies, intravesical blood clots4 and hemorrhagic cystitis5. These conditions may cause hematuria and can appear simply as an intravesical mass on imaging studies, making them difficult to distinguish from bladder cancer3-5. Abnormal ultrasonographic changes of the bladder wall are one of the indications for cystoscopic examination. We suggest that TVS scanning of the lower urinary tract may serve as an initial work-up for women with either gross or microscopic hematuria. For those women who have abnormal sonographic findings, cystourethroscopy is suggested, even in the presence of pyuria. However, for those women with normal ultrasound findings, medical treatment may be attempted to avoid the discomfort of cystourethroscopy. 3D TVS, in addition to detecting a bladder tumor, may also demonstrate bladder wall invasion, and thus assist in surgical planning6. W.-C. Huang*, S.-H. Yang , J.-M. Yang , * Department of Obstetrics Gynecology, Cathay General Hospital, 92 Chung-Shan North Road, Section 2, Taipei 104, Taiwan, R.O.C., Taipei Medical University, 92 Chung-Shan North Road, Section 2, Taipei 104, Taiwan, R.O.C., Division of Urogynecology, Department of Obstetrics Gynecology, Mackay Memorial Hospital, 92 Chung-Shan North Road, Section 2, Taipei 104, Taiwan, R.O.C.

Objective The aim was to verify our hypothesis that decreasing bladder wall thickness will facilitate ballooning of the bladder wall at this thin part that will be involved in a process of cystocele other than the last traditional reported factors. Patients and methods This prospective study included 80 female patients between 20 and 45 years of age who were divided into two groups. Group I: 40 women were normal (control group); 20 of them were married and 20 were virgins and Group II: Comprising 40 patients have clinical manifestations of cystocele. All underwent complete history taking, physical examination, translabial, and transabdominal ultrasound examination with measurement of anterior and posterior detrusor wall thickness (DWT); also multichannel urodynamic testing was done to diagnose if there is associated obstruction or not. Results In group I, the mean DWT in 20 virgin women was 3.28±0.79 at the anterior bladder wall and 2.72±0.77 at the posterior bladder wall by transabdominal ultrasound, whereas by translabial ultrasound it measured 3.34±0.83 at the anterior bladder wall and 2.62±0.94 at the posterior bladder wall. In 20 married women of the control group without cystocele the mean DWT was 2.85±0.72 and 2.70±0.75 at the anterior and the posterior bladder wall, respectively, by transabdominal ultrasound. Also, the mean DWT was 2.90±0.69 and 2.75±0.74 at the anterior and the posterior bladder wall, respectively, by translabial ultrasound. In group II the anterior and the posterior wall measured 2.95±0.95 and 2.25±0.73, respectively, by transabdominal ultrasound, while it measured 4.35±1.40 and 2.40±0.77, respectively, by translabial ultrasound. With obvious obstruction in group II, P det.Q max. was 29.18±7.54 whereas it was 18.10±13.40 in group I. An increased level of Q max was noticed in group I with a mean value of 25.73±8.56 whereas it was of a less value in group II (15.83±6.21). Conclusion Our findings verify our hypothesis that decreasing bladder wall thickness will facilitate ballooning of the bladder wall at this thin part. Moreover, an increase in intravesical pressure during micturition will form a pseudo-diverticulum of the bladder wall, which in turn had lost the scaffolding of the fascia and/or vaginal wall.

Objective: This study presents our initial experience with extraperitoneal and transperitoneal laparoscopic partial cystectomy (LPC) in the treatment of benign non-urothelial bladder tumors. Methods: Eleven patients with benign non-urothelial bladder tumors underwent extraperitoneal or transperitoneal LPC. The five cases with tumors located on the anterior/anterolateral bladder wall received the extraperitoneal approach. The six cases with tumors located around the bladder dome or over the posterior bladder wall received the transperitoneal approach. Key perioperative parameters were recorded. Results: All patients underwent laparoscopic resection smoothly without requiring a conversion to a traditional open procedure, and no patient displayed perioperative complications. Pathology showed benign non-urothelial bladder tumors with normal margins in all eleven patients, including five leiomyoma cases, three pheochromocytoma cases, two paraganglioma cases and one inflammatory fibrous histiocytoma case. Follow-up cystoscopy and imaging studies in all eleven patients (mean follow-up period 32 months) revealed neither residual nor local recurrence. Conclusions: LPC is safe and feasible in select patients with benign non-urothelial bladder tumors and yields satisfactory oncological and functional results. Extraperitoneal LPC should be preferred for lesions located on the anterior/anterolateral bladder wall, while transperitoneal LPC should be preferred for lesions around the bladder dome or over the posterior bladder wall.

PurposeDuring laparoscopic partial cystectomy (LPC), lesion identification is essential to help to determine the appropriate bladder incisions required to maintain adequate resection margins. The inability to use tactile senses makes it difficult for surgeons to locate lesions during laparoscopic surgery. Endoscopic India ink marking techniques are often used in laparoscopic gastroenterological surgery. We present our experience with performing LPC with India ink during the surgical resection of various bladder lesions.Materials and MethodsLPC with cystoscopic fine needle tattooing was performed on 10 patients at our institute. Tattooing was performed at 1- to 2-cm intervals approximately 1 cm away from the outer margin of the lesion with enough depth (the deep muscle layer) under cystoscopic guidance. LPC was performed by the transperitoneal approach. The clinical courses and pathologic results were analyzed.ResultsAll LPC with cystoscopic tattooing cases were performed successfully. The mean patient age was 39.1 years. The mean operative time was 130.5 minutes, and the mean estimated blood loss was 93 ml. The mean hospital stay was 13.1 days, and the mean duration of indwelling Foley catheterization was 10.7 days. There were no significant intraoperative or postoperative complications except 1 case of delayed urinary leak and 1 case of delayed wound healing. The pathological diagnosis included 1 urachal cancer, 1 urachal remnant, 4 urachal cysts, 2 pheochromocytomas, and 2 inflammatory masses. All specimens showed adequate surgical margins.ConclusionsCystoscopic tattooing in LPC is a simple and effective technique to assist in locating pathological bladder lesions intraoperatively. This technique can help to determine appropriate resection margins during LPC without incurring additional complicated procedures.

BACKGROUND An intrauterine device (IUD) is a contraceptive device placed in the uterine cavity and is a common contraceptive method for Chinese women. However, an IUD may cause complications due to placement time, intrauterine pressure and other factors. Ectopic IUDs are among the most serious complications. Ectopic IUDs are common in the myometrium and periuterine organs, and there are few reports of ectopic IUDs in the urinary bladder, especially in the anterior wall. CASE SUMMARY A 52-year-old woman was hospitalized due to a urinary bladder foreign body found via abdominal ultrasound and computed tomography (CT) examination. The patient had a 2-year history of recurrent abdominal distension and lower abdominal pain, accompanied by frequent urination, urgency, dysuria and other discomfort. Ultrasound examination revealed foreign bodies in the bladder cavity, with calculus on the surface of the foreign bodies. CT revealed a circular foreign body on the anterior wall of the urinary bladder, suggesting the possibility of an ectopic IUD. After laparoscopic exploration, an annular IUD was found in the anterior wall of urinary bladder, and an oval calculus with a diameter of approximately 2 cm was attached to the surface of the bladder cavity. The IUD and calculus were successfully and completely removed. The patient recovered well after surgery. CONCLUSION Abdominal ultrasound and CT are effective methods for detecting ectopic IUDs. The IUD is located in the urinary bladder and requires early surgical treatment. The choice of surgical method is determined by comprehensively considering the depth of the IUD in the bladder muscle layer, the situation of complicated calculus, the situation of intravesical inflammation and medical technology and equipment.

Objective To investigate the safety and efficacy of laparoscopic partial cystectomy in the treatment of bladder diverticulum cancer. Methods A retrospective analysis was conducted on the clinical data of 12 patients with bladder diverticulum cancer treated at the First Affiliated Hospital of Quanzhou, Fujian Medical University, from January 2016 to May 2023. All patients underwent laparoscopic partial cystectomy. The study evaluated surgical details, pathological results, postoperative complications, adjuvant treatments, and follow-up outcomes. Results All 12 patients successfully underwent laparoscopic partial cystectomy with no significant intraoperative complications. Postoperative pathological results confirmed urothelial carcinoma in all cases. After surgery, all patients received bladder instillation therapy, with 5 undergoing systemic intravenous chemotherapy and 1 receiving intra-arterial chemotherapy to further prevent tumor recurrence. During the follow-up period, which ranged from 16 to 49 months, 11 patients had no tumor recurrence, while 1 patient experienced recurrence 15 months after surgery. Conclusion Laparoscopic partial cystectomy is a safe and effective treatment for bladder diverticulum cancer, with minimal postoperative complications and good tumor control outcomes.

MP61-02 DETAILED CADAVERIC ANALYSIS FOR PERIVESICAL LYMPH NODES WITH POTENTIAL IMPLICATIONS IN BLADDER CANCER

Urinary Tract Endometriosis: Clinical, Diagnostic, and Therapeutic Aspects