Initial TUR Research Articles

Radical Cystectomy and Orthotopic Neobladder with Prostate and Seminal Sparing in Young Patients with Transitional Cell Carcinoma (TCC) of the Bladder

Introduction and Objectives: Radical cystectomy is considered the standard treatment for patients with invasive TCC of the bladder and for high grade, multifocal tumors refractory to conservative therapy. Preservation of sexual function, continence and fertility are important for surgery acceptance in young patients with this disease. The objectives of this study were to evaluate the results of our seminal and prostate sparing technique on cancer control, continence, potency and fertility in a selected group of young patients with TCC of the bladder. Materials and Methods: From March 2000 to November 2004, 312 radical cystectomies were performed on patients with bladder tumors. Fourteen patients (4.5%) met the eligibility criteria and were included in this study. Two patients were excluded from the group undergoing the seminal and prostate sparing procedure after the initial TUR because of the presence of TCC in the prostatic urethra. Twelve patients therefore had the operation, eleven of whom had superficial, recurrent, high grade tumors refractory to adjuvant immunotherapy (7) or chemotherapy (4) and one had a single invasive tumor. Staging was: T1G2 = 2, T1G3 = 6, Cis = 3, T2G3 = 1. The mean age was 52.5 years. Before surgery and during follow-up the EORTC Q-30 and the IIEF questionnaires were administered. The mean PSA was 1.8 ng/ml. Step 1 of the operation included TUR of the prostate maintaining the capsule intact. A frozen section of the peripheral prostatic chips was analyzed. The open surgical step consisted of a bilateral pelvic lymph node dissection and extraperitoneal radical cystectomy preserving the vas deferens, seminal vesicles and neuro-vascular bundles. Urinary diversion was performed with a modified Studer procedure in a “whale tail” shaped fashion (2 loops). The reservoir was anastomosed to the prostatic capsule with an interrupted suture on a 22 Fr catheter. Results: Mortality was 0. The mean operating time was 5.45 hours. The mean hospital stay was 17.3 days. The early post-operative complications were low: one patient had a bowel obstruction requiring reoperation. After a mean follow-up of 16 months no delayed complications were observed. No local or distant recurrences were observed and all the patients were alive. Day time continence was complete and immediate in all the patients (100%). One patient had night-time incontinence which lasted for 2 months. Erectile function was present in all the patients: the mean IIEF score was 23. The QoL measured by the EORTC Q-30 questionnaire returned to normal after 3–9 months. All patients had retrograde ejaculation; the sperm analysis from urine of 3 patients showed a mean of 8 million spermatozoa/ml. Conclusion: Radical cystectomy with seminal and prostatic capsule sparing and orthotopic neobladder is a good option for selected young patients with superficial and single localized invasive TCC of the bladder. Functional results are excellent. A longer follow-up is needed in order to confirm the present data.

Changes in mucosal immune cells of bladder tumor patient after BCG intravesical immunotherapy

The Bacillus Calmette-Guerin (BCG) is considered to be at least as effective, and perhaps superior to chemotherapy in the prophylaxis of recurrent superficial tumors. However, the mechanism of the antitumor effect of BCG is still not exactly known. We have conducted investigations to examine changes in bladder mucosal immune cells in patients with superficial bladder carcinoma treated with a first cycle of BCG. The study group included 15 BCG and 5 doxorubicin instillation patients, most in the intermediate or high risk group for recurrent tumor. Grossly normal bladder mucosal cold cup biopsies were performed at initial TUR and one week after six consecutive weekly instillations of BCG or doxorubicin. All specimens underwent immunohistochemical staining, both pre-treatment and post-treatment, including CD20, CD45RO, CD8, CD4 and CD57. Immunoreactive cell counts were evaluated from three different microscopic fields (x400) under the grid. The mean duration of follow-up was 52.8 months. The post-treatment bladder mucosal B-cells (CD20) and T-cells (CD45RO, CD4, CD8) were significantly increased compared to pre-treatment in patients treated with BCG instillation, but NK-cells (CD57) were not changed. However, there was no change in B-cells or T-cells in patient treated with doxorubicin. The CD20 cells in pre-treatment specimens did not correlate with any other cells. However, it was a statistically significant correlation with CD45RO in post-treatment specimens. The CD4 correlated with CD45RO and CD8 in pre-treatment, but it was correlated with CD45RO and CD57 in post-treatment specimens. There was no tumor recurrence in cases with significantly increased B-cells after BCG instillation. The results of these studies suggest that intravesical BCG immunotherapy for superficial bladder tumor induces a significant increase in T-cells as well as B-cells and that B-cells have a preventive effect on tumor recurrence. Further studies with a larger number of patients are needed to confirm the value of the B-cell increment after BCG instillation as a clinically independent prognostic factor.

The efficacy of re-TUR after 3 weeks of initial TUR treatment for locally advanced bladder cancer

Radical cystectomy was usually performed for the patient with advanced bladder cancer. The choice of surgical procedure whether bladder preserved therapy or radical cystectomy has sometime plagued us in bladder cancer treatment. Because we don't have clear guideline for the treatment of locally advanced bladder cancer (T2-T3a N0M0). We devised a radical treatment for the patients with locally advanced bladder cancer without radical cystectomy. We performed re-TUR treatment after 3 weeks of initial TUR for 13 patients with grade 2 and locally advanced bladder cancer diagnosed with pelvic CT scan, transurethral ultrasonography or bimanual examination under the anesthesia. We could successfully preserve all cases of bladder with the use of this devised TUR (periods 9-45 months median 22 months). This method has significantly reduced the cystectomy rate in such locally advanced cases compared with the cystectomy rate prior to 1993 (p < 0.001). This method has significance on treatment for locally advanced papillary bladder cancer as bladder preserving therapy with careful observation.