Male Patients Underwent Radical Cystectomy Research Articles

Penile Prosthesis Utilization After Radical Cystoprostatectomy for Bladder Cancer

ABSTRACT Introduction Radical cystoprostatectomy for bladder cancer may adversely affects sexual function in up to 80% of men. Penile prosthesis implantation can restore erectile function in these men, but the extent to which penile prosthesis is utilized in this patient population is unknown. Objective We aimed to determine the rate of and time to penile prosthesis implantation for men who have previously undergone radical cystectomy for bladder cancer. Methods Using the Premier Healthcare Database, we investigated all male patients undergoing radical cystectomy between 2000 and 2020 and identified the subgroup of patients undergoing penile prosthesis implantation. We compared sociodemographic characteristics in men who did and did not undergo implantation. Categorical variables were analyzed with Chi-squared tests and continuous variables were analyzed with Kolmogorov-Smirnov tests. Results We identified 142 men who underwent cystoprostatectomy and subsequently underwent penile prosthesis implantation. Among these 142 patients, 16 (11.27%) had a penile prosthesis placed on the day of cystectomy and 106 (74.65%) had a subsequent penile prosthesis placed at a median of 503.5 days (IQR 214-821 days) following cystectomy. Patients who underwent penile implant were statistically younger (64 years vs 68 years, p<0.001) and more likely to have private insurance (39% vs 25%, p<0.001), as compared to patients who did not have a follow up for penile prosthesis. Conclusions Sexual function is an important aspect of cancer survivorship and treatment of post-cystectomy erectile dysfunction should be considered a critical component of care. When penile prosthetics were utilized, this occurred with significant delay (median 503.5 days). Efforts to increase education about available treatment options, inclusion of sexual medicine urologists in post-cystectomy care pathways, and decreasing time to penile implantation may all improve quality of life for bladder cancer survivors. Disclosure No

The Use of 5-Alpha Reductase Inhibitors and Alpha-1 Blockers Does Not Improve Clinical Outcome in Male Patients Undergoing Radical Cystectomy for Bladder Cancer in Quebec, Canada.

Existing literature suggests that bladder cancer (BC) outcome may be improved when patients use 5α-reductase inhibitors and/or α1-blockers, but such a conclusion may be subject to publication bias. We evaluated whether preoperative use of 5α-reductase inhibitors or α1-blockers was associated with improved clinical outcomes in a cohort of patients with BC undergoing radical cystectomy (RC). Using provincial health administrative databases, we retrospectively identified male BC patients undergoing RC in Quebec province between 2000 and 2015, and we collected data from 2 years before RC until December 2016 or death. Survival analyses were conducted using Kaplan-Meier curves, log-rank tests, propensity score matching, and uni- and multivariable Cox proportional hazards models. Covariates included age, Charlson's comorbidity index, region of residence, year of RC, distance to hospital, hospital type, annual RC volume of each hospital and surgeon, neoadjuvant chemotherapy use, and type of bladder diversion. Of the 2822 patients included, 284 patients used 5α-reductase inhibitors and 1001 patients used α1-blockers prior to surgery. Median follow-up time was 7.7 years. Patients who used 5α-reductase inhibitors or α1-blockers were generally older, had more comorbidities, and were treated more recently in academic centers. Overall, bladder cancer-specific and recurrence-free survival did not differ significantly between those using 5α-reductase inhibitors prior to surgery and controls who never used 5α-reductase inhibitors. Adjusted hazard ratios were 1.03 (95% confidence interval [CI], 0.88-1.21) for overall survival, 1.12 (95% CI, 0.92-1.36) for bladder cancer-specific survival, and 1.19 (95% CI, 0.99-1.42) for recurrence-free survival. The aforementioned outcomes were significantly worse in patients who used α1-blockers prior to surgery compared to controls, with respective adjusted hazard ratios of 1.15 (95% CI, 1.04-1.27), 1.19 (95% CI, 1.05-1.35), and 1.18 (95% CI, 1.05-1.33). Preoperative use of 5α-reductase inhibitors and α1-blockers did not improve clinical outcome in our cohort of male patients undergoing radical cystectomy for bladder cancer.

Characterization of perioperative androgen profiles in men with bladder cancer undergoing radical cystectomy

BackgroundPrior studies have demonstrated declines in androgen levels in men with cancer and patients undergoing anesthesia and surgery. In this study, we hypothesized that decreased serum androgen levels are prevalent in male patients undergoing radical cystectomy (RC) for bladder cancer and that it persists in the postoperative period. We characterized perioperative androgen hormonal profiles and examined for associated changes indicative of sarcopenia on computed tomography scans in men undergoing RC. MethodsWe implemented a prospective observational trial in men with newly diagnosed non-metastatic bladder cancer undergoing RC. Baseline pre-operative total testosterone (TT), free testosterone (FT), and luteinizing hormone (LH) were obtained on morning lab draws with 30 days of surgery. TT and FT were then repeated on postoperative days (POD) 2, 3, 30, and 90. The threshold for normal TT was defined as >300 ng/dl, consistent with the AUA Guidelines for Evaluation and Management of Testosterone Deficiency. We evaluated postoperative changes in weight and psoas muscle cross-sectional area using computed tomography scans to assess for sarcopenic changes. ResultsUnivariable statistical analysis was performed. 25 patients were enrolled. The mean patient age was 68.9 years. The mean pre-operative TT was 308 ng/dl, and 12/23 (52.5%) patients had low testosterone. Mean TT onPOD 2 and 3 were 166 ng/dl and 161 ng/dl, respectively (range 24–345). 19/20 (95%) of men who had morning lab draws had decreased TT. The mean TT at 30 days was 253 ng/dl with 37.5% of men having low TT. Mean TT at 90 days was 306 ng/dl. The mean FT levels were 43 ng/dl, 29.25 ng/dl, 28.2 ng/dl, 40.89 ng/dl, and 42.62 ng/dl at baseline, POD 2, POD 3, POD 30, and POD 90, respectively. Mean LH at baseline was 9.9 IU/L. Average weight loss at 30- and 90- days postop was -4.29 and -4.38 kilograms, respectively. Weight loss was persistent with only 3/23 (13%) returning to their presurgery weight by 90 days. Despite significant declines in weight and perioperative TT, no significant differences in psoas muscle cross-sectional area were observed (net change -92 mm2, P= 0.13) ConclusionsPerioperative disruption of androgen levels is prevalent in men undergoing RC. Our trial demonstrates a pre-op, immediate postop, 30- and 90-day postoperative prevalence of low TT of 52%, 95%, 63%, and 37.5%, respectively. Significant changes in baseline weight were noted, although no significant changes in psoas muscle cross-sectional area were observed, limiting conclusions regarding a link between changes in androgens and sarcopenia in this setting.

Long term complications after radical cystoprostatectomy with orthotopic diversion in male patients: Preliminary experience

IntroductionRadical cystectomy is the standard treatment for patients with invasive bladder cancer and for those with superficial bladder cancer who did not respond to conservative TUR and intravesical therapy. Many diversions are available after radical cystectomy; the most attractive for the patients is orthotopic diversion due to better quality of life associated with this diversion. ObjectiveTo evaluate the long-term outcomes beyond 1 year, both functional and oncological, in male patients treated with radical cystectomy and orthotopic diversion for invasive bladder cancer. Patients and methodsThis is a retrospective study done at Cairo university hospitals. A total of 44 male patients underwent radical cystectomy and orthotopic diversion (W-pouch) for invasive bladder cancer with minimum follow up 1 year. Assessment included; neobladder function, renal pattern and function, ureteroenteric anastomotic stricture or reflux, survival, recurrence, erectile function, urolithiasis, and urinary tract infection.The tools used to assess the complications during each visit included; history including voiding diary and IIEF questionnaire, examination including PR, laboratory investigations including urine analysis and kidney function tests, pH (acidosis) and bicarbonates and radiological investigation including ultrasound, chest X-ray, CT abdomen and pelvis. ResultsThe mean follow up was 88 months (range 12–138). Stones developed post-operatively in four patients (two of them were pouch stones and the other two were renal stones), incision hernia developed in two patients (4.5%), uretero enteric anastomotic stricture in two patients (4.5%), recurrent UTI was recorded in 10 cases (23%), uremia and dialysis in 9.2% of cases, metastasis was recorded as follows: local 2%, distant 11.5% and both 4.5% and the mortality rate was 19% (over all survival was 81%).Nocturnal incontinence 29.5% (13 patients), stress incontinence 9.5% (4 patients), urge incontinence 9.5% (4 patients), total incontinence 4.5% (23 patients); while the remaining 21 patients (47.5%) were continent day and night.Erectile dysfunction developed post-operatively in 35 cases (80.5%). ConclusionLong term follow-up for patients with radical cystectomy and orthotopic diversion is associated with high complication rate. Long term follow up for those patients is needed to verify the causes of complications and how to prevent them.

Value of routine frozen section analysis of urethral margin in male patients undergoing radical cystectomy in predicting prostatic involvement

To prospectively investigate diagnostic value of routine frozen section analysis (FSA) of urethral margin for male patients undergoing cystectomy for bladder cancer. One hundred consecutive male patients were subjected to radical cystectomy for bladder cancer with routine FSA obtained from distal prostatic urethral margin. Definitive pathological condition of the specimens was reviewed to diagnose urethral±prostatic malignant involvement. The diagnostic value of FSA was identified and compared with different clinical and pathological predictors. Patients with false-negative results were followed for 5 years. Six patients showed evidence of malignancy by FSA of the prostatic urethral margin (one patient was false positive), and all were managed by urethrectomy. Prostatic ± urethral involvement was diagnosed in 15 patients by definitive histopathology (15%). Sensitivity and specificity of urethral margin frozen section were 33.3 and 98.8%, respectively, with overall accuracy of 89% while positive and negative predictive values were 83.3 and 89.4%, respectively. There was no significant correlation identified between tumor site or morphology, clinical staging, clinically suspicious prostate, cystoscopic involvement of bladder neck, tumor grade, and associated carcinoma in situ or nodal involvement with prostatic malignant involvement. Positive intraoperative FSA was the only predictor significantly associated with malignant urothelial involvement of the prostate. None of the 10 patients with false-negative results developed late urethral recurrence at 5 years. Intraoperative urethral frozen section shows high predictive diagnostic value of malignant prostatic involvement. Nevertheless, its impact in preventing late urethral recurrence is doubtful.

Early and Late Urodynamic Assessment of Padua Ileal Bladder

To report the data from a single series of 46 patients who underwent cystectomy and Padua ileal bladder (PIB) substitution during a 48-month period. Data are lacking concerning the changes in urodynamic characteristics of the orthotopic ileal neobladder. From January 2002 to April 2003, 46 consecutive male patients underwent radical cystectomy and PIB substitution for muscle-invasive bladder cancer. Uroflowmetry, cystometry, and urethral pressure profilometry were analyzed at 12 and 48 months after surgery. All patients were asked to complete a questionnaire regarding quality of life (the European Organization for Cancer Research and Treatment of Cancer Quality of Life Questionnaire and the bladder cancer-specific module). Of the 46 patients, 8 were lost to follow-up because of cancer-related death. When comparing the 12- and 48-month urodynamic characteristics, no significant changes were observed in cystometric capacity or urethral closing pressure. However, the end-filling pressure, peak flow pressure, and postvoid residual urine volume were significantly lower at the 48-month evaluation (P = .0005, P = .0007, and P = .013, respectively). The number of involuntary contractions at 48 months had increased significantly (P = .0012), and the amplitude of the contractions was comparable (P = .084). The daytime continence rate was 96% and 90% at 12 and 48 months, respectively. The nighttime continence rate was 60% at the 48-month evaluation. The questionnaires about the quality of life highlighted the excellent results. An ileal tone is maintained despite detubularization and most likely prevents enlargement of the neobladder. PIB was revealed to maintain an adequate capacity and low pressure during a 48-month period. The urodynamics results and quality of life support this urinary diversion as a valid treatment option for muscle-invasive bladder cancer.

Diagnosis, Risk Factors, and Outcome of Urethral Recurrences Following Radical Cystectomy for Bladder Cancer in 729 Male Patients

ObjectivesWe evaluated incidence, diagnosis, risk factors, and outcome of urethral recurrences (URs) following radical cystectomy in men with bladder urothelial carcinoma (UC). MethodsBetween 1978 and 2003, a total of 729 male patients underwent radical cystectomy for UC. We determined UR presentation mode and diagnosis. UR was analysed by multivariate analyses according to clinical and pathological risk factors. We evaluated the relative influence of bladder versus urethral pathology on overall survival. ResultsA total of 34 URs (4.6%) were identified. Previous history of non–muscle-invasive bladder cancer (NMIBC) (p=0.005), NMIBC pathological subgroup (pTis, pTa, pT1) (p=0.038) and prostate tumor involvement (p=0.0001) in cystectomy specimens were independent predictors of UR. URs developed in 5 (2.2%) of 219 cases with orthotopic diversion and in 29 (5.6%) of 510 with cutaneous diversion (p=0.073). The difference could be explained by patient selection. Cutaneous diversion group had more patients at risk of UR: more cases with prostate tumor involvement (p=0.026) and with a history of NMIBC (p=0.009).Neither bladder nor urethral pathology showed any superiority as a predictor of overall survival. ConclusionsPrevious history of NMIBC, and also NMIBC and prostate tumor involvement in cystectomy specimen were predictors of UR. The lower incidence of UR in patients with orthotopic diversion could be a result of patient selection. Bladder tumor, UR, and even an upper urinary tract tumor could have been the cause of death in these patients.

URETHRAL TUMOR RECURRENCE FOLLOWING CYSTECTOMY AND URINARY DIVERSION: CLINICAL AND PATHOLOGICAL CHARACTERISTICS IN 768 MALE PATIENTS

We evaluated the incidence and risks of urethral recurrence following radical cystectomy and urinary diversion in men with transitional cell carcinoma of the bladder. Clinical and pathological results were evaluated in 768 consecutive male patients undergoing radical cystectomy with intent to cure for bladder cancer with a median followup 13 years, including 397 (51%) who underwent orthotopic urinary diversion with a median followup of 10 years and 371 (49%) who underwent cutaneous urinary diversion with a median followup of 19 years. Demographically and clinically these 2 groups were well matched with the only exception being longer median followup in the cutaneous group (p <0.001). Urethral recurrence was analyzed by univariate and multivariable analysis according to carcinoma in situ, tumor multifocality, pathological characteristics (tumor grade, stage and subgroup), the presence and extent of prostate tumor involvement (superficial vs stromal invasion) and the form of urinary diversion (cutaneous vs orthotopic). A total of 45 patients (6%) had urethral recurrence at a median of 2 years (range 0.2 to 13.6), including 16 (4%) with an orthotopic and 29 (8%) with a cutaneous form of urinary diversion. Carcinoma in situ and tumor multifocality were not significantly associated with an increased risk of urethral recurrence (p = 0.07 and 0.06, respectively). The presence of any (superficial and/or stromal invasion) prostatic tumor involvement was identified in 129 patients (17%). Prostate tumor involvement was associated with a significantly increased risk of urethral recurrence (p = 0.01). The estimated 5-year chance of urethral recurrence was 5% without any prostate involvement, increasing to 12% and 18% with superficial and invasive prostate involvement, respectively. Patients undergoing orthotopic diversion demonstrated a significantly lower risk of urethral recurrence compared with those undergoing cutaneous urinary diversion (p = 0.02). Patients without any prostate tumor involvement and orthotopic diversion (lowest risk group) demonstrated an estimated 4% year chance of urethral recurrence compared with a 24% chance in those with invasive prostate involvement undergoing cutaneous diversion (highest risk group). On multivariate analysis any prostate involvement (superficial and/or invasive) and urinary diversion form remained independent and significant predictors of urethral recurrence (p = 0.035 and 0.01, respectively). At long-term followup urethral tumor recurrence occurs in approximately 7% of men following cystectomy for bladder transitional cell carcinoma. Involvement of the prostate with tumor and the form of urinary diversion were significant and independent risk factors for urethral tumor recurrence. Patients undergoing orthotopic diversion have a lower incidence of urethral recurrence compared with those undergoing cutaneous diversion. Although prostate tumor involvement is a risk factor for urethral recurrence, it should not preclude orthotopic diversion, provided that intraoperative frozen section analysis of the urethral margin is without evidence of tumor.

New Serosal Lined Antireflux Ureteroileal Implantation Technique on a Gia Stapler Detubularised Ileal Neobladder: Technical Considerations and Results

Objectives: To evaluate the adaptability and the possible advantages of the antireflux mechanism of the serous lined extramural tunnel for ureter re-implantation on a gastrointestinal anastomosis (GIA) Stapler detubularised ileal neobladder Methods: From April 1998 to July 2002 43 male patients underwent radical cystectomy and the creation of a Camey II ileal neobladder using this antireflux technique. Follow-up in all cases included excretory urography or T.C. scan and a retrograde cystography at 6 months and a renal scintigraphy with DMSA at 1 year follow-up, besides serum creatinine, blood urea and serum electrolytes every three months and renal-neovesical ultrasound every six months. Results: Early and late complications were low. At follow-up 1 case of neovesico-ureteral reflux and 2 cases of ureteroileal anastomotic strictures were found. DMSA scintigraphy showed no further renal scars. Conclusions: This preliminary experience was favourable due to overall reduced operating time (about 1 hour 45 minutes to create the orthotopic neobladder and the ureteroileal anastomosis), simplicity of execution and a low complication rate (6.9%) at a median follow-up of 38 months (range 12–52 months).

Functional Evaluation of Different Ileal Neobladders and Ureteral Reimplantation Techniques

Objectives: To compare and assess the function of ileal neobladders with different reconfiguration and with several types of ureteral reimplantation. Methods: Forty-five male patients underwent radical cystectomy and detubularized ileal neobladder. In 20 patients an ileal neobladder was carried out according to Studer’s technique, in 12 a ‘W’- and in 13 a ‘U’-shaped neobladder. In the Studer’s patients 60 cm of ileum was used, in the ‘W’ 40 and in the ‘U’ 30 cm. For the uretero-ileal anastomosis Nesbit’s technique was utilized in the Studer’s, in the ‘W’ and ‘U’ neobladders Camey Le Duc’s technique was performed instead. Four patients underwent a serous-lined extramural tunnel reimplantation. Follow-up included a functional and morphological study of the urinary system and a urodynamic study. Results: All Nesbit’s uretero-ileum anastomoses resulted refluent when the reservoir was filled up, 15 of 50 ureteral reimplantations according to the Camey Le Duc technique showed reflux at full filling. At 3, 6 and 12 months follow-up, the double reconfiguration reservoirs (Studer’s and ‘W’) showed a larger capacity and a lower maximum pressure than neobladders with a single bending. At 12 months, continence and the voiding interval time was significantly higher in the double reconfiguration than in the ‘U’ neobladders. Conclusion: The double reconfiguration of the reservoir (‘W’) might be preferable to that with a single one. As for the type of ureteral anastomosis to select, the problem is still debatable even if in our case-control study we have had better results in terms of reflux and stenosis with the uretero-enteric anastomosis with Nesbit’s and associated afferent long tubular ileal limb than with Studer’s technique.

Impact of the prostatic apex on continence and urinary flow in patients with intestinal neobladders.

To determine the impact of preserving the prostatic apex on continence and urinary flow in patients with post-cystectomy intestinal bladder substitutes. A total of 38 male patients underwent radical cystectomy for bladder carcinoma and construction of a neobladder from ileum [9], sigmoid [9] or an ileocaecal segment [20]. The intestinal reservoir was anastomosed to the membranous urethra in 25 patients and to the apical prostatic capsule in 13. A subjective evaluation of urinary continence, uroflowmetry and urethral pressure profilometry were performed 1-3 years after surgery. The only variable which showed a significant difference between patients with and without preservation of the prostatic apex was the functional profile length (P < 0.05). Conversely, there was no statistically significant difference in the continence result, peak flow rate and maximum urethral pressure between these two groups. However, there was a significant difference (P < 0.05) in peak flow rate among the three versions of neobladder in patients with a preserved prostatic apex (9.4 mL/s in ileal vs 15.8 mL/s in sigmoid and ileocaecal segments). Preservation of the prostatic apex does not improve urinary continence in patients with intestinal neobladders and may present an element obstructing the evacuation of ileal bladders.

Urethral Remnant Tumors Following Simultaneous Partial Urethrectomy and Cystectomy for Bladder Carcinoma

Partial urethrectomy (at least to the bulbous portion) was performed simultaneously in 128 consecutive male patients undergoing radical cystectomy for bladder cancer. Transitional cell carcinoma developed subsequently in the distal urethral remnant in 5 patients (4.0%) followed for 2.6 to 5.7 years (mean 4.1 years) postoperatively. These 5 patients originally had nonpapillary, multifocal and histologically high grade (5) and low stage (4) bladder cancer, 4 with associated carcinoma in situ. Our results suggest that simultaneous total urethrectomy should be considered strongly for patients with high grade nonpapillary multifocal bladder cancer associated with carcinoma in situ. Furthermore, the pattern of distal urethral recurrence in our patients may provide information regarding the appropriate management of the male urethra in potential candidates for continent urinary diversion. (J. Urol., 142: 983–987, 1989)

The Ileal Neobladder

An ileal neobladder for total bladder replacement was created in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70cm. ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to the method of Le Duc and Carney. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressures lower than 30cm. water and no reflux. Of the 11 patients with the neobladder 8 are completely dry day and night, while 3 have grade I stress incontinence. All 11 patients had recognizable sensations of bladder distension closely simulating those of normal bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers an alternative free of a stoma to urinary diversion, resulting in a highly compliant, low pressure bladder.

Indications for Ureterectomy in Men Undergoing Single Stage Radical Cystectomy for Bladder Cancer

During a 10-year period 174 consecutive male patients underwent radical cystectomy with pelvic lymph node dissection for transitional cell cancer of the bladder. Urethrectomy, either performed en bloc with the cystectomy or secondarily, was required in 23 patients. Of these 23 patients 9 died of metastatic disease and 4 deaths were believed to be directly related to development of tumor in the urethra. A careful review of our data suggests that patient selection is possible so that urethrectomy in all patients undergoing cystectomy may be avoided, while maintaining the ability to treat those at risk for carcinoma in the retained urethra before invasion occurs. We recommend the following indications for urethrectomy: 1) en bloc cystourethrectomy for clinically overt involvement of the anterior urethra with carcinoma or tumor extending into the prostatic urethra, 2) immediate or delayed total urethrectomy either during the initial hospitalization or within 2 months of cystectomy for all patients with pathological evidence of invasion of the prostate (P4) or carcinoma in situ of the prostatic urethra, 3) indefinite close followup of all patients whose bladder specimens demonstrate carcinoma in situ (urethral cytology within 4 months of cystectomy and every year thereafter, and immediate total urethrectomy for any urethral cytology positive for malignant cells), and 4) immediate total urethrectomy for any patient experiencing bloody urethral discharge.