Post-cystectomy Patients Research Articles

Ovarian mucinous cystadenoma recurred 2 years after laparoscopic surgery: A Case Report

Objective: Recurrence of ovarian mucinous cystadenomas is very rare. This report describes a case of ovarian mucous cystadenoma in a women that recurred 2 years after surgery.
 Case presentation: A 22-year-old patient, with a sizable ovarian tumor underwent laparoscopic-assisted cystectomy. On histopathology, the tumor was diagnosed to be an ovarian mucinous cystadenoma. The mucinous cystadenoma recurred 2 years after surgery and subsequently laparoscopic right adnexectomy was performed.
 Discussion: It has been reported that intraoperative cyst rupture and cystectomy instead of adnexectomy are risk factors for mucinous cystadenoma recurrence. Close follow-up is required for post-cystectomy patients because of the possibility of recurrence.
 Conclusion: The risk of recurrence and the preservation of fertility should be carefully considered when deciding on treatment in young patients with a mucinous cystadenoma. The follow-up is required for post-cystectomy patients because of the possibility of recurrence.

Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy

BackgroundSubmuscular reservoir placement has fulfilled a critical need for patients desiring multicomponent penile implants following pelvic surgery and radiation therapy. Passage of the reservoir through the inguinal canal into the submuscular space is often challenging and carries the risk of the reservoir being placed unknowingly outside of the targeted space. AimTo evaluate the safety and accuracy of a direct vision, transfascial (DVT) approach to submuscular reservoir placement. MethodsWe retrospectively reviewed outcomes for consecutive patients undergoing DVT submuscular reservoir placement abstracted from a large IRB-approved database at our institution. Postimplant cross-sectional imaging performed on many of these patients was used to ascertain the final location of the reservoir. OutcomesOutcome measures included the perioperative and intermediate-term safety and complications of the procedure. Postimplant imaging ascertained the accuracy in providing patients with a submuscular reservoir. ResultsThere were 107 DVT submuscular reservoirs placed in 100 consecutive patients. No intraoperative complications occurred, there were no postoperative rectus hematomas, and there were 4 (3.7%) postoperative infections. With a mean follow up of 17.5 +/- 20.5 months there was one reservoir herniation, one patient had autoinflation, and one patient required repositioning of a high riding pump. There were 4 mechanical malfunctions requiring revision at a median of 74 months (range: 69–108 months.) following implant placement. Of the 43 patients who underwent imaging: 34 (79%) reservoirs were accurately positioned, 5 (12%) were in the lateral abdominal wall, 1(2%) was in the retroperitoneum, and 3 (7%) were intraperitoneal. Intraperitoneal reservoirs occurred exclusively in postcystectomy patients. Clinical ImplicationsThe DVT approach is technically safe, although a slightly higher than expected infection risk was noted. It provides accurate reservoir placement for the majority of imaged patients. Postcystectomy patients have a risk of insidious intraperitoneal reservoir placement. Preoperative counseling should mention this and postimplant imaging may be considered for some of these patients. Imaging may also helpful prior to future revision surgery in order to identify and remove insidious intraperitoneal reservoirs. Strengths and LimitationsWe investigated 100 patients, almost half underwent cross sectional imaging. Weaknesses include the retrospective nature of this single-institutional study, which may not have similar outcomes at other centers. ConclusionDVT submuscular reservoir placement is safe following pelvic surgery and radiation therapy. Despite careful and deliberate surgical technique imaging found that approximately 20% of reservoirs are not in their expected location. Intraperitoneal reservoirs are of concern, particularly in postcystectomy patients.Kava BR, Levine A, Hauser N, et al. Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy. J Sex Med 2022;19:394–400.

Effect of designing Educational Program on Nurses` Performance for Immediate care of post cystectomy Patients at Intensive Care Unit

Background: Educational program today is very important for the nurses to increase knowledge and practice for immediate care of cystectomy.Aim to: evaluate the effect of educational program on nurses` knowledge and practice for immediate care of post cystectomy patients at intensive care unit. Research design : A quasi experimental design was conducted to achieve the aim of the study. Subjects: All available nurses' were 40 nurses caring for patients with cystectomy. Two tools were used for data collection, tool one, knowledge assessment structured interviewing questionnaire and tool two, an observational checklist. Results: Nurses` knowledge scores improved after implementation of the educational program from (15% to 97.5%), also the observed nurses` practice scores were improved from (20%) before the educational program to (100%) after the educational program .Conclusion: Nurses` knowledge and practice regarding the immediate care of patients with cystectomy becomes satisfactory level after the educational program. Recommendations: The study recommends focused on establishing plans by periodical educational programs for nurses to help them in improving their knowledge and practice.Background: Educational program today is very important for the nurses to increase knowledge and practice for immediate care of cystectomy.Aim to: evaluate the effect of educational program on nurses` knowledge and practice for immediate care of post cystectomy patients at intensive care unit. Research design : A quasi experimental design was conducted to achieve the aim of the study. Subjects: All available nurses' were 40 nurses caring for patients with cystectomy. Two tools were used for data collection, tool one, knowledge assessment structured interviewing questionnaire and tool two, an observational checklist. Results: Nurses` knowledge scores improved after implementation of the educational program from (15% to 97.5%), also the observed nurses` practice scores were improved from (20%) before the educational program to (100%) after the educational program .Conclusion: Nurses` knowledge and practice regarding the immediate care of patients with cystectomy becomes satisfactory level after the educational program. Recommendations: The study recommends focused on establishing plans by periodical educational programs for nurses to help them in improving their knowledge and practice.

HETEROTOPIC CONTINENT OR INCONTINENT URINARY DIVERSION:MAKING THE OPTIMAL CHOICE

Introduction. Quality of life and survival rate of post-cystectomy patients depend on the urinary diversion methods [1,2].Purpose of the study. A comparison of morbidity, survival rate, and quality of life in patients after heterotopic continent or incontinent urinary diversions.Materials and methods. During the period from 1998 to 2016, 36 heterotopic intestinal diversions were performed using urine containment method according to the Kock pouch scheme in our modification, and 61 incontinent heterotopic intestinal Bricker diversions. We evaluated the comorbid conditions (Charlson comorbidity index), postoperative complications (acc. to Clavien-Dindo), survival rate (acc. to E.L. Kaplan, P. Meier), and the quality of life of patients (SF-36) using complex statistical analysis.Results. Early and late complications not related and related to urinary diversion prevailed in the group of patients after Bricker surgery without statistical significance. With longer postoperative monitoring periods the share of complications related to urinary diversion increases, while the frequency of delayed complications and survival rate show no statistical difference in both groups. No reliable differences were revealed in the quality of life in all cases of cutaneous urinary diversion.Discussion. 80% of patients after the Kock pouch surgery (mod.) throughout the medium follow-up period of over 5 years remain continent and enjoy high quality of life. It is necessary to develop and implement in clinical practice new and more advanced statistical tools for evaluation of the patients’ quality of life depending upon the type of urinary diversion after cystectomy.Conclusion. Heterotopic continent diversion (Kock pouch (mod.)) in comparison with the incontinent method (Bricker) does not increase morbidity or decrease the survival rate, and provides for higher quality of life.

Expression of RCAS1 correlates with urothelial bladder cancer malignancy.

RCAS1 is a protein that participates in regulation of the tumor microenvironment and its immune responses, all in order to evade the immune system. The aim of this study was to analyze RCAS1 expression in urothelial bladder cancer cells (and in fibroblasts and macrophages of the tumor stroma) and its relationship with the histological pattern of malignancy. Eighty-three postcystectomy patients were enrolled. We analyzed the histological maturity (grade), progress (pT stage), tissue invasion type (TIT), nonclassic differentiation number (NDN), and the ability to metastasize (pN). The expression of RCAS1 protein was analyzed by immunohistochemistry. Indicators of histological malignancy were observed solely in association with the RCAS1 expression in cells in the border parts (BPs) of the tumor. Histological malignancy of the tumor, indicated by the pT and pN, and metastasis-free survival time, correlated significantly with RCAS1 expression in tumor neoplastic cells, whereas malignancy determined by grade, TIT, and NDN correlated with RCAS1 expression in fibroblasts and macrophages in the tumor microenvironment. These findings suggest that the increased RCAS1 expression depends on its cellular source and that RCAS1 expression itself is a component of various signaling pathways. The immune escape occurs within the tumor BPs, where the increase in the RCAS1 expression occurs within tumor cells and stromal cells in its microenvironment. We conclude that the histological pattern of tumor malignancy, indicated by grade, TIT, NDN, pT, and pN is a morphological indicator of immune escape.

Adjuvant radiation therapy for bladder cancer: A dosimetric comparison of techniques

Trials of adjuvant radiation after cystectomy are under development. There are no studies comparing radiation techniques to inform trial design. This study assesses the effect on bowel and rectal dose of 3 different modalities treating 2 proposed alternative clinical target volumes (CTVs). Contours of the bowel, rectum, CTV-pelvic sidewall (common/internal/external iliac and obturator nodes), and CTV-comprehensive (CTV-pelvic sidewall plus cystectomy bed and presacral regions) were drawn on simulation images of 7 post-cystectomy patients. We optimized 3-dimensional conformal radiation (3-D), intensity-modulated radiation (IMRT), and single-field uniform dose (SFUD) scanning proton plans for each CTV. Mixed models regression was used to compare plans for bowel and rectal volumes exposed to 35% (V35%), 65% (V65%), and 95% (V95%) of the prescribed dose. For any given treatment modality, treating the larger CTV-comprehensive volume compared with treating only the CTV-pelvic sidewall nodes significantly increased rectal dose (V35% rectum, V65% rectum, and V95% rectum; p < 0.001 for all comparisons), but it did not produce significant differences in bowel dose (V95% bowel, V65% bowel, or V35% bowel). The 3-D plans, compared with both the IMRT and the SFUD plans, had a significantly greater V65% bowel and V95% bowel for each proposed CTV (p < 0.001 for all comparisons). The effect of treatment modality on rectal dosimetry differed by CTV, but it generally favored the IMRT and the SFUD plans over the 3-D plans. Comparison of the IMRT plan vs the SFUD plan yielded mixed results with no consistent advantage for the SFUD plan over the IMRT plan. Targeting a CTV that spares the cystectomy bed and presacral region may marginally improve rectal toxicity but would not be expected to improve the bowel toxicity associated with any given modality of adjuvant radiation. Using the IMRT or the SFUD plans instead of the 3-D conformal plan may improve both bowel and rectal toxicity.

Confirming routine stentograms after cystectomy is unnecessary

In the current trend of earlier discharge from hospital and minimizing costs with selective intervention instead of routine "standard" orders, most institutions have abolished routine radiographic imaging of the collecting system before stent removal in postcystectomy patients, although clear supportive data from the recent literature is scarce. We retrospectively reviewed our experience with routine postoperative stentograms in 100 cystectomies to confirm that our decision to omit the stentogram procedure does not compromise patient safety and well-being. We retrospectively reviewed the records of 100 patients who underwent radical cystectomy for bladder cancer. All 100 patients (87 with ileal conduit and 13 with orthotopic neobladder reconstruction) had their ureteroenteric anastomoses stented with feeding tubes that were exteriorized. Retrograde stentogram was performed under fluoroscopic monitoring on postoperative days 7 to 9. The radiology reports were reviewed for any mention of extravasation. Extravasation was detected on the stentograms of 5 of 197 (2.5%) ureteroenteric anastomoses. Clinical signs suggestive of an anastomotic leak had preceded the imaging studies in 4 of the 5 cases. After expectant management, only 1 patient (1.0%) required intervention with percutaneous nephrostomy. The relatively low extravasation rate and the infrequent need for active intervention coupled with the fact that an anastomotic leak can usually be diagnosed on clinical grounds confirms that routine use of stentogram after ureteroenteric anastomoses is not justified. Our decision to perform postoperative stentograms selectively is appropriate.

Classifications of Urinary Diversions

Advantages and disadvantages of different types of urinary diversion and their choices are of utmost importance for the functional outcome and patient satisfaction. There is a variety of choices for incontinent urinary diversion (ureterocutaneostomy, ileal conduit, colonic conduit) and continent urinary diversion (continent urinary diversion, continent cutaneous urinary diversion, and urethral bladder substitution). The choices may be limited by patient criteria and/or medical criteria. Important patient criteria are preference, age and comorbidity, BMI, motivation, underlying disease, and indication for cystectomy. PERIOPERATIVE NURSING DESCRIPTION AT BRICKER INTERVENTION/ILEAL CONDUIT Teaching the patient with a newly formed stoma, but who also has low vision to manage his/her stoma independently, can be a difficult task. Practical tips on pre- and post-operative nursing care of the patient with a newly formed stoma are provided for the nurse. In some cases, unfortunately, complications may occur following stoma-forming surgery; these are discussed and nursing advice provided. One of the most important ways in which the nurse can support the patient is to teach the patient his/her stoma care, ensuring independence before discharge and showing empathy. There is still no conclusive evidence that any type of urinary diversion offers superior HRQOL (Health-related Quality of life) outcomes. In fact, though postcystectomy patients commonly experience urinary and sexual problems, HRQOL remains good irrespective of the method of urinary diversion. Future research should utilize the validated bladder cancer specific HRQOL instruments and perhaps explore the impact of pre-operative counseling on post-operative HRQOL.

SU-E-T-602: Comparison of Treatment Techniques for Pelvic Node Irradiation: Intensity-Modulated Photons versus Protons.

Radiotherapy planning for iliac pelvic nodes can be challenging due to the close proximity of sensitive healthy tissues such as the bowel and rectum. Modern treatment techniques like photon intensity-modulated radiotherapy (IMRT) and intensity-modulated proton therapy (IMPT) offer improved healthy tissue sparing for similar target coverage. In this study we compare IMRT and IMPT plans for six post-cystectomy patients. A dose of 50.4 Gy was prescribed to the planning target volume (PTV), which for IMRT is the clinical target volume (CTV) plus a 5 mm expansion for geometric uncertainties due to CTV and patient positioning errors, and for proton beams is the CTV plus the lateral 5 mm margin plus an additional longitudinal margin to allow for the proton range uncertainty. The optimization objectives are: 98% of the PTV receive at least 95% of the prescription, target maximum dose = 107% of prescription, rectum V[40Gy] < 30% and max = 105%, and bowel V[45Gy] < 125 cc and max = 107%. All IMRT and IMPT plans are made to achieve the target coverage objective. Using IMPT, the rectum would receive a mean dose of 9.0 Gy with an average (over the six patients) maximum dose of 38.1 Gy. Using IMRT, the rectum would receive a mean dose of 13.0 Gy and an average maximum dose of 37.6 Gy. The IMPT plans give a mean dose of 17.9 Gy and a maximum dose of 53.4 Gy for the bowel, whereas the IMRT plans give a mean dose of 23.8 Gy and a maximum dose of 53.2 Gy. Both the rectum and bowel show slightly lower mean doses for IMPT. Our results indicate that IMPT plans improve normal tissue sparing as compared to IMRT plans and provide adequate dose coverage of the target volume.

82 SYMPTOMATIC PULMONARY EMBOLISM IN MAJOR UROLOGIC CANCER SURGERY

INTRODUCTION AND OBJECTIVES: Venous thromboembolic events (VTE ), which progress from deep vein thrombosis (DVT) to pulmonary embolism (PE), are the most common preventable cause of hospital death. In urology, older obese patients with cancer frequently undergo major abdominal and pelvic surgery, which places them at the highest risk for VTE. Data describing VTE risk in urology is lacking because it is difficult to estimate risk retrospectively and early events (DVT) may be asymptomatic. However, PE is an ideal surrogate measure because it represents the furthest progression of VTE and is often symptomatic. The objective of this study was to evaluate the incidence and outcomes for symptomatic PE in cancer patients after prostatectomy, nephrectomy or cystectomy during a 5year period at a tertiary medical center. METHODS: Clinical and pathologic data was reviewed for all prostatectomy, nephrectomy, and cystectomy patients with a cancer diagnosis from January 1st 2006-December 31st 2010. All patients had mechanical prophylaxis per hospital protocol. Heparin prophylaxis is not routinely given for nephrectomy or prostatectomy. Routine heparin prophylaxis after cystectomy began in 2010. Symptomatic PE was assumed to be related to surgery if diagnosed within 90 days following surgery. Two patients with incidental PE were not included. RESULTS: A total of 1327 patients met eligibility criteria. The overall symptomatic PE incidence was 1.6% (21/1327), including 6/827(0.7%) for prostatectomy, 4/307(1.3%) for nephrectomy and 11/ 189(5.8%) for cystectomy. Death resulted from PE in 2/21(9.5%) of patients (2 postcystectomy). Patients with symptomatic PE had mean age of 64.7 years (44-81). SOB was the most common presenting symptom (58.8%), and diagnosis was most commonly obtained from CT chest angiography (81.0%). The average time from symptoms to diagnosis was 1.3 days (0-11). PE was diagnosed during the initial hospital stay in 11 of 21(52.4%) of patients. PE was diagnosed in 16/21(76.2% )on days 0-30, 3/31 (14.3%)on days 31-60 and 2/21(9.5%) on days 61-90 postoperatively. Hospital readmission for PE was required in 10 patients for 81 hospital days. In post-cystectomy PE patients, 6/11(54%) received heparin prophylaxis at any time (27% presurgery). In post-cystectomy patients without PE, 26/178(15%) were given prophylactic heparin at any time (6.1% presurgery). CONCLUSIONS: Symptomatic PE is rare after prostatectomy or nephrectomy, but common after cystectomy. VTE incidence after cystectomy is significantly elevated and extended heparin prophylaxis should be considered in these patients.

Penile haemodynamic changes in post-radical cystectomy patients

The aim of this study was to assess the penile vascular changes in post-radical cystectomy patients. A prospective assessment took place between January 2003 and January 2005 of 45 potent men who underwent radical cystectomy and diversion for invasive bladder cancer. Nerve sparing (NS) technique was applied in 21 cases, while others were not subjected to NS (non-nerve sparing group; NNS = 24 cases). All patients were comparable in preoperative clinical and pathological parameters. A control arm was the preoperative normal indices of the same patients. Preoperative penile duplex ultrasounds (PDU) for all cases were carried out, and then follow-up 2, 6 and 12 months thereafter. On first postoperative visit, none of NS cases showed any arterial insufficiency, while two cases of NNS (8.3%) had peak systolic velocity (PSV) < 30 cm/sec. Moreover, all cases of both groups showed early increase of end diastolic velocity (EDV) > 5 cm/sec. In NS cystectomy group, the PSV showed statistically insignificant change [p > 0.05 (mean: 53.6, cm/sec)]. Shortly after surgery, the EDV values increased, followed by gradually significant improvement (decrease in EDV values) in comparison with control state (mean: 5.9 cm/sec). On the other hand, the NNS cases showed statistically insignificant changes in PSV (mean: 49.3 cm/sec), with deterioration in EDV that did not improve with time, in contrast to NS cases (mean: 13.15 cm/sec). The main significant penile vascular changes were in EDV (venogenic mechanism) in post-cystectomy patients. There was a gradual progressive improvement in venogenic competence mechanism in NS cases with insignificant deterioration of arteriogenic mechanism in both groups (NS/NNS).

Transitional cell carcinoma of the bladder: patterns of recurrence after cystectomy as determined by CT.

CT scans have been recommended for examination of patients at risk for recurrent transitional cell carcinoma after cystectomy. For CT to be useful in this regard, the location and type of recurrences must be known, so that appropriate scans can be made. Therefore, we retrospectively studied CT scans in 27 postcystectomy patients with recurrent transitional cell carcinoma of the bladder to identify the type and location of the recurrent disease. Recurrence was documented by biopsy in 18 patients and by progression of disease shown on serial CT scans in nine patients. All 27 patients had pelvic CT, and 23 had concomitant abdominal CT. Tumor recurred at the cystectomy site in 10 (37%) of 27 patients, pelvic adenopathy was present in 18 (67%) of 27 patients, and retroperitoneal adenopathy was present in 13 (57%) of 23 patients. Tumor recurrence at the cystectomy site was associated with pelvic adenopathy in seven of 10 patients, and the cystectomy site was the solitary site of disease in the remaining three patients. Conversely, in 11 of 18 patients with pelvic adenopathy no recurrence was seen at the cystectomy site. Combined retroperitoneal and pelvic adenopathy was identified in 11 of 23 patients, but two patients had retroperitoneal lymphadenopathy as their only site of recurrence. Hepatic metastases were seen in seven (30%) of 23 patients; six of these seven patients had metastases elsewhere. In four of five patients in whom underestimation of recurrent disease occurred, the deep pelvis and/or deep perineal space were involved. Our results show that the pelvis is the most common site for recurrence. Cystectomy site or retroperitoneal nodal recurrences are usually accompanied by pelvic adenopathy, but the converse is not as common. Our findings of deep perineal and isolated abdominal recurrences indicate that proper protocol for CT follow-up of the postcystectomy patient should include abdominal scans and scans through the perineum.

A New Technique for Ileal Nipple Fixation: Preliminary Report

A new technique for ileal nipple fixation is described in 6 post-cystectomy patients (4 with an ileal bladder substitute and 2 with an ileal reservoir) for the prevention of reflux. Nipple formation is helped by deperitonealization and defatting of the nipple mesentery. A full circumferential incision is made, except for the mesenteric border, and through both nipple layers down to the mucosa of the inner layer. The seromuscular layers on each side of the incision are closed together with continuous 3-zero polyglycolic acid suture. The overlying outer mucosa of both edges then is closed. Endoscopic and radiographic study 6 to 12 months postoperatively showed a stable nipple without reflux. The anatomical and physiological rationale of the technique is discussed. (J. Urol., 144: 1192–1193, 1990)

Use of CT in evaluation of postcystectomy patients.

Twenty-one patients with prior cystectomy for transitional cell carcinoma of the bladder were evaluated by computed tomography. In eight patients who developed local pelvic recurrence, CT diagnosis was correct in seven. CT also detected distant metastasis in five patients and local pelvic abscesses in two additional patients. Our data show CT to be a more sensitive means than conventional radiologic methods including gray scale sonography in the detection of local recurrence and postoperative complications. Examples of normal postcystectomy changes in the pelvis as well as recurrent disease and surgical complications are illustrated. The pitfalls and the proper role of CT in these patients are also discussed.