Urethral Recurrence Research Articles

Anterior Exenteration with Subsequent Ureteroileal Urethrostomy in Females, Anatomy, Risk of Urethral Recurrence, Surgical Technique, and Results

Anterior Exenteration with Subsequent Ureteroileal Urethrostomy in Females, Anatomy, Risk of Urethral Recurrence, Surgical Technique, and Results

Urethral Recurrence of Transitional Cell Carcinoma of the Bladder

Objective: The management of the male urethra after cystectomy for bladder cancer continues to be a dilemma. Patients who undergo a cystectomy require either urinary diversion or bladder substitution. Therefore, the use of the urethra to ensure voiding is important. On the other hand, the probable risk of urethral carcinoma recurrence is generally estimated at approximately 10%. The aim of this study was to assess the predictive value of preoperative urethral biopsies, and of frozen sections during cystoprostatectomy, in patients with invasive bladder cancer. Methods: From 1982 to 1986, 118 male patients underwent a cystoprostatectomy for transitional cell carcinoma of the bladder. All patients underwent endoscopic latero-montanal biopsies 2 weeks preoperatively and urethral frozen cut section during radical prostatocystectomy. Results: Carcinoma was observed in 12 patients on both examinations. All patients underwent en bloc urethrectomy during cystectomy. In the remaining 106 patients, the frozen cut margin was negative (including 9 with positive latero-montanal biopsies), and these patients had the urethra preserved. After a 10-year minimum follow-up, no recurrence was observed in these patients with negative frozen cut section. No significant risk factors for urethral recurrence were found. Latero-montanal biopsies did not reveal a positive specificity, and this procedure was later abandoned in our institution (in 1986). Conclusions: The urethral frozen section was the only guideline used for simultaneously performing the urethrectomy. All male patients with negative frozen cut sections should be considered candidates for bladder substitution. A prophylactic urethrectomy is only indicated in patients with carcinoma (minimum carcinoma in situ) in the frozen urethral margin section during cystectomy.

Our experience in orthotopic bladder substitution

Research in the field of orthotopic neobladders springs from the need to improve their morphofunctional aspects and to simplify surgical procedures. The authors report their experience on a new method of orthotopic neobladder in 20 patients subjected to radical cystectomy for advanced bladder neoplasia between March 1991 and February 1996. The surgical technique consisted of preparing a reservoir with a simil Carney 2 type procedure modified by the authors using 45 cm of ileus, 30 cm of which are detubularised and reshaped into a spherical/ovoidal form with Poligya 75 staplers. The remaining segment was left intact for the ureteroileal anastomosis performed with the Wallace 1 procedure. This technique offers the following advantages: staplers enable rapid preparation of the neobladder, thus reducing operating time; the technique is easy to learn for urologists familiar with ureteroileostomy according to Wallace; an isoperistaltic segment of ileus for ureteral anastomosis reduces ureteral mobilisation and possibilities of reflux; reconversion into ileal conduit is easy in the event of reservoir failure or neoplastic urethral recurrence. The criteria for patient selection are given and the diagnostic follow-up algorithm done with biochemical, echographic, radiological and pressure studies. Particular attention was paid to the quality of life in relation to diurnal/nocturnal continence and micturitional interval. The authors conclude that this technique is surgically simple and rapid giving satisfactory clinical and urodynamic results.

DOES PROSTATE TRANSITIONAL CELL CARCINOMA PRECLUDE ORTHOTOPIC BLADDER RECONSTRUCTION AFTER RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER?

Purpose We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death. Materials and Methods The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented. Results Of 81 patients, 70 were evaluated (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death. Conclusions The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.

Orthotopic Lower Urinary Tract Reconstruction in Women Using the Kock Ileal Neobladder: Updated Experience in 34 Patients

Purpose Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction at our institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients. Materials and Methods Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70). Results There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%) and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming. Conclusions The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy.

Tumors in Bladder Remnant After Augmentation Enterocystoplasty

We attempted to determine the tissue of origin of tumors after augmentation enterocystoplasty. We retrospectively reviewed the histological findings of 4 tumors that developed after clam ileocystoplasty. Tumors were primarily adenocarcinoma that originated on the bladder side of the anastomosis. The urothelium showed glandular metaplasia and dysplasia with intestinalization overlying normal detrusor muscle. These changes were also present in the renal pelvis in 1 patient with ureteral reflux. Bowel mucosa was normal except for inflammation. These tumors are derived from urothelium, which may be due to elevated urinary nitrosamines in this group of patients.

Right colonic reservoir with submucosally embedded tapered ileum--'Tiflis pouch'.

Seventeen patients with invasive bladder cancer aged between 44 and 67 years underwent radical cystectomy and construction of the continent urinary reservoir from 20 to 25 cm cecoascendum reconfigurated a.m. Heineke-Mikulicz. and submucosally embedded tapered ileum as a continence mechanism--'Tiflis pouch'. There were no perioperative mortalities and only minor complication but abdominal wound dehiscence occurred with a subsequent hernia in 1 obese patient. One patient died of urethral recurrence and malignancy progression 14 months after surgery. During the follow-up period of 9-37 months, all renal units remained unobstructed. Eleven of 15 preoperatively dilated units improved. No case of pouch stone formation, stomal stenosis or difficulties with catheterization was observed. All patients are continent but 4 need catheterization at 3-hour intervals. The functional capacity is in the range of 310-560 ml. The Tiflis pouch is a capacious reservoir in which the continence state is satisfactory, perioperative complication rate is low and quality of life is high.

Urethral Recurrence in Patients with Orthotopic Ileal Neobladders

Purpose We identified the risk of urethral recurrence following cystectomy for transitional cell bladder carcinoma, stratified by pathological characteristics of the bladder tumor and type of urinary diversion. Materials and Methods The pathological characteristics and clinical courses of 174 men with a Kock ileal neobladder and 262 with a cutaneous urinary diversion were analyzed for time to urethral recurrence. Results Urethral recurrence was identified in 34 patients at a median of 1.6 years after cystectomy, for an overall 7.9 percent 5-year risk of recurrence. Carcinoma in situ (p = 0.71) and multifocality (p = 0.17) did not independently confer an increased risk of recurrence. Prostatic urethral involvement, particularly stromal invasion, significantly increased the probability of recurrence (p less than 0.001). Patients with a Kock ileal neobladder had a significantly lower probability of recurrence compared to those with cutaneous diversion (p = 0.015), even when associated with prostatic urethral involvement. Conclusions Patients with a Kock ileal neobladder have a lower risk of urethral recurrence than those with cutaneous urinary diversion, even when associated with a high risk pathological condition predicting increased risk of urethral recurrence.

Management of Urethral Recurrence after Radical Cystectomy and Neobladder Creation by Urethroscopic Resection and Fulguration

The incidence of urethral recurrence after radical cystectomy has been reported to be 4 to 17%.l We describe a case in which urethral recurrence after cystectomy and neobladder creation was treated with urethroscopic resection and fulguration. CASE REPORT

Urethral Recurrence in Patients with Orthotopic Ileal Neobladders

Urethral Recurrence in Patients with Orthotopic Ileal Neobladders

Management of Urethral Recurrence after Radical Cystectomy and Neobladder Creation by Urethroscopic Resection and Fulguration

Management of Urethral Recurrence after Radical Cystectomy and Neobladder Creation by Urethroscopic Resection and Fulguration

Total Replacement of Urethral Mucosa with Oral Mucosa in Dogs

Purpose If the urethral mucosa is replaced by another mucosa, urethral recurrence might decrease in patients who undergo neobladder construction for bladder cancer. We determined whether such replacement is possible. Materials and Methods Six dogs underwent an operation consisting of a longitudinal urethral incision at its full length and immediate closure. In 6 other dogs, after the urethral mucosa was totally removed, a tubularized sublingual mucosa was closely set inside the urethral lumen. Postoperatively, the urinary stream and external meatus were observed every day. To measure urine leakage, a 10-minute pad test was performed once a month. All dogs were sacrificed 3 to 12 weeks after the operation for histological examination of the urethra. The excised urethras were examined with a 12F catheter for urethral patency. Results All dogs were continent postoperatively. The results of the 10-minute pad test showed no significant difference in the weight increase of the pad among the control, sham-operated and mucosa-replaced dogs. Urethral stricture developed in 1 mucosa-replaced dog. Histological examination revealed that all of the grafted oral mucosa survived in the urethra. Conclusion These results indicate that the urethral mucosa can be replaced by oral mucosa without damaging the continence mechanism in female dogs.

Total replacement of urethral mucosa with oral mucosa in dogs.

If the urethral mucosa is replaced by another mucosa, urethral recurrence might decrease in patients who undergo neobladder construction for bladder cancer. We determined whether such replacement is possible. Six dogs underwent an operation consisting of a longitudinal urethral incision at its full length and immediate closure. In 6 other dogs, after the urethral mucosa was totally removed, a tubularized sublingual mucosa was closely set inside the urethral lumen. Postoperatively, the urinary stream and external meatus were observed every day. To measure urine leakage, a 10-minute pad test was performed once a month. All dogs were sacrificed 3 to 12 weeks after the operation for histological examination of the urethra. The excised urethras were examined with a 12F catheter for urethral patency. All dogs were continent postoperatively. The results of the 10-minute pad test showed no significant difference in the weight increase of the pad among the control, sham-operated and mucosa-replaced dogs. Urethral stricture developed in 1 mucosa-replaced dog. Histological examination revealed that all of the grafted oral mucosa survived in the urethra. These results indicate that the urethral mucosa can be replaced by oral mucosa without damaging the continence mechanism in female dogs.

Mohs' micrographic surgery and distal urethrectomy with immediate urethral reconstruction for glanular carcinoma in situ with significant urethral extension

Objectives To report the use of conservative extirpative surgical techniques to manage glanular carcinoma in situ with significant urethral extension. Methods Over a 5-year period, 2 patients with carcinoma in situ of the glans with significant distal urethral involvement, who refused penectomy, were managed with combined treatment modalities using Mohs' micrographic surgery and distal urethrectomy with immediate urethral reconstruction. Results At follow-up of 5 years and of 12 months, there has been no evidence of meatal or proximal urethral recurrence. Conclusions Mohs' micrographic surgical excision and distal urethrectomy with immediate urethral reconstruction offers an acceptable alternative to partial penectomy in patients with perimeatal carcinoma in situ who fail conservative treatment or refuse penectomy. UROLOGY ® 47: 108–110, 1996.

MANAGEMENT OF THE PATIENT WITH BLADDER CANCER: Urethral Recurrence

Urethral recurrence develops in roughly 10% of patients following cystectomy for bladder cancer and appears to be another manifestation of the multicentric nature of TCC. By far the greatest risk factor for recurrence is tumor involvement of the prostate in the radical cystectomy specimen, with prostatic stromal invasion more ominous than either ductal or mucosal involvement. For patients in whom orthotopic diversion is contemplated, precystectomy screening of the prostate is recommended by means of deep transurethral biopsy. Surveillance of the urethra following cystectomy should be done by urethral wash cytology at 6-month to yearly intervals and must be continued for life. Management of documented urethral recurrence should be by total urethrectomy, including the meatus.

Urethral Recurrences following Radical Cystectomy for Invasive Transitional Cell Carcinoma of the Bladder

A total of 177 patients with invasive transitional cell carcinoma of the bladder underwent radical cystoprostatectomy, of whom 13 underwent simultaneous urethrectomy. The remaining 164 patients were followed up regularly with urethroscopy and urethral cytology. Fifteen patients developed urethral recurrences, 4 of which were associated with relapses at other sites (recurrence rate 9%), with a mean recurrence-free interval of 13.5 months. Nine of the 11 patients with isolated urethral recurrences underwent total urethrectomy and all except 1 are alive and disease-free 2 to 8 years later. One patient was salvaged by radiation therapy and refused further treatment. The 4 patients with other associated relapses died within 18 months. The urethral recurrence rate was correlated to different risk groups defined on the basis of tumour characteristics in the cystectomy specimen. This revealed a 70% urethral recurrence rate in the high risk group, 9.6% in the moderate risk group and 1.2% in the low risk group. However, no conclusion could be drawn regarding the influence of prostatic involvement on the urethral recurrence rate.

Modified Ileocolonic Bladder: 5Years of Experience

A total of 25 patients 17 to 78 years old (mean age 61 years) underwent bladder replacement with a modified ileocolonic bladder: 20 underwent construction of the neobladder following cystoprostatectomy for invasive bladder tumor, 4 after cystectomy for severe interstitial cystitis and 1 for undiversion. There were 21 men and 4 women. Followup ranged from 3 to 66 months. There were no perioperative deaths. The early complication (perioperative 3 months) and late complication rates were 18% and 16%, respectively. Complications included ureterocolonic anastomotic strictures in 4 ureters (3 were treated via endoscopic retrograde balloon dilation and 1 with endourological antegrade dilation), urethral strictures in 2 patients, treated by urethral dilation, pancreatitis 2 weeks postoperatively in 1 and mild hyperchloremia without concomitant acidosis in 2. One patient presented 3 years postoperatively with a left mid ureteral stone that was managed by ureteroscopic extraction. Three patients died of recurrent carcinoma (none with urethral recurrence). The daytime continence rate was 100% and the nighttime continence rate was 92%. The ureters in this modified ileocolonic bladder were placed in an anatomically correct position to resemble a trigone near the mouth of the neobladder with the left ureter uncrossed. This placement provided easy visualization and instrumentation of the upper urinary tract. No patient had vesicoureteral reflux.

Perineal Urethrectomy for Transitional Urethral Tumours in Bladder Cancer Patients

Transitional cell carcinoma is often multicentric in the urinary tract and urethral tumours are not infrequent in bladder cancer patients. The occurrence of urethral carcinoma is simultaneous or recurrent after radical cystectomy. The management of urethral neoplasms and results of 12 simultaneous and 10 post-cystectomy cases treated with perineal urethrectomy are reported. The Authors debate the role of primary and secondary surgical treatment and the perineal or prepubic technique. One case of urethral recurrence after orthotopic bladder substitution emphasizes that patients must be accurately evaluated to exclude urethral disease before cystoprostatectomy, and monitored for carcinoma of urethral remnant.

Superficial bladder cancer treated by total cystectomy: tumour characteristics and patient survival.

Of 113 patients with bladder cancer who underwent total cystectomy from January 1980 to December 1990, 30 (27%) had superficial tumours (pTa, pTis, and pT1). Nineteen of these 30 patients (63%) were primarily treated by total cystectomy and the remaining 11 (37%) had a past history of treatment for bladder cancer. Major reasons for choice of total cystectomy were multifocal tumours, frequent recurrence, and diffuse carcinoma in situ. Histologically stage pT1, grade 3 tumours were frequently accompanied by carcinoma in situ and often by lymphatic invasion. None of the 24 patients undergoing pelvic lymphadenectomy had lymph node metastasis. Of 25 male patients 15 (60%) underwent simultaneous prophylactic urethrectomy. Two of the remaining 10 males (20%) not undergoing this additional operation died of subsequent urethral recurrence. The 5-year actuarial survival rate was 80% for the 30 patients when all causes of death were considered. It was concluded that patients with superficial bladder cancer who undergo total cystectomy without prophylactic urethrectomy require close follow-up with urethral washings for cytology to detect early urethral recurrence, an important determinant for survival.

MANAGEMENT OF THE MALE URETHRA AFTER CYSTECTOMY FOR BLADDER CANCER

All patients with locally advanced transitional-cell carcinoma of the bladder should undergo thorough precystectomy assessment of the prostatic urothelium for evidence of malignancy. Those with carcinoma or carcinoma in situ should not be considered candidates for orthotopic continent diversion, and urethrectomy should be recommended. Regardless of risk status, all patients with a urethral remnant after cystectomy should have semiannual urethral washings performed for cytologic analysis. Any positive result should be followed by urethrectomy. By identifying and modifying the treatment plan for those patients who are clearly at increased risk of developing a urethral recurrence, it should be possible to reduce the morbidity and anxiety that urethral recurrence can entail. More importantly, the risk of noncompliance in follow-up with disastrous results is reduced, and both the patient and the physician can be assured that the best management for urothelial malignancy has been offered, not simply isolated treatment of the primary bladder carcinoma.