Urologic Oncology-seminars and Original Investigations, Nov 1, 2013
To evaluate the outcomes of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) fo... more To evaluate the outcomes of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for clinically organ confined prostate cancer (CaP) with regional lymph node metastases (pN1) treated in the era of prostate-specific antigen (PSA) screening. A single institution cohort of 2,487 men with cT1-T2 CaP treated with open radical prostatectomy and pelvic lymph node dissection between 1988 and 2008 were analyzed. Kaplan-Meier and Cox proportional regression models were used to analyze overall survival (OS), clinical recurrence-free survival (cRFS), and biochemical recurrence-free survival (bRFS). Overall, 150 out of 2,487 patients (6%) had pN1 disease, with a median follow-up of 10.4 years. The predicted 10-year OS, cRFS, and bRFS rates for patients with pN0 and pN1 were 86% and 74% (Log rank P < 0.001), 97% and 84% (Log rank P < 0.001), and 88% and 57% (Log rank P < 0.001), respectively. In the subset of pN1 patients treated with surgery only (n = 49), the predicted 10-year OS, cRFS, and bRFS rates were 81%, 80%, and 59%, respectively. Exploratory univariate regression analysis showed that age (P = 0.003), total number of lymph nodes identified (P = 0.040), and total number of positive lymph nodes identified (P = 0.004) were associated with OS. Total number of positive lymph nodes (LNs) identified was also significantly associated with cRFS (P = 0.05). The incidence of pN1 in patients with cT1-T2 CaP treated with surgery in the era of PSA screening was low. RP and PLND demonstrated therapeutic efficacy in a subset of pN1 patients treated with surgery alone.
INTRODUCTION AND OBJECTIVES: To compare clinical and pathologic outcomes of radical cystectomy fo... more INTRODUCTION AND OBJECTIVES: To compare clinical and pathologic outcomes of radical cystectomy for muscle invasive bladder cancer in relation to prior history of non-invasive urothelial carcinoma. METHODS: The Canadian Bladder Cancer Network was used to retrospectively analyze data from 1150 patients managed by radical cystectomy for urothelial carcinoma of the bladder. Patients with clinical stage T2 or more were included and divided into two groups: (Group 1) patients with prior history of non-invasive urothelial carcinoma (NÏ365), and (Group 2) patients with clinical muscle invasive cancer de novo (NÏ785). Variables analyzed included patient age, gender, pathologic stage, adjuvant chemotherapy, recurrence and mortality. RESULTS: Both groups were nearly equal in mean age and gender distribution, with mean ages of 67.2 and 66.7 years, and 79.7% and 79.5%, respectively (P 0.4 and 0.9, respectively). The presence of preoperative hydronephrosis was 20.8% and 32.6% (P 0.0007) for groups 1 and 2, respectively. The rate of higher pathological stage (T3 or T4) was 36.3% and 58% (P Ͻ0.0001), positive lymph nodes was 20.1% and 28.8% (P 0.002) and lymphovascular invasion was 31.7% and 46.2% (P 0.0001) for groups 1 and 2, respectively. The rate of adjuvant chemotherapy was 15.5% and 23.3% (P 0.002) for groups 1 and 2, respectively. None of the sampled patients received neoadjuvant chemotherapy. The overall survival (OS) and disease-specific survival (DSS) rates at 5 years was 62% and 70% for group 1 and 51% and 60% for group 2, respectively, while at 10 years, OS and DSS was 46% and 66% for group 1 and 35% and 49% for group 2, respectively (P 0.0001 and 0.0002 respectively). Using multivariate analysis examining factors affecting recurrence and survival, we found that previous non-invasive bladder tumour history was associated with a significantly reduced risk of mortality and recurrence (Hazard ratio of 0.7 for all risks, P 0.0002). CONCLUSIONS: Our retrospective study suggests that patients with non-invasive urothelial carcinoma of the bladder that progress to muscle-invasion and require radical cystectomy appear to have better pathologic and clinical outcome than patients presenting with clinical muscle invasive disease de novo.
To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir ... more To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir with its continent antirefluxing nipple valves, laboratory investigations in dogs were done simultaneously with clinical trials in humans in 1983. Fifteen dogs underwent creation of hemi-Kock ileal reservoirs (without the efferent valve and limb) that were anastomosed to their bladders as enterocystoplasties. The afferent antirefluxing nipple valves were intussuscepted after 7 cm of underlying mesentery had been removed. The nipples were further stabilized with metal and absorbable (Polysorb) staples and Marlex collars. The right ureters were anastomosed to the afferent limb of the reservoirs with the contralateral systems left intact as controls. Ten dogs were able to be followed at the vivaria for twelve to thirty-six months and then studied. All nipple valves remained intact, viable, and nonrefluxing without revision. All kidneys remained histologically normal except those in dogs with dilated ureters secondary to ureteroileal stenosis with concurrent calculi formation. Calculi formed on exposed metal staples and Marlex. The absorbable staples were found to promote appropriate healing and were never the nidus for stone formation. It appears that the intussuscepted nipple valve (with its mesentery removed) is reproducible and functionally reliable in preventing reflux. It also appears these valves can histologically preserve diverted kidneys if the upper urinary tract drainage is normal and calculi are minimized. The proper placement of staples and the elimination of Marlex-anchoring collars are indicated to minimize calculi.
We describe our surgical technique of tube gastrostomy and report our experience with 709 patient... more We describe our surgical technique of tube gastrostomy and report our experience with 709 patients who underwent cystectomy and urinary diversion with gastrostomy tube placement from January 1988 to December 1997. This modified Stamm technique provides an effective means of gastric decompression without the discomfort associated with nasogastric decompression, is associated with a low complication rate (0.05%), and may be considered as the procedure of choice when gastric drainage is required after radical cystectomy and lower urinary tract reconstruction.
From August 1982 through March 1988, 531 patients have undergone continent urinary diversion usin... more From August 1982 through March 1988, 531 patients have undergone continent urinary diversion using an ileal reservoir constructed according to the method of Kock. For the last 18 months we have used the principle of Kock reservoir construction for primary lower urinary tract reconstruction after cystectomy in 39 highly selected male patients by means of a ureteroileal urethrostomy. Early complications occurred in 86 of 531 patients (16.2 per cent), resulting in an operative mortality rate of 1.9 per cent (10 of 531). The early complication rate was 16.5 per cent among patients undergoing 1-stage cystectomy and Kock pouch construction, and 15.2 per cent among patients undergoing Kock pouch conversion. Late complications have been analyzed in 489 patients who have undergone Kock cutaneous diversion. The complications unique to continent urinary diversion, their incidence and the effect of technical modifications in reducing the number of late complications are shown. Note that since the last modification in July 1985 the over-all incidence of late complication has decreased to 22 per cent. Based on this ongoing experience we conclude that the continent ileal reservoir, as conceived by Kock, remains the ideal internal reservoir for bladder replacement in terms of volume accommodation with the lowest internal pressures, and the intussuscepted ileal nipple valve mechanism is a reproducible, highly effective mechanism that prevents reflux and pyelonephritis in greater than 95 per cent of the patients and produces excellent continence. Our enthusiasm remains tempered by the need for reoperation in approximately 10 to 15 per cent of the patients, usually due to a pinhole fistula or false passage at the base of the efferent nipple valve mechanism. Electrolyte abnormalities rarely occur and in the absence of radiation gastrointestinal dysfunction is unusual. Continent urinary diversion is a viable concept that provides a real alternative in terms of quality of life and self-image for the patient who requires urinary diversion for any reason.
PurposeSince 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder h... more PurposeSince 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993.
5136 Background: Subclinical activation of hemostasis and fibrinolysis is common in cancer and ha... more 5136 Background: Subclinical activation of hemostasis and fibrinolysis is common in cancer and has been linked with outcome. We have previously presented (2007 Prostate Cancer Symposium) preliminary data on the relationship of laboratory markers to age and prognostic variables. We now expand our report on peri-operative (op) complication implications in early prostate cancer. Methods: With IRB approval and informed consent, blood was collected prior to open radical retropubic prostatectomy with lymph node dissection. Pre-op therapy, thrombosis, and anticoagulation were exclusion criteria. Plasma was assayed in duplicate for D-dimer, thrombin-antithrombin complex (TAT), IL-6, and IL-8. Relationships to peri-op bleeding/thrombotic events (pre-op to POD#2 hemoglobin (Hgb) drop, estimated blood loss (EBL), transfusion, post-op thrombosis) were analyzed in univariate then multivariable linear regression. Results: 153 subjects have been analyzed. Median age was 63.1 (range 35–81), pre-op ...
C tumors. Of the 17 patients undergoing lymphadenectomy only as a staging procedure before defini... more C tumors. Of the 17 patients undergoing lymphadenectomy only as a staging procedure before definitive radiation therapy 12 had nodal involvement, while 15 of 64 patients with combined and prostatectomy had nodal disease, crnmrmc;ai;1m1s involved 6 patients with thromboembolic disease, including l death while the hospitalized of pulmonary embolism, All 6 thromboembolic complications occurred ,-,u,vn,u,,u who had not received anticoagulation, for an incidence of 1L5 per cent compared to no of thromboembolism among 30 patients prophylactically anticoagulated with warfarin sodium, Late complications of chronic l.ymphedema occurred in 15 patients, 10 of whom had radiation. We recommend lymphadenectomy as an adjunct to radical prostatectomy but its role as a before definitive radiation therapy to the pelvis appears to yield increased morbidity in terms of incidence of chronic lymphedema, suggesting that its use be reserved for highly selected We also recommend the prophylactic postoperative administration of anticoagulants and norrn,=r awareness of risk factors contributing to chronic lymphedema.
The stoma is the weak link of external urinary diversion. Improper stomal position or configurati... more The stoma is the weak link of external urinary diversion. Improper stomal position or configuration produces the unnecessary burden of leakage for the patient with diversion. Stomal bleeding, incrustation and peristomal dermatitis cause inconvenience and expense. Stomal stenosis is the most common reason for repeat operation of an ileal conduit. The Turnbull loop stoma obviates many of these problems. We have performed 100 urinary diversions using this stoma with minimal stomal complications and no episodes of stomal stenosis from 1 to 7 years postoperatively. The significant complication has been parastomal hernia. Minor modifications of the technique have lowered the incidence of hernia. Loop stomas are our principal form of stomal construction.
Urinary diversion via the continent ileal reservoir has been performed at our institution since 1... more Urinary diversion via the continent ileal reservoir has been performed at our institution since 1982. During a 3-year period 250 patients have sought this procedure as an alternative to other forms of cutaneous urinary diversion. We analyzed our data in terms of late complications resulting directly from the operation or from this form of urinary diversion. In this context 77 of the 245 patients who survived the operation have suffered 1 or more late complications, requiring 85 reoperations. The late complications mainly have involved problems with continence or ease of catheterization and they were detected within 6 months. We report our experience and describe the technical aspects of treatment.
We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional... more We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional cell carcinoma of the bladder (with or without squamous or glandular differentiation) to adjuvant chemotherapy or to observation after radical cystectomy and pelvic lymph node dissection. For most patients chemotherapy was planned as 4 courses at 28-day intervals of 100 mg./M. 2 cisplatin, 60 mg./M. 2 doxorubicin and 600 mg./M. 2 cyclophosphamide. A significant delay was shown in the time to progression (p = 0.0010) with 70% of the patients assigned to chemotherapy free of disease at 3 years compared to 46% in the observation group. Median survival time for patients in the chemotherapy group was 4.3 years compared to 2.4 years in the observation group (p = 0.0062). In addition to treatment groups, important prognostic factors included age, gender and lymph node status. The number of involved lymph nodes was the single most important variable. We recommend adjuvant chemotherapy for patients with invasive transitional cell carcinoma after definitive surgical resection.
Between January 1979 and 1987, 411 consecutive patients were considered candidates for bilateral ... more Between January 1979 and 1987, 411 consecutive patients were considered candidates for bilateral pelvic iliac lymph node dissection and radical cystectomy for the management of bladder cancer. From this group 160 were identified as having pathological stage P2 or less disease, including 11 who also had positive nodes. The 5-year actuarial survival rate for the respective stages at 95% confidence limits was 100% for stage PO/A, 80% for stage Pl, 78% for stage Pl with stage PIS, 85% for pure stage PIS, 76% for stage P2 and 87% for stage P2 with stage PIS. Additionally, we identified a group of patients with stage P2 transitional cell carcinoma who were at significant risk for development of metastatic disease. Of 46 patients with stage P2 transitional cell carcinoma 18 had vascular space invasion resulting in 6 of 18 cancer-related deaths (33%). Our study demonstrates that radical cystectomy has been highly effective in curing patients with high grade superficial disease, including those with superficially invasive disease associated with nodal metastases.
Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical remov... more Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical removal of renal or adrenal tumors with direct extension of the tumor into the vena cava. Of the patients 4 had renal cell carcinoma and 1 had adrenocortical carcinoma. Magnetic resonance imaging staged correctly the level of vena caval tumor thrombus involvement in 4 patients and missed the presence of right atrial tumor extension in 1. This noninvasive imaging modality can be used instead of contrast venography in most patients to assess the presence and extent of vena caval tumor involvement by renal cell carcinoma. Contrast venography should be used for those patients with suspected cardiac involvement and for those whose tumor thrombus extent remains unclear after magnetic resonance imaging.
Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruct... more Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patients acceptance with few late complications or need for reoperation.
Urologic Oncology-seminars and Original Investigations, Nov 1, 2013
To evaluate the outcomes of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) fo... more To evaluate the outcomes of radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for clinically organ confined prostate cancer (CaP) with regional lymph node metastases (pN1) treated in the era of prostate-specific antigen (PSA) screening. A single institution cohort of 2,487 men with cT1-T2 CaP treated with open radical prostatectomy and pelvic lymph node dissection between 1988 and 2008 were analyzed. Kaplan-Meier and Cox proportional regression models were used to analyze overall survival (OS), clinical recurrence-free survival (cRFS), and biochemical recurrence-free survival (bRFS). Overall, 150 out of 2,487 patients (6%) had pN1 disease, with a median follow-up of 10.4 years. The predicted 10-year OS, cRFS, and bRFS rates for patients with pN0 and pN1 were 86% and 74% (Log rank P < 0.001), 97% and 84% (Log rank P < 0.001), and 88% and 57% (Log rank P < 0.001), respectively. In the subset of pN1 patients treated with surgery only (n = 49), the predicted 10-year OS, cRFS, and bRFS rates were 81%, 80%, and 59%, respectively. Exploratory univariate regression analysis showed that age (P = 0.003), total number of lymph nodes identified (P = 0.040), and total number of positive lymph nodes identified (P = 0.004) were associated with OS. Total number of positive lymph nodes (LNs) identified was also significantly associated with cRFS (P = 0.05). The incidence of pN1 in patients with cT1-T2 CaP treated with surgery in the era of PSA screening was low. RP and PLND demonstrated therapeutic efficacy in a subset of pN1 patients treated with surgery alone.
INTRODUCTION AND OBJECTIVES: To compare clinical and pathologic outcomes of radical cystectomy fo... more INTRODUCTION AND OBJECTIVES: To compare clinical and pathologic outcomes of radical cystectomy for muscle invasive bladder cancer in relation to prior history of non-invasive urothelial carcinoma. METHODS: The Canadian Bladder Cancer Network was used to retrospectively analyze data from 1150 patients managed by radical cystectomy for urothelial carcinoma of the bladder. Patients with clinical stage T2 or more were included and divided into two groups: (Group 1) patients with prior history of non-invasive urothelial carcinoma (NÏ365), and (Group 2) patients with clinical muscle invasive cancer de novo (NÏ785). Variables analyzed included patient age, gender, pathologic stage, adjuvant chemotherapy, recurrence and mortality. RESULTS: Both groups were nearly equal in mean age and gender distribution, with mean ages of 67.2 and 66.7 years, and 79.7% and 79.5%, respectively (P 0.4 and 0.9, respectively). The presence of preoperative hydronephrosis was 20.8% and 32.6% (P 0.0007) for groups 1 and 2, respectively. The rate of higher pathological stage (T3 or T4) was 36.3% and 58% (P Ͻ0.0001), positive lymph nodes was 20.1% and 28.8% (P 0.002) and lymphovascular invasion was 31.7% and 46.2% (P 0.0001) for groups 1 and 2, respectively. The rate of adjuvant chemotherapy was 15.5% and 23.3% (P 0.002) for groups 1 and 2, respectively. None of the sampled patients received neoadjuvant chemotherapy. The overall survival (OS) and disease-specific survival (DSS) rates at 5 years was 62% and 70% for group 1 and 51% and 60% for group 2, respectively, while at 10 years, OS and DSS was 46% and 66% for group 1 and 35% and 49% for group 2, respectively (P 0.0001 and 0.0002 respectively). Using multivariate analysis examining factors affecting recurrence and survival, we found that previous non-invasive bladder tumour history was associated with a significantly reduced risk of mortality and recurrence (Hazard ratio of 0.7 for all risks, P 0.0002). CONCLUSIONS: Our retrospective study suggests that patients with non-invasive urothelial carcinoma of the bladder that progress to muscle-invasion and require radical cystectomy appear to have better pathologic and clinical outcome than patients presenting with clinical muscle invasive disease de novo.
To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir ... more To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir with its continent antirefluxing nipple valves, laboratory investigations in dogs were done simultaneously with clinical trials in humans in 1983. Fifteen dogs underwent creation of hemi-Kock ileal reservoirs (without the efferent valve and limb) that were anastomosed to their bladders as enterocystoplasties. The afferent antirefluxing nipple valves were intussuscepted after 7 cm of underlying mesentery had been removed. The nipples were further stabilized with metal and absorbable (Polysorb) staples and Marlex collars. The right ureters were anastomosed to the afferent limb of the reservoirs with the contralateral systems left intact as controls. Ten dogs were able to be followed at the vivaria for twelve to thirty-six months and then studied. All nipple valves remained intact, viable, and nonrefluxing without revision. All kidneys remained histologically normal except those in dogs with dilated ureters secondary to ureteroileal stenosis with concurrent calculi formation. Calculi formed on exposed metal staples and Marlex. The absorbable staples were found to promote appropriate healing and were never the nidus for stone formation. It appears that the intussuscepted nipple valve (with its mesentery removed) is reproducible and functionally reliable in preventing reflux. It also appears these valves can histologically preserve diverted kidneys if the upper urinary tract drainage is normal and calculi are minimized. The proper placement of staples and the elimination of Marlex-anchoring collars are indicated to minimize calculi.
We describe our surgical technique of tube gastrostomy and report our experience with 709 patient... more We describe our surgical technique of tube gastrostomy and report our experience with 709 patients who underwent cystectomy and urinary diversion with gastrostomy tube placement from January 1988 to December 1997. This modified Stamm technique provides an effective means of gastric decompression without the discomfort associated with nasogastric decompression, is associated with a low complication rate (0.05%), and may be considered as the procedure of choice when gastric drainage is required after radical cystectomy and lower urinary tract reconstruction.
From August 1982 through March 1988, 531 patients have undergone continent urinary diversion usin... more From August 1982 through March 1988, 531 patients have undergone continent urinary diversion using an ileal reservoir constructed according to the method of Kock. For the last 18 months we have used the principle of Kock reservoir construction for primary lower urinary tract reconstruction after cystectomy in 39 highly selected male patients by means of a ureteroileal urethrostomy. Early complications occurred in 86 of 531 patients (16.2 per cent), resulting in an operative mortality rate of 1.9 per cent (10 of 531). The early complication rate was 16.5 per cent among patients undergoing 1-stage cystectomy and Kock pouch construction, and 15.2 per cent among patients undergoing Kock pouch conversion. Late complications have been analyzed in 489 patients who have undergone Kock cutaneous diversion. The complications unique to continent urinary diversion, their incidence and the effect of technical modifications in reducing the number of late complications are shown. Note that since the last modification in July 1985 the over-all incidence of late complication has decreased to 22 per cent. Based on this ongoing experience we conclude that the continent ileal reservoir, as conceived by Kock, remains the ideal internal reservoir for bladder replacement in terms of volume accommodation with the lowest internal pressures, and the intussuscepted ileal nipple valve mechanism is a reproducible, highly effective mechanism that prevents reflux and pyelonephritis in greater than 95 per cent of the patients and produces excellent continence. Our enthusiasm remains tempered by the need for reoperation in approximately 10 to 15 per cent of the patients, usually due to a pinhole fistula or false passage at the base of the efferent nipple valve mechanism. Electrolyte abnormalities rarely occur and in the absence of radiation gastrointestinal dysfunction is unusual. Continent urinary diversion is a viable concept that provides a real alternative in terms of quality of life and self-image for the patient who requires urinary diversion for any reason.
PurposeSince 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder h... more PurposeSince 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993.
5136 Background: Subclinical activation of hemostasis and fibrinolysis is common in cancer and ha... more 5136 Background: Subclinical activation of hemostasis and fibrinolysis is common in cancer and has been linked with outcome. We have previously presented (2007 Prostate Cancer Symposium) preliminary data on the relationship of laboratory markers to age and prognostic variables. We now expand our report on peri-operative (op) complication implications in early prostate cancer. Methods: With IRB approval and informed consent, blood was collected prior to open radical retropubic prostatectomy with lymph node dissection. Pre-op therapy, thrombosis, and anticoagulation were exclusion criteria. Plasma was assayed in duplicate for D-dimer, thrombin-antithrombin complex (TAT), IL-6, and IL-8. Relationships to peri-op bleeding/thrombotic events (pre-op to POD#2 hemoglobin (Hgb) drop, estimated blood loss (EBL), transfusion, post-op thrombosis) were analyzed in univariate then multivariable linear regression. Results: 153 subjects have been analyzed. Median age was 63.1 (range 35–81), pre-op ...
C tumors. Of the 17 patients undergoing lymphadenectomy only as a staging procedure before defini... more C tumors. Of the 17 patients undergoing lymphadenectomy only as a staging procedure before definitive radiation therapy 12 had nodal involvement, while 15 of 64 patients with combined and prostatectomy had nodal disease, crnmrmc;ai;1m1s involved 6 patients with thromboembolic disease, including l death while the hospitalized of pulmonary embolism, All 6 thromboembolic complications occurred ,-,u,vn,u,,u who had not received anticoagulation, for an incidence of 1L5 per cent compared to no of thromboembolism among 30 patients prophylactically anticoagulated with warfarin sodium, Late complications of chronic l.ymphedema occurred in 15 patients, 10 of whom had radiation. We recommend lymphadenectomy as an adjunct to radical prostatectomy but its role as a before definitive radiation therapy to the pelvis appears to yield increased morbidity in terms of incidence of chronic lymphedema, suggesting that its use be reserved for highly selected We also recommend the prophylactic postoperative administration of anticoagulants and norrn,=r awareness of risk factors contributing to chronic lymphedema.
The stoma is the weak link of external urinary diversion. Improper stomal position or configurati... more The stoma is the weak link of external urinary diversion. Improper stomal position or configuration produces the unnecessary burden of leakage for the patient with diversion. Stomal bleeding, incrustation and peristomal dermatitis cause inconvenience and expense. Stomal stenosis is the most common reason for repeat operation of an ileal conduit. The Turnbull loop stoma obviates many of these problems. We have performed 100 urinary diversions using this stoma with minimal stomal complications and no episodes of stomal stenosis from 1 to 7 years postoperatively. The significant complication has been parastomal hernia. Minor modifications of the technique have lowered the incidence of hernia. Loop stomas are our principal form of stomal construction.
Urinary diversion via the continent ileal reservoir has been performed at our institution since 1... more Urinary diversion via the continent ileal reservoir has been performed at our institution since 1982. During a 3-year period 250 patients have sought this procedure as an alternative to other forms of cutaneous urinary diversion. We analyzed our data in terms of late complications resulting directly from the operation or from this form of urinary diversion. In this context 77 of the 245 patients who survived the operation have suffered 1 or more late complications, requiring 85 reoperations. The late complications mainly have involved problems with continence or ease of catheterization and they were detected within 6 months. We report our experience and describe the technical aspects of treatment.
We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional... more We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional cell carcinoma of the bladder (with or without squamous or glandular differentiation) to adjuvant chemotherapy or to observation after radical cystectomy and pelvic lymph node dissection. For most patients chemotherapy was planned as 4 courses at 28-day intervals of 100 mg./M. 2 cisplatin, 60 mg./M. 2 doxorubicin and 600 mg./M. 2 cyclophosphamide. A significant delay was shown in the time to progression (p = 0.0010) with 70% of the patients assigned to chemotherapy free of disease at 3 years compared to 46% in the observation group. Median survival time for patients in the chemotherapy group was 4.3 years compared to 2.4 years in the observation group (p = 0.0062). In addition to treatment groups, important prognostic factors included age, gender and lymph node status. The number of involved lymph nodes was the single most important variable. We recommend adjuvant chemotherapy for patients with invasive transitional cell carcinoma after definitive surgical resection.
Between January 1979 and 1987, 411 consecutive patients were considered candidates for bilateral ... more Between January 1979 and 1987, 411 consecutive patients were considered candidates for bilateral pelvic iliac lymph node dissection and radical cystectomy for the management of bladder cancer. From this group 160 were identified as having pathological stage P2 or less disease, including 11 who also had positive nodes. The 5-year actuarial survival rate for the respective stages at 95% confidence limits was 100% for stage PO/A, 80% for stage Pl, 78% for stage Pl with stage PIS, 85% for pure stage PIS, 76% for stage P2 and 87% for stage P2 with stage PIS. Additionally, we identified a group of patients with stage P2 transitional cell carcinoma who were at significant risk for development of metastatic disease. Of 46 patients with stage P2 transitional cell carcinoma 18 had vascular space invasion resulting in 6 of 18 cancer-related deaths (33%). Our study demonstrates that radical cystectomy has been highly effective in curing patients with high grade superficial disease, including those with superficially invasive disease associated with nodal metastases.
Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical remov... more Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical removal of renal or adrenal tumors with direct extension of the tumor into the vena cava. Of the patients 4 had renal cell carcinoma and 1 had adrenocortical carcinoma. Magnetic resonance imaging staged correctly the level of vena caval tumor thrombus involvement in 4 patients and missed the presence of right atrial tumor extension in 1. This noninvasive imaging modality can be used instead of contrast venography in most patients to assess the presence and extent of vena caval tumor involvement by renal cell carcinoma. Contrast venography should be used for those patients with suspected cardiac involvement and for those whose tumor thrombus extent remains unclear after magnetic resonance imaging.
Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruct... more Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patients acceptance with few late complications or need for reoperation.
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Papers by Gary Lieskovsky