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Introduction Our objectives were to evaluate the long-term renal function after radical cystectomy (RC) and ileal conduit diversion (ICD) and to analyze year-by-year the estimated glomerular filtration rate (eGFR) and morphologic upper urinary tract changes. Patients and Methods We retrospectively identified 226 patients who had undergone RC and ICD from 1980 to 2008, with regular postoperative follow-up visits. The eGFR was calculated using the Modification of Diet in Renal Disease equation at baseline and during follow-up. A decrease in renal function was defined as > 1 mL/min/1.73 m 2 annually. Results The median follow-up period after RC was 91 months (range, 61-235 months). The median eGFR decreased from 66 mL/min/1.73 m 2 (range, 17-139 mL/min/1.73 m 2 ) to 59 mL/min/1.73 m 2 (range, 33-102 mL/min/1.73 m 2 ). A rapid decline in renal function occurred during the first 2 postoperative years (−9 mL/min/1.73 m 2 and −4 mL/min/1.73 m 2 in the first and second year, respectively), with a moderate to slight decrease in the subsequent years. Urinary obstruction was diagnosed in 51 patients (23%). Among the patients who underwent prompt surgical treatment, we did not find any association with the eGFR decline ( P = .8). Conclusion Patients with urinary ICD have a lifelong risk of chronic kidney disease. Regular monitoring of renal function and the morphologic upper urinary tract will permit early diagnosis and treatment of modifiable factors, avoiding irreversible kidney damage.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To evaluate the results in terms of functional results and morbidity of Z-shaped ileal neobladder performed in a single center. PATIENTS AND METHODS 329 consecutive male patients who had an orthotopic bladder replacement using the Z-shaped ileal neobladder between May 1990 and January 2009. RESULTS The mean age of the patients was 64.4 ± 9.6 years, with a mean follow-up of 59.4 ± 55 months. Eighty-three early complications in 80/294 patients (27.2%) occurred. The average Clavian rate of these early complications was 2.24. Among these, 12 complications in 12 patients (4.1%) were pouch-related, and 3 reoperations were required. Two patients died from cardiac complications. Sixty-three late complications in 60/294 patients (20.4%) were recorded. The average Clavian rate of these late complications was 2.98. Among these, 47 complications in 45/294 patients (15.3%) were pouch-related, and 18 reoperations were required, essentially for ureteral anastomosis stricture. Satisfactory daytime urinary continence was achieved in 92% of patients. Daytime continence was obtained within, on average, 6.8 ± 16.4 months. The interval between each daytime urination was 2.6 ± 0.8 h (median = 2.5 [1–5] h). Forty-four (15%) patients developed metabolic acidosis which only required oral medication. Satisfactory nocturnal urinary continence was achieved in 87% of patients. Night-time continence was obtained within, on average, 10.8 ± 22.4 months. Hyper-continence with subsequent need for CISC was observed in 4%. CONCLUSION In our series of 329 patients, compared with the other techniques, the Z-shaped ileal neobladder had an ‘expected’ complication rate for this high risk surgery with satisfactory daytime and night-time continence in nine out of ten patients.

Urinary tract involvement is rarely described in APS. We report the case of a 40 year-old man with primitive APS who was diagnosed an arterial and venous unilateral ureteral ischemia, revealed by a hydronephrosis. He had been on oral anticoagulation for six years because of two deep venous thromboses. He developed then a massive splenic infarct and an acute myocardial infarct, which required intensification of his anticoagulation, add of aspirin and high doses of corticosteroids. Three months later, he was explored for a latero-thoracic pain. Biology found an acute renal failure and microscopic haematuria. CT scan showed hypoperfusion of the left kidney, an ostial defect on renal artery and left hydronephrosis. Retrograde pyelography found a proximal ureteral stenosis. A dilatation with stenting failed, leading to a partial left ureteral resection. Histology confirmed ureteral segmental organized arterial thrombosis and venous thrombosis. Evolution was favourable with stabilization of creatinine level.Urinary tract involvement is rarely described in antiphospholipid syndrome (APS). We report the case of a 40 year-old man with primitive APS who developed an arterial and venous unilateral ureteral ischemia revealed by painful unilateral hydronephrosis. The patient was on oral anticoagulation for six years because of two deep venous thromboses. He developed then a massive splenic infarct and an acute myocardial infarct, which required the intensification of his anticoagulation and high doses of corticosteroids. Three months later, he was explored for a latero-thoracic pain. Biology found an acute renal failure and microscopic haematuria. CT scan showed a hypoperfusion of the left kidney, an ostial defect on renal artery and a left hydronephrosis. Retrograde pyelography found a stenosis of the proximal ureter. A dilatation with stenting failed, leading to a partial left ureteral resection. Histology confirmed ureteral segmental organized arterial thrombosis and venous thrombosis. Evolution was favourable with stabilization of creatinine. DOI: http://dx.doi.org/10.3126/jaim.v2i2.7659 Journal of Advances in Internal Medicine 2013;02(02):78-80

Purpose: After cystectomy for bladder cancer, when pelvic lymph nodes are positive, bladder replacement remains controversial. The aim of this study was to evaluate the outcome of patients who underwent neobladder replacement despite bladder cancer metastasis to the regional lymph nodes. Materials and Methods: From 1981 to 1997, a total of 504 consecutive cystectomies for bladder cancer were performed at our institution. For 150 patients, pelvic lymphadenectomy were positive, nevertheless 71 patients underwent a neobladder replacement (50 N1 and 21 N2). The distribution of patients by clinical stage, according to the TNM 97 classification, was 4 T1, 14 T2, 32 T3 and 21 T4. No patient showed signs of metastasis on diagnosis. Results: Five-year disease specific survival rate of the entire group (71 patients) was 46%. With a mean follow-up of 8.3 years (3.2–20 years), 25 patients (35%) were alive and free of disease (72% with day continence), five patients were alive with recurrence (three bone metastasis, one chest metastasis and one with local recurrence), 41 patients died, (three non-cystectomy related). Of the 46 patients who recurred, a total of eight patients had local recurrence. For five patients, a severe dysfunction of the plasty appeared: two needed definitive bladder drainage until they died, one patient became totally incontinent, one patient needed a conversion of the plasty to Bricker ileal conduit. For the remaining patient the tumor involvement provoked recto-plasty-cutaneous fistula. All these five patients died in the 6 months after the plasty dysfunction appeared. Conclusions: Although prognosis in bladder cancer metastasis to the regional lymph nodes has been reported to be poor, this study demonstrates that after cystectomy, it is justified to propose a neobladder replacement to well selected patients. Local recurrence only occurred in 11% of patients and there was no damage to enteroplasty function for nearly half of the patients, and considering benefit to the quality of life, orthotopic bladder substitution should be considered as the preferential diversion in this patient population.

Objectives. To assess in a prospective study whether extracorporeal shock wave therapy (ESWT) using a standard radioscopic location lithotriptor is effective in the treatment of Peyronie’s disease. Methods. Fifty-four patients were included in this prospective study. Before and after treatment, the angulation was calculated by auto-photography. Pain severity was assessed by a visual analog pain scale. A self-evaluation questionnaire (International Index of Erectile Function) was used. All patients had symptoms (35 had pain during erection and 51 angulation greater than 20°). The mean disease duration was 16 months. The mean angulation before treatment was 48° (range 10° to 100°). Twenty-four patients had erectile dysfunction (questionnaire score less than 18). The Multiline Siemens lithotriptor was used. The plaque was located by palpation, and 1 mL of contrast agent was injected. Scopic visualization was used. Each patient received a minimum of one session of ESWT (3000 shock waves, 7 kJ) applied to a flaccid penis. Results. All patients completed the protocol. The tolerance and safety were excellent. Of the 35 patients with pain on erection, 31 (91%) noticed relief immediately after ESWT (mean reduction 2.9 on the visual analog pain scale) (P

Introduction and Objectives: The aim of this study was to evaluate preliminary results of tension–free vaginal tape (TVT), a new surgical procedure, performed during the learning ph

The aim of this retrospective study was to evaluate the effects and results of low-dose bacillus Calmette-Guérin (BCG) therapy on a selective high-risk population of stage T1, grade 3 (G3) bladder tumours. Recurrence and progression were also analysed. Thirty-five consecutive patients presenting with T1 G3 tumours were treated with intravesical BCG. All patients underwent complete transurethral tumour resection. A course of BCG 75 mg Pasteur strain was begun 4 weeks after the first resection of the diagnosed tumour and continued for a 6-week period. At the end of treatment, a complete urological evaluation was routinely carried out: urine cytology test, cystoscopy with bladder biopsies randomly performed, and any recurrences were resected. In cases of abnormal cytology and/or recurrence an additional course of BCG was initiated, followed by the same tests. Follow-up examination and cystoscopy or fibroscopy were conducted every 3 months for 1 year, semiannually and annually thereafter. Median follow-up was 45 months (range 10-120); 7 patients (20%) did not respond to BCG instillations. Of these patients, 5 underwent cystectomy and in 2 patients the bladder was left in place in spite of recurrence because of age (+80 years). Twenty-eight patients (80%) responded positively, 24 after one single course of BCG, and 4 patients after two courses. During follow-up, recurrence was observed in 8 cases: stage T1 G3 in 4 patients, T1 CIS (carcinoma in situ) in 2 patients, Ta G2 and Ta G1 in 2 patients. Three of these patients were treated by cystectomy and the remaining patients with transurethral resection alone or combined with additional courses of BCG. Overall, 25 patients (71%) were considered free of tumour occurrence after low-dose BCG therapy. Ten patients underwent cystectomy (29%) or remained in occurrence and 2 patients died of the disease. These results can be closely compared to the results of other trials conducted on stage T1 G3 and BCG treatment, using a different dosage and BCG protocol therapy. BCG is an effective prophylactic and therapeutic agent for T1 G3 carcinoma of the bladder responders. The identification of these responders before beginning instillations still remains a challenge.

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.

The purpose of this study was to determine health-related quality of life (HRQoL) among long-term disease-free survivors in women who underwent radical cystectomy (RC) for urothelial carcinoma and orthotopic ileal neobladder (ONB) reconstruction, using validated patient-reported outcome instruments.From 2000 to 2011, a total of 46 women with urothelial bladder carcinoma had RC and ONB at our institution; 31 (67 %) eligible women completed 3 validated questionnaires: the medical outcome study short form 12 (SF-12), the urinary symptom profile, and the Contilife, respectively evaluating general HRQoL, voiding function, and urinary incontinence specific HRQoL. Unadjusted analyses were performed to analyze standardized measures of HRQoL and voiding symptoms; p0.05 was considered significant.The mean follow-up was 5.7 years; 24 women (77 %) considered their health as good, very good, or excellent. The SF-12 physical and mental scores were not significantly different between the population study and the general population (p0.05). A total of 20 women (65 %) declared to be fully continent. Daytime incontinence, nighttime incontinence, and hypercontinence were reported by 26, 29, and 31 % of women, respectively. On unadjusted analysis, incontinence was associated with age65 years at the time of surgery (p0.001). Hypercontinence was not associated with any variable.This study suggests that in the setting of radical cystectomy in women, ileal neobladder reconstruction provides long-term satisfaction with maintained HRQoL. For properly selected women, orthotopic neobladder can be considered an appropriate diversion choice.

Purpose: Resection of ileal segments may result in malabsorption and a decrease in intestinal uptake of different substances. The use of intestinal segments in the urinary tract may also cause metabolic disorders. We studied long-term metabolic consequences of enterocystoplasty after radical cystoprostatectomy for bladder cancer.Materials and Methods: We reviewed 17 patients with a Camey type I enterocystoplasty for a mean of 12.9 years (range 10 to 22) after radical cystoprostatectomy. The enterocystoplasty was constructed with a 35 cm. ileal segment resected 20 cm. proximal to the ileocecal valve. All patients underwent complete physical and radiological examinations, including renal ultrasonography and excretory urography. Laboratory studies included blood count with mean corpuscular volume and packed cell volume. Serum was analyzed for electrolytes, hepatic function, cholesterol, triglycerides, albumin, protein, vitamins B12 and B9, iron, ferritin, calcium, phosphate, vitamin D, parathyroid ho...

Pelvic arteriovenous malformations (AVM) are rare, and the treatment of this condition presents an interesting challenge. We report the first case of a major AVM in a patient with Down syndrome which was revealed by a massive hematuria. Arteriography showed a bilateral complex iliac artery malformation. The first proximal embolization (unilateral) did not prevent bladder hemorrhage, and the second distal (bilateral) immobilization produced bladder necrosis. However, the patient died despite an emergency cystectomy.

To assess the efficacy and the safety of a new transurethral endoscopic device using bipolar electrocautery, the Gyrus system. This system permits rapid prostate tissue removal by endoscopic vaporization with little bleeding and no pad return using saline irrigation and therefore eliminating TURP syndrome.Forty-two patients (mean age 70; range 49-90 years) with symptomatic benign prostatic hyperplasia (BPH) without suspected cancer, confirmed by digital rectal examination and PSA tests, were treated between October 1998 and February 1999 with the Gyrus and evaluated at 1 and 3 months postoperatively by the International Prostate Symptom Score (IPSS) and maximum urinary flow rate.No postoperative bleeding necessitating catheterization for postoperative retention occurred. The duration of the procedure wasor = 30 minutes in 12 patients, 30 to 60 minutes in 27 patients, and60 minutes in 3 patients. The mean time of postoperative continuous bladder irrigation was 1.2 days (0.5-3 days). The mean catheterization time was 1.4 days (range 0.5-5 days). Urethral stricture requiring treatment occurred in two patients. Dysuria was reported by four patients (mild two, severe two). The postoperative hospitalization was a mean of 2.2 days. The mean peak flow rate increased from 7.9 to 19.7 mL/sec at 3 months, and the IPSS decreased from 16 to 9 at 3 months.Our preliminary results with a bipolar electrode for electrovaporization of the prostate using the Gyrus suggest that it is a useful and safe endoscopic device. It appears to be an effective treatment for BPH; however, long-term results (i.e., 1-year follow-up) should be evaluated. This pilot series permits a comparative study with TURP to assess the benefits for patients and the health care system.

The aim of this study was to determine if p53 status, assessed before intravesical bacillus Calmette-Guerin (BCG) therapy, can predict clinical outcome in a high risk population of patients with stage T1, grade G3 bladder cancer and if it can be used to select patients responsive to therapy.After complete transurethral resection 35 patients with T1G3 bladder carcinoma received 6 weekly instillations of BCG and nonresponsive patients received a second course. After treatment cystoscopy and randomized biopsies of the bladder mucosa were performed. Pathologists had sufficient material to perform immunomarking in 25 cases using the peroxidase-antiperoxidase technique with antiprotein monoclonal antibody p53. The results were expressed in percentage of marked nuclei. We established 5% increment thresholds from 0 to 60%. Contingent tables were established, and chi-square and Fisher's exact test were performed for each 5% threshold.Median followup was 51.3 months (range 25 to 144). Of the 25 patients 8 (32%) did not respond to BCG therapy and 17 (68%) did. Immunomarkings were not statistically different between BCG responsive and nonresponsive patients for 0, 5, 10, 20, 35, 40, 45, 55 and 65 thresholds. Chi-square and Fisher's exact test were 0.91 and 0.83, 0.40 and 0.20, 0.58 and 0.29, 0.96 and 0.81, 0.80 and 0.88, 0.67 and 0.73, 0.91 and 0.83, 0.80 and 0.38, 0.69 and 0.32, respectively.Our results indicate that the percentage of p53 immunomarked cell cannot currently be used to predict clinical response to BCG therapy and, therefore, p53 over expression is not a viable indicator of T1G3 recurrence when using this treatment.

Between January 1987 and January 1991, 110 detubularized U-shaped ileocystoplasties (Camey II) following radical cystectomy were carried out in our Department of Urology (CMC Foch Suresnes, France). Our first evaluation of this procedure was carried out in 1989 and reviewed initial 57 patients operated on. These data were compared with those of the Camey I operation. The improvement in neobladder capacity as well as nighttime urinary control achieved by the detubularization required in the Camey II operation was obvious. In this article we review the first 110 patients treated by Camey II bladder replacement following cystectomy.

Purpose: Bacillus Calmette-Guerin (BCG) therapy is considered to be an effective prophylactic and therapeutic agent for high risk superficial transitional cell carcinoma of the bladder. Nevertheless, in a select uncommon population of stage Ta grade 3 superficial lamina-free tumors the results of this treatment have not yet been well established. We evaluated recurrence and progression rates, and the success of BCG therapy in a population with stage Ta grade 3 transitional cell carcinoma of the bladder. Materials and Methods: Of the 605 patients treated at our institution from 1982 to 1996 for the histopathological diagnosis of primary bladder cancer 32 (5.3%) with stage Ta grade 3 noninvasive primary bladder tumor were treated with intravesical instillations of 75 mg. Pasteur strain BCG in 50 ml. saline weekly for 6 weeks. At a followup of 2 to 13 years (mean 58.4 months) patients were evaluated with urinary cytology, cystoscopy, transurethral resection and random mucosal biopsies. Recurrence, grade and stage progression, death and causality were analyzed. Results: Of the 32 patients 9 (28%) responded positively to BCG without recurrence, while disease recurred as stage Ta in 8 (25%) and T1 in 7 (22%), and progressed to muscle layer infiltration in 8 (25%). Four patients (12%) died of bladder cancer. The number of tumors at primary resection, gross examination, the mitotic index or an association with carcinoma in situ did not appear to be predictive factors of progression to muscle invasion. Urine cytology (I to II versus III to IV) appeared to correlate highly with progression and BCG response (p Conclusions: Our study demonstrates the high progression potential of stage Ta grade 3 tumors, since nearly 50% recurred and 25% progressed to invasive disease. These results may be closely compared with the results of previous trials of stage T1 grade 3 disease. We suggest that recurrence should be detected at an early stage using long-term followup with strict observance of the surveillance protocols during a minimum 5-year tumor-free period.