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Thermal ablation is expanding as a technique to treat small renal masses. Damage to the collecting system is uncommon with either radiofrequency ablation or cryoablation. Early evidence suggests that cryoablation is less damaging to the urinary tract, and investigators have advocated the use of aggressive treatment in central tumors in contact with the renal hilum. The authors report a nonhealing urinary fistula after successful cryoablation of an exophytic upper pole renal mass in a patient with an ileal conduit. The presence of an ileal conduit may present an increased risk of urinary fistula after thermal ablation.
PURPOSE - Before the early 1990s total urethrectomy at radical cystectomy for bladder cancer in women was considered the standard of care. As our understanding of the natural history of urethral urothelial carcinoma in women has improved, neobladders have been increasingly created in carefully selected women with bladder cancer. We reviewed the literature regarding the incidence of urethral involvement, the risk factors for urethral involvement and the incidence of urethral recurrence in women undergoing orthotopic urinary diversion for bladder cancer.
MATERIALS AND METHODS - A comprehensive literature review was performed regarding the natural history of urethral tumor involvement by urothelial carcinoma, risk factors and the incidence of urethral recurrence following radical cystectomy and orthotopic diversion in women with bladder cancer.
RESULTS - Urethral tumor involvement occurs in approximately 12% of female patients with bladder cancer undergoing radical cystectomy for high grade, invasive urothelial carcinoma. Preoperative involvement of the bladder neck or anterior vaginal wall with urothelial carcinoma is an important risk factor for urethral tumor involvement. Intraoperative frozen section analysis of the proximal urethra is an appropriate and reliable method of identifying female candidates for orthotopic diversion. The rate of secondary tumor recurrence in the retained urethra of women following radical cystectomy and orthotopic urinary diversion is low but the condition requires long-term followup.
CONCLUSIONS - Orthotopic urinary diversion can be performed safely in appropriately selected women with bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence. Preoperative bladder neck involvement is an important risk factor for urethral involvement but not an absolute contraindication to orthotopic diversion should intraoperative frozen section of the proximal urethra be without evidence of malignancy.
BACKGROUND - The authors report their experience with radical cystectomy for transitional cell carcinoma (TCC) of the bladder comparing clinical outcomes, including complication rates, among older patients versus younger patients in a high-volume center specializing in the treatment of patients with advanced carcinoma of the urinary bladder.
METHODS - A retrospective review was undertaken of 1054 patients who underwent radical cystectomy for bladder TCC from 1971 through 1997. Four age groups were compared; < 60 years at the time of cystectomy (n = 309 patients), age 60-69 years (n = 381 patients), age 70-79 years (n = 314 patients), and age > or = 80 years (n = 50 patients).
RESULTS - The median length of hospital stay in patients ages < 60 years, 60-69 years, 70-79 years, and > or = 80 years was 10 days, 10 days, 11 days, and 11 days, respectively (P < 0.001). The corresponding rates of overall early complications were 24%, 25%, 37%, and 30%, respectively (P = 0.002); whereas the corresponding late complication rates were 36%, 30%, 22%, and 14%, respectively (P < 0.001). The rate of early diversion-related complications did not differ significantly (11%, 8%, 12%, and 6%, respectively; P = 0.14). The operative mortality rates were 1%, 3%, 4%, and 0%, respectively (P = 0.14). There was no difference with respect to early complications, early diversion-related complications, late complications, or operative mortality comparing patients age > 70 years who underwent ileal conduit versus orthotopic urinary diversion (P = 0.20, P = 0.61, P = 0.53, and P = 0.78, respectively).
CONCLUSIONS - Elderly patients who underwent cystectomy for TCC had similar mortality and early diversion-related complication rates. Carefully selected elderly patients safely can be offered an orthotopic urinary diversion. Chronological age, per se, is not a contraindication for radical cystectomy in the setting of invasive bladder carcinoma.
The incidence of urethral TCC after radical cystectomy is approximately 8% overall. The most important risk factor for urethral TCC after radical cystectomy and urinary diversion is prostatic involvement by TCC, particularly stromal invasion. The safety of using the urethra for orthotopic urinary diversion seems to be best when intra-operative frozen section analysis of the urethral margin is performed at the time of radical cystectomy. There is provocative but unconfirmed evidence that orthotopic urinary diversion may be protective against the development of urethral TCC. Although most urethral "recurrences" occur within 5 years, delayed recurrences have been documented, mandating life-long follow-up of the retained urethra. Follow-up should include urinary cytology, either voided or urethral wash cytology as appropriate, with evaluation by endoscopy of any urethral related symptoms or change in voiding symptoms. The management of urethral TCC after cystectomy remains a total urethrectomy including excision of the meatus; however, in carefully selected patients with superficial disease and an orthotopic urinary diversion, urethra sparing may be attempted after a careful discussion with the patient. Survival after urethral TCC has generally been disappointing. The relative value of urethral versus original cystectomy pathologic stage and symptomatic versus nonsymptomatic recurrence in predicting survival remains controversial and awaits further studies that will most likely require the pooling of data from several large series.
PURPOSE - Continent forms of urinary diversion have become a gold standard of urinary tract reconstruction after radical cystectomy, based mostly on the premise of improved quality of life. It is unclear whether the existing body of literature supports this assumption.
MATERIALS AND METHODS - We performed a systematic review to determine if differences exist in health related quality of life (HRQOL) outcomes among different types of urinary diversion after radical cystectomy. A MEDLINE search was performed inclusive of the dates 1966 to January 2004. Inclusion criteria included adult patients, patients with bladder cancer, comparative studies, original research, primary study outcome related to quality of life, and use of a quality of life instrument to measure outcomes. Only studies comparing neobladder, continent reservoir, or conduit diversion were included.
RESULTS - Of 378 initial articles 15 studies met all inclusion criteria. None of the studies were randomized trials. Only 1 study was prospective. Of 15 studies 10 (67%) used some type of previously validated HRQOL instrument, 10 (67%) used some form of ad hoc instrument, 11 (73%) used bladder cancer disease specific instruments, while 9 (60%) used general instruments. Only 1 of the bladder cancer specific instruments had been previously validated. Common limitations included unvalidated HRQOL instruments, use of general HRQOL instruments only, lack of baseline data, cross- sectional analysis, and retrospective study design.
CONCLUSIONS - To date, the current body of published literature is insufficient to conclude that 1 form of urinary diversion is superior to another based on HRQOL outcomes. Future studies should attempt to incorporate prospective data collection, longer term followup and validated disease specific HRQOL instruments.
At most centers with experience in urinary diversion, an orthotopic urinary reservoir is the diversion of choice after radical cystectomy for bladder cancer. The paradigm has shifted in the past 10 years from actively looking for reasons to do an orthotopic diversion to carefully considering why a patient cannot undergo reconstruction to their native urethra. In our institution, any patient who is to undergo a radical cystectomy for bladder cancer is a potential candidate for orthotopic diversion provided they do not have chronic renal insufficiency. In addition, they must have a negative urethral margin on frozen section at the time of cystectomy, and have the mental and physical capacity to understand what is required to manage the reservoir after surgery. Proper patient selection is the key to success. Notably, chronologic age is not an absolute contraindication to orthotopic diversion. Instead, careful consideration of the patient's comorbid conditions should guide eligibility. In addition, locally advanced disease is not a contraindication to an orthotopic diversion. To have the flexibility to manage whatever situation presents itself intraoperatively, the surgeon performing a urinary diversion after radical cystectomy must be facile with several diversion techniques. At the very least, the surgeon must be comfortable with one type of each major form of urinary diversion, a conduit (incontinent) diversion, a continent cutaneous diversion, and an orthotopic diversion. As a result, radical cystectomy and urinary diversion should be performed at centers with significant experience in all three types of diversions.
The operative management of invasive transitional cell carcinoma has advanced significantly in the past year, particularly with respect to continent urinary diversion. The long term safety and efficacy of this form of urinary reconstruction is being established in terms of both operative and metabolic complications. The availability of continent diversion can decrease the interval to cystectomy and therefore may impact positively on survival. It has also been shown that continent diversion can safely be offered to patients at high risk for local recurrence. The importance of urethral sensory threshold on postoperative continence is being established. These findings and others continue to enhance the survival and quality of life of patients undergoing cystectomy for invasive bladder cancer.
OBJECTIVES - To evaluate the prognostic significance of ureteral obstruction in women with cervical cancer and the result of aggressive urinary diversion.
METHODS - The clinical history and X-rays of 52 women with Stage III and IV cervical cancer seen at Vanderbilt University between 1981 and 1991 were retrospectively reviewed.
RESULTS - Twenty-nine (55.8%) of these patients had unilateral  or bilateral  ureteral obstruction. There was no statistically significant difference in the survival of patients whether or not ureteral obstruction was present. Ten of fourteen women with bilateral ureteral obstruction and 4 of the 15 patients with unilateral obstruction underwent urinary diversion by percutaneous nephrostomy  or retrograde ureteral catheterization . Complications were few. Although patients who underwent urinary diversion had somewhat better survival, it was not statistically significant.
CONCLUSIONS - Some patients with ureteral obstruction due to advanced cervical cancer can be salvaged by prompt, aggressive urinary diversion, but large trials are needed to validate this approach.
In a variety of recent studies in animals with chronic renal diseases, investigators have found a tight correlation between the elevation in glomerular pressures and flows versus glomerular hypertrophy. To investigate a possible causal link between the glomerular hyperfunction and hypertrophy, we studied the functional and morphological sequelae of nephrectomy and those of unilateral ureteral diversion (UD) into the peritoneal cavity (that is, removal of renal clearance function while keeping the kidney tissue in situ). In all nine experimental groups of 54 Munich-Wistar rats, 2/3 of the renal mass was removed from the left kidney by ligation of two or three branches of the left renal artery. In addition, right nephrectomy (NPX) was performed in Groups 1B, 2B and 3B or UD in Groups 1C, 2C and 3C. The right kidney was left untouched in control groups, Groups 1A, 2A and 3A. Micropuncture measurements and histological studies were performed at four days (Groups 1A, 1B and 1C), two weeks (Groups 2A, 2B and 2C) or four weeks (Groups 3A, 3B and 3C). At both four days and two weeks, NPX and UD groups had marked and comparable degrees of glomerular hypertension, hyperperfusion and hyperfiltration compared to the control group in the left kidney.(ABSTRACT TRUNCATED AT 250 WORDS)