Patients with bladder cancer need frequent controls over long follow-up time due to high recurrence rate and risk of conversion to muscle invasive cancer with poor prognosis. We identified cancer-related molecular signatures in apparently healthy bladder in patients with subsequent muscular invasiveness during follow-up. Global proteomics of the normal tissue biopsies revealed specific proteome fingerprints in these patients prior to subsequent muscular invasiveness. In these presumed normal samples, we detected modulations of proteins previously associated with different cancer types. This study indicates that analyzing apparently healthy tissue of a cancer-invaded organ may suggest disease progression.

Objectives To investigate the long‐term functional outcomes and complications after continent cutaneous diversion with the Lundiana pouch. Patients and Methods Complications, re‐operations, renal function, and continence were ascertained from patient charts. Outcome variables were validated by a second and independent review of the patient files. Results A complication of Clavien–Dindo grade ≥ III , including unscheduled re‐admissions, occurred in 45/193 patients (23%) at ≤90 days of surgery. At a median follow‐up of 13 years, 105/193 patients (54%) had undergone at least one re‐operation, with uretero‐intestinal stricture being the most prevalent cause [28 patients (15%)]. Re‐operations were more prevalent in patients operated during the first half of the study period than during the second half (2000–2007; 62% vs 47%; P = 0.03), and they were also more frequent in patients who underwent surgery for benign causes than in patients who underwent surgery for malignancy (60% vs 51%; P = 0.04). Continence was achieved in 172/188 patients (91%). In all, 16% of all patients required revisional surgery of the outlet to remain continent with an easily catheterisable pouch or to address stomal stenosis. The mean decrease in estimated glomerular filtration rate was more pronounced in patients with benign indications for urinary diversion than in those with malignancies, even after adjusting for younger age at surgery and longer follow‐up in the former group (22 vs 11 mL /min/1.73 m 2 ; P < 0.006). A disinterested third‐party assessment revealed 10 postoperative complications, 17 re‐operations during follow‐up, and seven occasions of hospitalisation due to pyelonephritis (included in data above) not recorded at the primary data review. Conclusions The Lundiana pouch is associated with a high risk of re‐operation, although the functional results are good. Independent review by a third party increased the validity of the outcome data.

OBJECTIVE:This study aimed to reveal the late results of rediversion after urinary diversion.MATERIAL AND METHODS:From 1985 to 2009, 28 patients underwent rediversion at the Department of Urology, Lund University Hospital, Sweden. Median follow-up after rediversion was 147 months (range 7-300 months, interquartile range 63-214). The following rediversions were performed: ileal conduit, cutaneous ureterostomy, ureterosigmoidostomy and rectal bladder to continent cutaneous diversion (group I, n = 17); cutaneous ureterostomy to neobladder (group II, n = 1); ileal conduit and cutaneous ureterostomy to gastric conduit (group III, n = 2); and continent cutaneous diversion and neobladder to ileal conduit (group IV, n = 8).RESULTS:In group I, reoperations were necessary after rediversion in nine of the 17 patients. Excellent functional results were obtained in 14 patients. Two patients, both with Kock pouches, underwent multiple operations and finally required rediversion to an ileal conduit. The sole patient in group II had a ureteric reimplantation owing to ureterointestinal stricture and is now continent but performs clean intermittent catheterization. Both patients in group III underwent reoperations owing to ureteric strictures and renal stones. In group IV, one patient had ureteric stenosis, and one died owing to complications related to later surgery for small bowel obstruction.CONCLUSIONS:Complications are common after urinary rediversion, and several of the present patients required reoperations for a variety of reasons. Modern techniques for continent cutaneous diversion can provide excellent functional results. Patients with difficulties in accepting a urostomy bag pose special problems and need extensive information and counselling.

Context: A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications. Objective: To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD). Evidence acquisition: An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis. Evidence synthesis: Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%. Conclusions: RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results. (C) 2012 European Association of Urology. Published by Elsevier B. V. All rights reserved.

Objective. The correlation between clinical tumour stage and pathological tumour stage in radical cystectomy specimens in locally advanced bladder cancer is suboptimal. Radiological methods have so far been of limited value in preoperative staging; however, the resolution with magnetic resonance imaging (MRI) has improved with further technical developments of the method. The aim of this study was to compare tumour stage at MRI with pathological tumour stage in the cystectomy specimen. Material and methods. Prospectively, 53 patients with invasive bladder cancer were preoperatively investigated with 3 tesla (3T) MRI using a standardized protocol. 3T MRI was performed at a standardized bladder volume. Clinical tumour stage, tumour stage at MRI and pathological tumour stage groups (Ta, Cis, T1/T2a, T2b/T3a, T3b/T4a), were compared, and sensitivity and specificity for organ-confined and non-organ-confined disease (stage T3a or above or lymph-node metastases) were analysed. Results. MRI overestimated tumour stage in 23 out of 47 patients (49%), whereas six patients (13%) were understaged. In the three groups of patients (those with the same stage group at MRI as in the cystectomy specimen, overestimated tumour stage and understaged patients), the time interval between transurethral resection of the bladder (TURB) and MRI did not differ significantly. Conclusions. Preoperative MRI overestimated tumour stage in almost half of the patients investigated in this study. Postoperative changes could have contributed to such overstaging with MRI.

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 20121174 LONG-TERM FOLLOW-UP OF RENAL FUNCTION AFTER CONTINENT CUTANEOUS DIVERSION A.M. LUNDIANA Wiking Mansson, Thomas Davidsson, Abai Xu, Sigurdur Gudjonsson, and Fredrik Liedberg Wiking ManssonWiking Mansson Malmö, Sweden More articles by this author , Thomas DavidssonThomas Davidsson Malmö, Sweden More articles by this author , Abai XuAbai Xu Guangzhou, China, People's Republic of More articles by this author , Sigurdur GudjonssonSigurdur Gudjonsson Malmö, Sweden More articles by this author , and Fredrik LiedbergFredrik Liedberg Malmö, Sweden More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1398AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Lundiana Pouch for continent cutaneous diversion is a modification of the Indiana Pouch. In the former the ileocaecal valve is diminished in diameter and fixed against the caecal wall as a flap valve using stapling instruments. The ureters are implanted with antirefluxing technique due to risk of intermittent high pressure in the pouch. Preservation of renal function at long-term follow-up is a prerequisite for acceptance of this type of urinary diversion METHODS During the years 1992-2007 continent cutaneous diversion a.m. Lundiana was performed in 200 patients. 160 patients underwent cystectomy (144 with bladder cancer and 16 with rectal or anal cancer). In 40 patients there were benign indications for the diversion. Five patients died within 90 days of surgery. In this analysis 2 other patients were excluded; 1 due to uremia preoperatively and postoperatively, and 1 due to bilateral ureteric carcinoma. The analysis is thus based upon 193 patients. However, for some parameters the number is lower due to i.e. early tumor recurrence. 374 ureters were implanted, 352 of them according to the le Duc technique, 8 with submucous tunnel and 14 according to other techniques. Median time to the most recent intravenous pyelography (IVP) or computerized tomography (CT) during follow-up was 4.5 years. In the 114 patients who are alive follow-up is 2.5 – 19.2 years, median 9.2 years. RESULTS Stricture of 1 ureterointestinal anastomosis occurred in 10% of the patients (n=19), while 2 ureters were affected in 1% (n=2). Ureteric reimplantation due to stricture was performed in 9 of these patients. In 4% of the patients a kidney ceased to function and in 1.5% nephrectomy was performed due to malignancy. 6.5% of the patients developed upper tract stones. Clinical symptoms of UTI/pyelonephritis required hospital admission in 9% of the patients. During the observation period mean serum creatinine increased from 77 to 89.5 μmol/l, median increase being 3.5 μmol/l (p<0.0001). The last IVP/CT during follow-up was normal in 89.7% of the patients. CONCLUSIONS At long-term follow-up patients operated with continent cutaneous diversion do suffer stricture of the ureterointestinal anastomosis, upper tract stones and pyelonephritis in a high percentage, resulting in decrease in renal function. These patients need life long regular surveillance with regard to renal function and morphology. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e475-e476 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.Metrics Author Information Wiking Mansson Malmö, Sweden More articles by this author Thomas Davidsson Malmö, Sweden More articles by this author Abai Xu Guangzhou, China, People's Republic of More articles by this author Sigurdur Gudjonsson Malmö, Sweden More articles by this author Fredrik Liedberg Malmö, Sweden More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Lundiana Pouch for continent cutaneous diversion is a modification of the Indiana Pouch. In the former the ileocaecal valve is diminished in diameter and fixed against the caecal wall as a flap valve using stapling instruments. The pouch is drained through 2 catheters during the first 4 weeks and thereafter the patient starts intermittent self catheterization, most often using a 16 F Foley catheter.

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 20111145 CONTINENT CUTANEOUS DIVERSION A.M. LUNDIANA IN 200 PATIENTS–COMPLICATIONS FROM RESERVOIR AND OUTLET Wiking Mansson, Thomas Davidsson, Fredrik Liedberg, Sigurdur Gudjonsson, and Abai Xu Wiking ManssonWiking Mansson Malmö, Sweden More articles by this author , Thomas DavidssonThomas Davidsson Kristianstad, Sweden More articles by this author , Fredrik LiedbergFredrik Liedberg Malmö, Sweden More articles by this author , Sigurdur GudjonssonSigurdur Gudjonsson Malmö, Sweden More articles by this author , and Abai XuAbai Xu Guangzhou, China, People's Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.744AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Lundiana Pouch for continent cutaneous diversion is a modification of the Indiana Pouch. In the former the ileocaecal valve is diminished in diameter and fixed against the caecal wall as a flap valve using stapling instruments. The pouch is drained through 2 catheters during the first 4 weeks and thereafter the patient starts intermittent self catheterization, most often using a 16 F Foley catheter. METHODS During the years 1992–2007 continent cutaneous diversion a.m. Lundiana was performed in 200 patients. 160 patients underwent cystectomy (144 with bladder cancer and 16 with rectal or anal cancer). In 40 patients there were benign indications for the diversion. In the 114 patients who are alive follow-up is 2.5–19.2 years, median 9.2 years. RESULTS Mortality within 90 days was 2.5%. 46 patients suffered postoperative complications that required open or endoscopic surgery or placement of drainage tubes in 25. Some patients had early tumour recurrence and the catheters draining the pouch were not removed. Evaluation of the functional results is based on 191 patients who started intermittent self catheterization. Revision of the outlet due to incontinence or, in two cases, due to difficult catheterization was performed in 13 patients. Revision of the stoma due to stenosis was done in 14 patients. 14 patients suffered from episodes of difficult catheterization. Pouch stones developed in 22 patients and in 2 patients the pouch had to be augmented due to poor capacity. Rupture/perforation of the pouch occurred in 8 patients. In one patient the pouch was removed and an ileal conduit was fashioned after failed revision of the outlet due to incontinence. Continence was achieved in 177 patients. Continence was achieved less often among patients with benign disorders (33/39 vs 144/152; p=0.04) and in that group reoperation was more common (18/39 vs 31/152; p<0.001). CONCLUSIONS Continent cutaneous diversion a.m. Lundiana gives excellent functional results. However, complications from the reservoir and the outlet are not uncommon, especially among patients diverted due to benign disorders. Patients who have undergone urinary diversion need life long control of their urinary tracts. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e459-e460 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wiking Mansson Malmö, Sweden More articles by this author Thomas Davidsson Kristianstad, Sweden More articles by this author Fredrik Liedberg Malmö, Sweden More articles by this author Sigurdur Gudjonsson Malmö, Sweden More articles by this author Abai Xu Guangzhou, China, People's Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

We compared extended and limited lymph node dissections performed during radical cystectomy with regard to impact on survival and time to recurrence in bladder cancer patients.

BACKGROUND:To decrease recurrences in non-muscle-invasive bladder cancer (NMIBC), the European Association of Urology (EAU) guidelines recommend immediate, intravesical chemotherapy after transurethral resection (TUR) for all patients with Ta/T1 tumours. OBJECTIVE:To study the benefits of a single, early, intravesical instillation of epirubicin after TUR in patients with low- to intermediate-risk NMIBC. DESIGN, SETTING, AND PARTICIPANTS:In this prospective randomised multicentre trial, 305 patients with primary as well as recurrent low- to intermediate-risk (Ta/T1, G1/G2) tumours were enrolled between 1997 and 2004. Patients were randomly allocated to receive 80 mg of epirubicin in 50 ml of saline intravesically within 24 h of TUR or no further treatment after TUR. MEASUREMENTS:The primary end point was time to first recurrence. RESULTS AND LIMITATIONS:A total of 219 patients remained for analysis after exclusions. The median follow-up time was 3.9 yr. During the study period, 62% (63 of 102) of the patients in the epirubicin group and 77% (90 of 117) in the control group experienced recurrence (p=0.016). In a multivariate model, the hazard ratio (HR) for recurrence was 0.56 (p=0.002) for early instillation of epirubicin versus no treatment. In a subgroup analysis, the treatment had a profound recurrence-reducing effect on patients with primary, solitary tumours, whereas it provided no benefits in patients with recurrent or multiple tumours. Furthermore, patients with a modified European Organisation for Research and Treatment of Cancer (EORTC) risk score of 0-2 with and without single instillation had recurrence rates of 41% and 69%, respectively (p=0.003), whereas the corresponding rates for those with a risk score of > or = 3 were 81% and 85%, respectively (p=0.35). CONCLUSIONS:A single, early instillation of epirubicin after TUR for NMIBC reduces the likelihood of tumour recurrence; however, the benefit seems to be minimal in patients at intermediate or high risk of recurrence. Future trials will determine the value of early instillation in addition to serial instillations in NMIBC.

Background: Fluorescent light (FL)-guided cystoscopy induced by 5-aminolevulinic acid (5-ALA) has been reported to detect more tumours compared with standard white-light (WL) cystoscopy. Most reports are from single centres with relatively few patients.Objective: To evaluate whether 5-ALA-induced FL and WL cystoscopy at transurethral resection (TUR) is superior compared with standard procedures under WL only with respect to tumour recurrence and progression in patients with non-muscle-invasive bladder cancer.Design, setting, and participants: This randomised, multicentre, observer- and pathologist-blinded, prospective phase 3 clinical trial enrolled 300 patients, and of those patients, 153 were randomised to FL cystoscopy and 147 were randomised to standard WL cystoscopy.Intervention: All patients were first inspected under WL and all lesions were recorded. Patients randomised to FL underwent a second inspection. TUR was carried out in both groups.Measurements: Control cystoscopy under WL was performed in all patients every 3 mo during the first year after randomisation and biannually thereafter.Results and limitations: At the first TUR, the mean number of resection specimens per patient was 2.5 (FL: 2.5; WL: 2.4; p = 0.37) and the resulting mean number of resected tumours was 1.7 with FL and 1.8 with WL (p = 0.85). More patients were diagnosed with carcinoma in situ (CIS) in the WL group (13%) than in the FL group (4.2%). Within-patient comparison of FL patients only showed that FL detected more lesions than WL. Tumour lesions solely detected by FL cystoscopy that would not otherwise be detected by WL cystoscopy included 52% dysplasia, 33% CIS, 18% papillary neoplasms, 13% pT1, and 7% pTa. Outcome at 12 mo did not show any difference between groups with regard to recurrence-free and progression-free survival rates.Conclusions: In this prospective, randomised, multi-institutional study, we found no clinical advantage of FL cystoscopy compared with WL cystoscopy and TUR. (c) 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.

OBJECTIVE:In the European Association of Urology guidelines on prostate cancer an extended pelvic lymphadenectomy (ePLND) is now recommended, instead of a dissection limited to the obturator fossae (lPLND). This recommendation relies on studies reporting that metastatic disease is identified twice as often with ePLND as with lPLND, with only moderately increased complications. However, these studies were from high-volume centres. This study investigated whether these results could be repeated in a hospital with lower surgical volume, more typical for the Nordic countries.MATERIAL AND METHODS:From January 2002 to September 2007 172 patients underwent radical prostatectomy and PLND at the University Hospital of Lund, 108 with ePLND and 64 with lPLND. Perioperative complications and the number of lymph-node metastases found were registered.RESULTS:A median of 17 lymph nodes was identified with ePLND compared with seven with lPLND. Metastases were identified in four out of 64 patients in the lPLND group (6%), versus 22 out of 108 in the ePLND group (20%). In the ePLND group 10 of the patients with metastases had such exclusively outside the obturator fossae. Complications were significantly more common after ePLND (p=0.007): lymphoceles (18 vs 9%), pulmonary embolism (4.6 vs 1.6%), deep venous thrombosis (1 vs 1.5%) and other (haematomas and infectious including sepsis (8 vs 0%).CONCLUSIONS:Almost half of the patients with metastases are misclassified by lPLND. Complications are significantly more common after ePLND. This implies that ePLND should be performed, but in selected patients and by high-volume surgeons only.

A functionally distinct subset of CD103(+) dendritic cells (DCs) has recently been identified in murine mesenteric lymph nodes (MLN) that induces enhanced FoxP3(+) T cell differentiation, retinoic acid receptor signaling, and gut-homing receptor (CCR9 and alpha 4 beta 7) expression in responding T cells. We show that this function is specific to small intestinal lamina propria (SI-LP) and MLN CD103(+) DCs. CD103(+) SI-LP DCs appeared to derive from circulating DC precursors that continually seed the SI- LP. BrdU pulse-chase experiments suggested that most CD103(+) DCs do not derive from a CD103(-) SI- LP DC intermediate. The majority of CD103(+) MLN DCs appear to represent a tissue- derived migratory population that plays a central role in presenting orally derived soluble antigen to CD8(+) and CD4(+) T cells. In contrast, most CD103(+) MLN DCs appear to derive from blood precursors, and these cells could proliferate within the MLN and present systemic soluble antigen. Critically, CD103(+) DCs with similar phenotype and functional properties were present in human MLN, and their selective ability to induce CCR9 was maintained by CD103(+) MLN DCs isolated from SB Crohn ' s patients. Thus, small intestinal CD103(+) DCs represent a potential novel target for regulating human intestinal infl ammatory responses.