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COMPLICATIONS OF MODIFIED SIGMA RECTUM POUCH (MAINZ POUCH 2) URINARY DIVERSION: EXPERIENCE OF 238 PATIENTS
1081
1082
LONG-TERM RESULTS OF SURGICAL TREATMENT FOR UPPER URINARY TRACT TRANSITIONAL CELL CANCER
COMPLICATIONS OF MODIFIED SIGMA RECTUM POUCH (MAINZ POUCH 2) URINARY DIVERSION: EXPERIENCE OF 238 PATIENTS
Vukotic- Maletic V., Lazic M., Kojic D.
Hadzi Djokic J.1, Basic D.2, Colovic V.3
KBC “Dr Dragisa Misovic”, Urology, Belgrade, Serbia and Montenegro
1
INTRODUCTION & OBJECTIVES: Urothelial tumours of the upper urinary tract (renal pelvis and ureters- UUT) are rare: the most common of these are Transitional Cell Carcinomas (TCC), usually localised in the bladder (75% of cases), whereas only 7-10% arise in the renal pelvis and 2, 5-5% in the ureter. Transitional cell carcinoma of the renal collecting system is traditionally managed by open nephroureterectomy with en bloc resection of a bladder cuff, the most controversial and challenging feature is the oncological correct management of the distal ureter. AIM of this study was to find out risk factors influencing prognosis in term of survival in our patients treated with different types of open surgery for UUT TCC. MATERIAL & METHODS: In the 9 year period from May 1995 to May 2004 124 patients were surgically treated for suspicious UUT TCC, which was histologically confirmed in 113 patients. 87 patients were followed, while 26 pts were lost for control. Statistical analysis was performed using SPSS for descriptive static’s, life table and log rank tests for analysis of prognostic factors. RESULTS: Tumour was located only in pylon in 31 pts, in ureter in 56, while pylon and ureter were involved in 26 pts. The localisation of the tumour in ureter was lumbal (25 pts), illiac (15), pelvic (21), and intramural (19). The grade of the tumour was 2 (63 pts), Gr 1 in 27 pts, gr III in 23 pts. The stage of the disease was 1 in 21 pts, 2 in 45, 3 in 37 and 4 in 10 pts. Open nephroureterectomy (NUT) was performed in 54 pts, through two incisions while only one pararectal incision was used in 30 pts. Subtotal nephrectomy was done in 33 pts, with later ureterectomy in 3. Tumour ablation was performed in 12 pts. In 6 pts partial cystectomy was performed along with NUT for intramural ureteral tumour. Of 87 patients followed patients 43 died, 38 related to the UUT. Mean survival was 2.63 years, 11 died in the first postoperative year. Grade was not associated with survival, while stage of the disease significantly influenced survival (p<0.05). The type of surgical procedure did not influence the survival. Different types of NUT (one or two incisions) as well did not differ in prognosis and survival; mean expected survival for two incisions being 4.99 years, for one incision 6.4 years. CONCLUSIONS: Our results were worse than expected in term of survival. Stage showed to be the only parameter influencing disease related survival According to our results surgery should not be the sole treatment for patients with higher stages of disease. In those patients systemic adjuvant haemotherapy might be considered.
P65 STONES MISCELLANEOUS Friday, 7 April, 15.45-17.15, Room Maillot / Level 2 1083 SHOCK WAVE LITHOTRIPSY (SWL) FOR ALL-LOCATION LARGE (> 10 MM) URETERAL STONES USING HM3 LITHOTRIPTOR Halachmi S., Nagar M., Golan S., Goldin O., Kaufman Z., Ofer Y., Meretyk S. Rambam Medical Centre, Urology, Haifa, Israel INTRODUCTION & OBJECTIVES: Optimal treatment for large ureteral stones (>10mm) is still controversial. Our aim was to assess the efficacy of SWL using the HM3 lithotriptor to achieve stone free status in patients with large ureteral calculi. MATERIAL & METHODS: We retrospectively reviewed the charts and radiology films of patients who had SWL for large ureteral stones (> 10 mm). Following SWL with the HM3 lithotripter patients had imaging at 1, and 3 months, and thereafter according to stones residue status. RESULTS: During 2000-2003, 96 patients underwent SWL for large ureteral stones. This group had a mean age of 51 years, 75 were males and 21 females. Sixty-six stones were located in the upper ureter, 20 in mid, and 10 in the lower ureter. 90 were calcified stones. The average stone size was 1.4cm, (range 12.2cm). Over all success rate was 86.5%, 83/96 patients were stone free in average time of 7.75 weeks, median time to stone free status was 4 weeks. Eighty percent of the patients were stone free after single treatment 19% following 2 sessions and a single patient had 3 SWLs. In 13 patients SWL failed and they were referred to ureteroscopic procedure. Complications occurred in 13 (13.5%) patients who needed I.V antibiotics for urinary tract infection. CONCLUSIONS: Our data show that SWL using HM3 lithotripter for very large ureteral stones has a high success rate with minimal morbidity. SWL using the HM3 lithotripter is our preferable primary method for the treatment of all location large ureteral calculi.
Clinical Centre of Serbia, Urological Clinic, Belgrade, Serbia and Montenegro, 2Clinical Centre, Urological Clinic, Nis, Serbia and Montenegro, 3Clinical Centre Bezanijska Kosa, Department of Urology, Belgrade, Serbia and Montenegro INTRODUCTION & OBJECTIVES: As a modification of classic ureterosigmoidostomy, regarding sigmoid colon detubularization, sigma rectum pouch (Mainz pouch 2) became an optional technique of urinary diversion. In our study complications of sigma rectum pouch were analysed. MATERIAL & METHODS: From October 1994 to December 2003, a total of 238 patients, mean age 57.2 (range 29 to 72) underwent modified sigma rectum pouch procedure. of these, 170 were male and 68 female. The mean follow – up period was 22 (1-86) months. The indications for the procedure were bladder cancer (n=222), irreparable vesico-vaginal fistula (n= 5), gynaecological cancer infiltrating bladder (n= 5), complicated urethral stricture (n= 4) and traumatic loss of urethra in female (n= 2). Preoperatively, all patients underwent standard diagnostic protocol. The procedure was performed with following modifications: ureteral implantation using Camey Le-Duck technique, fixation of ureteral stents to mucosa by plain catgut sutures, fixation of ureteral stents exteriorly to the gluteal skin. We observed early and late postoperative surgical complications, metabolic complications and continence rates. RESULTS: Perioperative mortality was nil. Early (<30 days) 43 postoperative complications occurred in 26 patients (11%) as follow: prolonged ileus (n= 6), pyelonephritis (n=17), unilateral ureterohydronephrosis (n=12), bilateral ureterohydronephrosis (n=2) and incipient renal failure (n=6). Pyelonephritis was caused from ureteral obstruction in 10 renal units. None of these complications required surgical therapy. Late (>30 days) 19 postoperative complications occurred in 16 patients (7%) as follow: ureterointestinal anastomotic site stenosis (n=17) and ventral hernia (n=4). Nine patients had unilateral and three had bilateral ureterointestinal anastomotic site stenosis. In the treatment of ureterointestinal anastomotic site stenosis, balloon catheter dilatation was performed in nine and metal Strecker stent insertion in six renoureteral units, with successful outcome in 13 renoureteral units (87%). Oral alkalinizing therapy regarding hyperchloraemic metabolic acidosis prevention was necessary for 98 patients (41%). 174 patients (73%) answered the questionnaire related to some problems regarding urinary diversion. All of them, but three (2%) were continent during the day. CONCLUSIONS: Risks of ureterointestinal anastomosis malignant transformation and metabolic acidosis are the main disadvantages of Mainz pouch 2 urinary diversion. Regarding simplicity and safety of surgical technique, acceptable surgical and metabolic complication rates and satisfying continence rate, the Mainz pouch 2 is a good alternative option in selected cases.
1084 CLINICAL RESULT OF ULTRASOUND-BASED REAL-TIME TRACKING FOR UROLITHIASIS IN EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Chang C.1, Chen C.R.2 1
Hsin-chu Hospital, Department of Health, The Executive Yuan, Urology, Hsinchu, Taiwan, 2Hua-lien Hospital, Department of Health, The Executive Yuan, Urology, Hua-lien, Taiwan INTRODUCTION & OBJECTIVES: Localisation of urolithiasis during extracorporeal shock wave lithotripsy (ESWL) tends to be impaired by movement of the calculus second to respiration of the patient during the procedure. This greatly reduces the efficiency of every shock wave by as much as 70% and may consequently damage the renal parenchyma by peak pressure when shock wave focusing is inaccurate. In vitro result of real-time ultrasound localisation of urolithiasis during ESWL has been reported previously in 2002. The system, utilising the special servomotor coupled to the tracking unit, greatly enhances the efficiency by limits firing of the shock wave only with the calculus in the designated area. We report the preliminary clinical data using the system. MATERIAL & METHODS: Five hundred and fourteen patients aged 21 to 76 years (mean 42) were treated with LiteMed®9200 Elma (Taipei, Taiwan), a system featuring real-time ultrasound tracking, during the period between December 2004 and September 2005. The greatest diameter of calculi (including renal and ureteral) treated ranges from 6.3 mm to 28 mm (mean 11.4 mm). RESULTS: The stone-free rate after single treatment averaged 81% after four weeks of follow-up. Complication included gross hematuria on first-voided urine (19.6%) and hypertension (6.4%). There was no incidence of hematoma, renal or subcapsular. All cases required no analgesics during the treatment. CONCLUSIONS: Real-time ultrasound tracking lithotriptor appears to perform ESWL efficiently and safely as expected from data in vitro. The operational cost should be reduced from the maintenance and shock wave generator. Further accumulation of clinical data is required to fully establish the safety and efficacy of the system. Eur Urol Suppl 2006;5(2):293
1082
LONG-TERM RESULTS OF SURGICAL TREATMENT FOR UPPER URINARY TRACT TRANSITIONAL CELL CANCER
COMPLICATIONS OF MODIFIED SIGMA RECTUM POUCH (MAINZ POUCH 2) URINARY DIVERSION: EXPERIENCE OF 238 PATIENTS
Vukotic- Maletic V., Lazic M., Kojic D.
Hadzi Djokic J.1, Basic D.2, Colovic V.3
KBC “Dr Dragisa Misovic”, Urology, Belgrade, Serbia and Montenegro
1
INTRODUCTION & OBJECTIVES: Urothelial tumours of the upper urinary tract (renal pelvis and ureters- UUT) are rare: the most common of these are Transitional Cell Carcinomas (TCC), usually localised in the bladder (75% of cases), whereas only 7-10% arise in the renal pelvis and 2, 5-5% in the ureter. Transitional cell carcinoma of the renal collecting system is traditionally managed by open nephroureterectomy with en bloc resection of a bladder cuff, the most controversial and challenging feature is the oncological correct management of the distal ureter. AIM of this study was to find out risk factors influencing prognosis in term of survival in our patients treated with different types of open surgery for UUT TCC. MATERIAL & METHODS: In the 9 year period from May 1995 to May 2004 124 patients were surgically treated for suspicious UUT TCC, which was histologically confirmed in 113 patients. 87 patients were followed, while 26 pts were lost for control. Statistical analysis was performed using SPSS for descriptive static’s, life table and log rank tests for analysis of prognostic factors. RESULTS: Tumour was located only in pylon in 31 pts, in ureter in 56, while pylon and ureter were involved in 26 pts. The localisation of the tumour in ureter was lumbal (25 pts), illiac (15), pelvic (21), and intramural (19). The grade of the tumour was 2 (63 pts), Gr 1 in 27 pts, gr III in 23 pts. The stage of the disease was 1 in 21 pts, 2 in 45, 3 in 37 and 4 in 10 pts. Open nephroureterectomy (NUT) was performed in 54 pts, through two incisions while only one pararectal incision was used in 30 pts. Subtotal nephrectomy was done in 33 pts, with later ureterectomy in 3. Tumour ablation was performed in 12 pts. In 6 pts partial cystectomy was performed along with NUT for intramural ureteral tumour. Of 87 patients followed patients 43 died, 38 related to the UUT. Mean survival was 2.63 years, 11 died in the first postoperative year. Grade was not associated with survival, while stage of the disease significantly influenced survival (p<0.05). The type of surgical procedure did not influence the survival. Different types of NUT (one or two incisions) as well did not differ in prognosis and survival; mean expected survival for two incisions being 4.99 years, for one incision 6.4 years. CONCLUSIONS: Our results were worse than expected in term of survival. Stage showed to be the only parameter influencing disease related survival According to our results surgery should not be the sole treatment for patients with higher stages of disease. In those patients systemic adjuvant haemotherapy might be considered.
P65 STONES MISCELLANEOUS Friday, 7 April, 15.45-17.15, Room Maillot / Level 2 1083 SHOCK WAVE LITHOTRIPSY (SWL) FOR ALL-LOCATION LARGE (> 10 MM) URETERAL STONES USING HM3 LITHOTRIPTOR Halachmi S., Nagar M., Golan S., Goldin O., Kaufman Z., Ofer Y., Meretyk S. Rambam Medical Centre, Urology, Haifa, Israel INTRODUCTION & OBJECTIVES: Optimal treatment for large ureteral stones (>10mm) is still controversial. Our aim was to assess the efficacy of SWL using the HM3 lithotriptor to achieve stone free status in patients with large ureteral calculi. MATERIAL & METHODS: We retrospectively reviewed the charts and radiology films of patients who had SWL for large ureteral stones (> 10 mm). Following SWL with the HM3 lithotripter patients had imaging at 1, and 3 months, and thereafter according to stones residue status. RESULTS: During 2000-2003, 96 patients underwent SWL for large ureteral stones. This group had a mean age of 51 years, 75 were males and 21 females. Sixty-six stones were located in the upper ureter, 20 in mid, and 10 in the lower ureter. 90 were calcified stones. The average stone size was 1.4cm, (range 12.2cm). Over all success rate was 86.5%, 83/96 patients were stone free in average time of 7.75 weeks, median time to stone free status was 4 weeks. Eighty percent of the patients were stone free after single treatment 19% following 2 sessions and a single patient had 3 SWLs. In 13 patients SWL failed and they were referred to ureteroscopic procedure. Complications occurred in 13 (13.5%) patients who needed I.V antibiotics for urinary tract infection. CONCLUSIONS: Our data show that SWL using HM3 lithotripter for very large ureteral stones has a high success rate with minimal morbidity. SWL using the HM3 lithotripter is our preferable primary method for the treatment of all location large ureteral calculi.
Clinical Centre of Serbia, Urological Clinic, Belgrade, Serbia and Montenegro, 2Clinical Centre, Urological Clinic, Nis, Serbia and Montenegro, 3Clinical Centre Bezanijska Kosa, Department of Urology, Belgrade, Serbia and Montenegro INTRODUCTION & OBJECTIVES: As a modification of classic ureterosigmoidostomy, regarding sigmoid colon detubularization, sigma rectum pouch (Mainz pouch 2) became an optional technique of urinary diversion. In our study complications of sigma rectum pouch were analysed. MATERIAL & METHODS: From October 1994 to December 2003, a total of 238 patients, mean age 57.2 (range 29 to 72) underwent modified sigma rectum pouch procedure. of these, 170 were male and 68 female. The mean follow – up period was 22 (1-86) months. The indications for the procedure were bladder cancer (n=222), irreparable vesico-vaginal fistula (n= 5), gynaecological cancer infiltrating bladder (n= 5), complicated urethral stricture (n= 4) and traumatic loss of urethra in female (n= 2). Preoperatively, all patients underwent standard diagnostic protocol. The procedure was performed with following modifications: ureteral implantation using Camey Le-Duck technique, fixation of ureteral stents to mucosa by plain catgut sutures, fixation of ureteral stents exteriorly to the gluteal skin. We observed early and late postoperative surgical complications, metabolic complications and continence rates. RESULTS: Perioperative mortality was nil. Early (<30 days) 43 postoperative complications occurred in 26 patients (11%) as follow: prolonged ileus (n= 6), pyelonephritis (n=17), unilateral ureterohydronephrosis (n=12), bilateral ureterohydronephrosis (n=2) and incipient renal failure (n=6). Pyelonephritis was caused from ureteral obstruction in 10 renal units. None of these complications required surgical therapy. Late (>30 days) 19 postoperative complications occurred in 16 patients (7%) as follow: ureterointestinal anastomotic site stenosis (n=17) and ventral hernia (n=4). Nine patients had unilateral and three had bilateral ureterointestinal anastomotic site stenosis. In the treatment of ureterointestinal anastomotic site stenosis, balloon catheter dilatation was performed in nine and metal Strecker stent insertion in six renoureteral units, with successful outcome in 13 renoureteral units (87%). Oral alkalinizing therapy regarding hyperchloraemic metabolic acidosis prevention was necessary for 98 patients (41%). 174 patients (73%) answered the questionnaire related to some problems regarding urinary diversion. All of them, but three (2%) were continent during the day. CONCLUSIONS: Risks of ureterointestinal anastomosis malignant transformation and metabolic acidosis are the main disadvantages of Mainz pouch 2 urinary diversion. Regarding simplicity and safety of surgical technique, acceptable surgical and metabolic complication rates and satisfying continence rate, the Mainz pouch 2 is a good alternative option in selected cases.
1084 CLINICAL RESULT OF ULTRASOUND-BASED REAL-TIME TRACKING FOR UROLITHIASIS IN EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Chang C.1, Chen C.R.2 1
Hsin-chu Hospital, Department of Health, The Executive Yuan, Urology, Hsinchu, Taiwan, 2Hua-lien Hospital, Department of Health, The Executive Yuan, Urology, Hua-lien, Taiwan INTRODUCTION & OBJECTIVES: Localisation of urolithiasis during extracorporeal shock wave lithotripsy (ESWL) tends to be impaired by movement of the calculus second to respiration of the patient during the procedure. This greatly reduces the efficiency of every shock wave by as much as 70% and may consequently damage the renal parenchyma by peak pressure when shock wave focusing is inaccurate. In vitro result of real-time ultrasound localisation of urolithiasis during ESWL has been reported previously in 2002. The system, utilising the special servomotor coupled to the tracking unit, greatly enhances the efficiency by limits firing of the shock wave only with the calculus in the designated area. We report the preliminary clinical data using the system. MATERIAL & METHODS: Five hundred and fourteen patients aged 21 to 76 years (mean 42) were treated with LiteMed®9200 Elma (Taipei, Taiwan), a system featuring real-time ultrasound tracking, during the period between December 2004 and September 2005. The greatest diameter of calculi (including renal and ureteral) treated ranges from 6.3 mm to 28 mm (mean 11.4 mm). RESULTS: The stone-free rate after single treatment averaged 81% after four weeks of follow-up. Complication included gross hematuria on first-voided urine (19.6%) and hypertension (6.4%). There was no incidence of hematoma, renal or subcapsular. All cases required no analgesics during the treatment. CONCLUSIONS: Real-time ultrasound tracking lithotriptor appears to perform ESWL efficiently and safely as expected from data in vitro. The operational cost should be reduced from the maintenance and shock wave generator. Further accumulation of clinical data is required to fully establish the safety and efficacy of the system. Eur Urol Suppl 2006;5(2):293