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RE: URETHRAL RECURRENCE OF TRANSITIONAL CELL CARCINOMA IN A FEMALE PATIENT AFTER CYSTECTOMY AND ORTHOTOPIC ILEAL NEOBLADDER
0022-5347/01/1664-1402/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 166, 1402–1403, October 2001 Printed in U.S.A.
Letters to the Editor RE: MANAGEMENT OF DIAPHRAGMATIC INJURY DURING LAPAROSCOPIC NEPHRECTOMY S. R. Potter, L. R. Kavoussi
AND
S. V. Jackman
J Urol, 165: 1203–1204, 2001 To the Editor. The authors describe a rare, potentially life threatening complication of laparoscopic radical nephrectomy, and propose a technique to repair the diaphragmatic injury and relieve the pneumothorax. This report is important as this complication may occur more frequently with the increasing popularity of laparoscopic techniques. This technique to treat the pneumothorax involves a “blind” procedure with new potential risks to the patient. We offer a different approach using similar techniques. Instead of inserting the catheter at the end of the operation through the intercostal space, we insert the needle through the abdominal wall using laparoscopic vision before tying the sutures used to repair the diaphragmatic tear. The catheter is then inserted through the tear and the pneumothorax is aspirated under a deep inspiratory breath provided by the anesthesiologist, as reported by the authors. Once the pneumothorax has resolved, the sutures are tied and the catheter is withdrawn. The good results of this procedure are confirmed intraoperatively by normalization of the respiratory parameters, namely end inspiratory pressure and tidal carbon dioxide levels. Although our technique to treat this complication constitutes a minor change of the technique described previously, we believe it is safer because it is performed under direct vision and may help urologists to manage this injury better. Respectfully, Oscar Fugita Divisa˜o de Urologia Hospital das Clı´nicas Faculdade de Medicina da Universidade de Sa˜o Paulo Sa˜o Paulo, Brazil
Reply by Authors. As noted by Fugita, diaphragmatic injury may occur more frequently as laparoscopy becomes increasingly popular. The method of pneumothorax aspiration reported by Fugita seems excessively complex. Aspiration before desufflation is counterintuitive, as insufflated carbon dioxide will enter the chest with every patient exhalation until desufflation or diaphragm closure is performed. We advise against Fugita’s recommendation of confirming pneumothorax resolution by normalization of respiratory parameters alone. In patients with adequate cardiac reserve a significant injury may be missed in this manner and resolution must be confirmed by intraoperative radiography. The use of a modified central venous catheter for aspiration of intrathoracic air is a time tested technique that is safe, quick, inexpensive and uses readily available equipment without prolonging operative time.
pressure, posterior urethral sensitivity or neobladder capacity. Overall, urinary control seemed to improve using this technique in this pilot series. Wide anatomical dissection around the prostate during radical cystectomy and prostatectomy, including the posterior aspects of the bladder base and seminal vesicles, may disrupt afferent and efferent innervation of the trigone, neobladder neck and posterior urethra. The increase in posterior urethral sensitivity after radical prostatectomy is suggestive of partial damage to the pelvic innervation.1 Therefore, we have proposed previously the concept of the seminal vesicle sparing technique to preserve the pelvic plexus and improve urinary continence in patients undergoing radical prostatectomy.2 Complete resection of the seminal vesicles is not necessary from an oncological viewpoint.3 Finally, recent immunohistochemical studies have shown that quantified nerve fiber density in trigonal biopsies before and after radical prostatectomy corresponded with posterior urethral sensory threshold and urinary continence.4 These findings indicate that intraoperative pelvic denervation and reinnervation take place during the first postoperative months. Seminal vesicle sparing tumor surgery for prostate and bladder cancer seems to achieve better early urinary continence rates. Thus, we encourage the authors to enlarge this series and add conclusive preoperative and postoperative urodynamic evaluations. Respectfully, Hubert John and Dieter Hauri Clinic of Urology Zu¨rich University Hospital 8091 Zu¨rich Switzerland 1. John, H., Sullivan, M. P., Bangerter, U. et al: Effect of radical prostatectomy on sensory threshold and pressure transmission. J Urol, 163: 1761, 2000 2. John, H. and Hauri, D.: Seminal vesicle sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology, 55: 820, 2000 3. Korman, H. J., Watson, R. B., Civantos, F. et al: Radical prostatectomy: is complete resection of the seminal vesicles really necessary? J Urol, 156: 1081, 1996 4. John, H., Hauri, D., Leuener, M. et al: Evidence of trigonal denervation and reinnervation after radical retropubic prostatectomy. J Urol, 165: 111, 2001
RE: URETHRAL RECURRENCE OF TRANSITIONAL CELL CARCINOMA IN A FEMALE PATIENT AFTER CYSTECTOMY AND ORTHOTOPIC ILEAL NEOBLADDER J. Jones, S. W. Melchior, R. Gillitzer, J. Fichtner, M. El-Mekresh and J. W. Thu¨roff J Urol, 164: 1646, 2000
To the Editor. While we have at least 2 decades of experience with orthotopic bladder reconstruction in men undergoing radical cystectomy for bladder cancer, the experience with urethra sparing cystectomy and orthotopic bladder substitution in women has RE: NERVE AND SEMINAL SPARING RADICAL CYSTECTOMY gained popularity only recently. This report describes an adverse WITH ORTHOTOPIC URINARY DIVERSION FOR SELECT outcome in a woman with an orthotopic ileal neobladder. This PATIENTS WITH SUPERFICIAL BLADDER CANCER: AN failure among many successfully cases is definitely noteworthy to INNOVATIVE SURGICAL APPROACH show the shortcomings of this procedure. However, in view of several R. Colombo, R. Bertini, A. Salonia, L. F. Da Pozzo, F. Montorsi, unusual circumstances in this extraordinary case it can be dangerM. Brausi, M. Roscigno AND P. Rigatti ous to make general conclusions about urethra sparing cystectomy and orthotopic ileal neobladder in women. J Urol, 165: 51–55, 2001 The location of the tumor at cystectomy was at the bladder base. In To the Editor. The authors report excellent functional results in 8 previous publications we have emphasized that a common lymphatic patients who underwent cystoprostatectomy with a nerve and sem- drainage exists between the bladder and the vagina, particularly in inal vesicle sparing technique. Daytime and nighttime urinary con- the area of the bladder base.1 Therefore, we and other institutions tinence had been achieved completely at catheter removal in all have advocated removing the anterior vaginal wall in patients with patients, which is early in our experience. However, the authors do transitional cell cancer of the bladder, regardless of location.2 Leavnot report any urodynamic data, such as maximal urethral closure ing the entire vagina, as was apparently done, is even more risky in 1402
1403
LETTERS TO THE EDITOR this case due to the tumor location in the adjoining bladder base and its known lymphatic spread. Grossly involved lymph nodes may be considered an additional risk factor, which may result in alterations of the lymph drainage leading to centripetal lymphatic tumor cell spread caudally alongside the urethra or dorsally towards the paravaginal and pararectal space. Once this tumor reaches a certain size, it is almost impossible to differentiate whether it originated from a local metastasis or is a recurrence at the urethrointestinal anastomosis. Long-term survival in patients with lymph node involvement is dependent on the number of positive nodes and extent of lymphadenectomy during cystectomy.3 However, even if complete cystourethrectomy and extensive lymphadenectomy had been performed in this patient, the probability that she would have survived the next 5 years without systemic chemotherapy would be in the range of 17% to 35%, depending on the number of tumor positive nodes. At cystectomy several adverse signs for performing urethra sparing cystectomy, namely tumor location, preservation of the entire vaginal wall and advanced pelvic lymph node involvement, were disregarded. If one had become aware of the true pathological stage on receipt of the final pathology report, the current mandatory treatment for such a patient would have been systemic combination chemotherapy and careful regular followup, including cytology, urethroscopy and vaginal inspection. Considering the problematic management of this case and the dire prognoses due to disease biology at cystectomy, it is difficult to make any conclusions on the use of an orthotopic neobladder in female patients undergoing cystectomy for bladder cancer truly confined to the bladder. A constellation of such findings occurs in only a small fraction of patients undergoing cystectomy. However, recommendations based on this case cannot be applied to the majority of female patients undergoing cystectomy in whom tumor is confined to the bladder specimen. These women will be good candidates for orthotopic bladder substitution, which does not mean an oncological compromise but a significant benefit in quality of life. Respectfully, Arnulf Stenzl Department of Urology University of Innsbruck Medical School A-6020 Innsbruck Austria 1. Stenzl, A., Colleselli, K., Poisel, S. et al: The use of neobladders in women undergoing cystectomy for transitional-cell cancer. World J Urol, 14: 15, 1996 2. Stenzl, A., Colleselli, K., Poisel, S. et al: Rationale and technique of nerve sparing radical cystectomy before an orthotopic neobladder procedure in women. J Urol, 154: 2044, 1995 3. Lerner, S., Skinner, D., Lieskovsky, G. et al: The rationale for en bloc pelvic lymph node dissection for bladder cancer patients with nodal metastases: long-term results. J Urol, 149: 758, 1993
misprint in my editorial indicated that I discontinue prophylactic antibiotics and imaging in children older than 5 or 6 years who have persistent asymptomatic bacteruria grade III to V. This statement should have been that I discontinue prophylactic antibiotics and imaging in children older than 5 or 6 years with asymptomatic grades of reflux less than III/V (III out of V). It is not my practice to discontinue treatment in high grades of reflux, even in asymptomatic children. While this method may have some merit, there are only preliminary data to support nontreatment. Respectfully, David B. Joseph Department of Surgery, Section of Pediatric Urology Children’s Hospital University of Alabama at Birmingham 1600 7th Ave. S Birmingham, AL 35233-1711 1. Cooper, C. S., Chung, B. I., Kirsch, A. J. et al: The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol, 163: 269, 2000
Reply by Authors. Our approach to the management of asymptomatic high grade vesicoureteral reflux involves eliminating risk factors that contribute to breakthrough infections, which represent the most common indication for antireflux surgery. We concur with the editorial and currently continue all patients with high grade reflux on prophylactic antibiotics in conjunction with directed therapy to address dysfunctional pelvic floor, which we believe is the underlying etiology of breakthrough infection and perhaps reflux in a significant number. We institute a conservative medical program that concentrates on hydration, timed voiding, hygiene and, most importantly, elimination of constipation via an intense bowel management program to compliment our computer game assisted, biofeedback program. With this approach an impressive reduction in breakthrough infection has been demonstrated in patients with voiding dysfunction and vesicoureteral reflux.1 Although plausible in the near future, a paucity of evidence currently exists that supports the discontinuation of prophylactic antibiotics in patients with asymptomatic high grade reflux. 1. McKenna, P. H. and Herndon, C. D. A.: Voiding dysfunction associated with incontinence, vesicoureteral reflux and recurrent urinary tract infections. Curr Opin Urol, 10: 599, 2000
ERRATUM RE: SURVEY RESULTS ON MEDICAL AND SURGICAL FOLLOWUP OF PATIENTS WITH VESICOURETERAL REFLUX FROM AMERICAN ASSOCIATION OF PEDIATRICS, SECTION ON UROLOGY MEMBERS C. D. A. Herndon, F. A. Ferrer
AND
P. H. McKenna
J Urol, 165: 559 –563, 2001 To the Editor. I agree with the authors regarding their response to my comments on the treatment of high grade vesicoureteral reflux. A
VON HIPPEL-LINDAU DISEASE Volume 165, Number 4, page 1207: Sentence 1 in the Case Report is, “An asymptomatic 47-year-old woman was diagnosed as an obligate carrier of a mutant VHL gene (the diagnosis of VHL in her daughter led to retrospective diagnoses in her brother and mother).”
Vol. 166, 1402–1403, October 2001 Printed in U.S.A.
Letters to the Editor RE: MANAGEMENT OF DIAPHRAGMATIC INJURY DURING LAPAROSCOPIC NEPHRECTOMY S. R. Potter, L. R. Kavoussi
AND
S. V. Jackman
J Urol, 165: 1203–1204, 2001 To the Editor. The authors describe a rare, potentially life threatening complication of laparoscopic radical nephrectomy, and propose a technique to repair the diaphragmatic injury and relieve the pneumothorax. This report is important as this complication may occur more frequently with the increasing popularity of laparoscopic techniques. This technique to treat the pneumothorax involves a “blind” procedure with new potential risks to the patient. We offer a different approach using similar techniques. Instead of inserting the catheter at the end of the operation through the intercostal space, we insert the needle through the abdominal wall using laparoscopic vision before tying the sutures used to repair the diaphragmatic tear. The catheter is then inserted through the tear and the pneumothorax is aspirated under a deep inspiratory breath provided by the anesthesiologist, as reported by the authors. Once the pneumothorax has resolved, the sutures are tied and the catheter is withdrawn. The good results of this procedure are confirmed intraoperatively by normalization of the respiratory parameters, namely end inspiratory pressure and tidal carbon dioxide levels. Although our technique to treat this complication constitutes a minor change of the technique described previously, we believe it is safer because it is performed under direct vision and may help urologists to manage this injury better. Respectfully, Oscar Fugita Divisa˜o de Urologia Hospital das Clı´nicas Faculdade de Medicina da Universidade de Sa˜o Paulo Sa˜o Paulo, Brazil
Reply by Authors. As noted by Fugita, diaphragmatic injury may occur more frequently as laparoscopy becomes increasingly popular. The method of pneumothorax aspiration reported by Fugita seems excessively complex. Aspiration before desufflation is counterintuitive, as insufflated carbon dioxide will enter the chest with every patient exhalation until desufflation or diaphragm closure is performed. We advise against Fugita’s recommendation of confirming pneumothorax resolution by normalization of respiratory parameters alone. In patients with adequate cardiac reserve a significant injury may be missed in this manner and resolution must be confirmed by intraoperative radiography. The use of a modified central venous catheter for aspiration of intrathoracic air is a time tested technique that is safe, quick, inexpensive and uses readily available equipment without prolonging operative time.
pressure, posterior urethral sensitivity or neobladder capacity. Overall, urinary control seemed to improve using this technique in this pilot series. Wide anatomical dissection around the prostate during radical cystectomy and prostatectomy, including the posterior aspects of the bladder base and seminal vesicles, may disrupt afferent and efferent innervation of the trigone, neobladder neck and posterior urethra. The increase in posterior urethral sensitivity after radical prostatectomy is suggestive of partial damage to the pelvic innervation.1 Therefore, we have proposed previously the concept of the seminal vesicle sparing technique to preserve the pelvic plexus and improve urinary continence in patients undergoing radical prostatectomy.2 Complete resection of the seminal vesicles is not necessary from an oncological viewpoint.3 Finally, recent immunohistochemical studies have shown that quantified nerve fiber density in trigonal biopsies before and after radical prostatectomy corresponded with posterior urethral sensory threshold and urinary continence.4 These findings indicate that intraoperative pelvic denervation and reinnervation take place during the first postoperative months. Seminal vesicle sparing tumor surgery for prostate and bladder cancer seems to achieve better early urinary continence rates. Thus, we encourage the authors to enlarge this series and add conclusive preoperative and postoperative urodynamic evaluations. Respectfully, Hubert John and Dieter Hauri Clinic of Urology Zu¨rich University Hospital 8091 Zu¨rich Switzerland 1. John, H., Sullivan, M. P., Bangerter, U. et al: Effect of radical prostatectomy on sensory threshold and pressure transmission. J Urol, 163: 1761, 2000 2. John, H. and Hauri, D.: Seminal vesicle sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology, 55: 820, 2000 3. Korman, H. J., Watson, R. B., Civantos, F. et al: Radical prostatectomy: is complete resection of the seminal vesicles really necessary? J Urol, 156: 1081, 1996 4. John, H., Hauri, D., Leuener, M. et al: Evidence of trigonal denervation and reinnervation after radical retropubic prostatectomy. J Urol, 165: 111, 2001
RE: URETHRAL RECURRENCE OF TRANSITIONAL CELL CARCINOMA IN A FEMALE PATIENT AFTER CYSTECTOMY AND ORTHOTOPIC ILEAL NEOBLADDER J. Jones, S. W. Melchior, R. Gillitzer, J. Fichtner, M. El-Mekresh and J. W. Thu¨roff J Urol, 164: 1646, 2000
To the Editor. While we have at least 2 decades of experience with orthotopic bladder reconstruction in men undergoing radical cystectomy for bladder cancer, the experience with urethra sparing cystectomy and orthotopic bladder substitution in women has RE: NERVE AND SEMINAL SPARING RADICAL CYSTECTOMY gained popularity only recently. This report describes an adverse WITH ORTHOTOPIC URINARY DIVERSION FOR SELECT outcome in a woman with an orthotopic ileal neobladder. This PATIENTS WITH SUPERFICIAL BLADDER CANCER: AN failure among many successfully cases is definitely noteworthy to INNOVATIVE SURGICAL APPROACH show the shortcomings of this procedure. However, in view of several R. Colombo, R. Bertini, A. Salonia, L. F. Da Pozzo, F. Montorsi, unusual circumstances in this extraordinary case it can be dangerM. Brausi, M. Roscigno AND P. Rigatti ous to make general conclusions about urethra sparing cystectomy and orthotopic ileal neobladder in women. J Urol, 165: 51–55, 2001 The location of the tumor at cystectomy was at the bladder base. In To the Editor. The authors report excellent functional results in 8 previous publications we have emphasized that a common lymphatic patients who underwent cystoprostatectomy with a nerve and sem- drainage exists between the bladder and the vagina, particularly in inal vesicle sparing technique. Daytime and nighttime urinary con- the area of the bladder base.1 Therefore, we and other institutions tinence had been achieved completely at catheter removal in all have advocated removing the anterior vaginal wall in patients with patients, which is early in our experience. However, the authors do transitional cell cancer of the bladder, regardless of location.2 Leavnot report any urodynamic data, such as maximal urethral closure ing the entire vagina, as was apparently done, is even more risky in 1402
1403
LETTERS TO THE EDITOR this case due to the tumor location in the adjoining bladder base and its known lymphatic spread. Grossly involved lymph nodes may be considered an additional risk factor, which may result in alterations of the lymph drainage leading to centripetal lymphatic tumor cell spread caudally alongside the urethra or dorsally towards the paravaginal and pararectal space. Once this tumor reaches a certain size, it is almost impossible to differentiate whether it originated from a local metastasis or is a recurrence at the urethrointestinal anastomosis. Long-term survival in patients with lymph node involvement is dependent on the number of positive nodes and extent of lymphadenectomy during cystectomy.3 However, even if complete cystourethrectomy and extensive lymphadenectomy had been performed in this patient, the probability that she would have survived the next 5 years without systemic chemotherapy would be in the range of 17% to 35%, depending on the number of tumor positive nodes. At cystectomy several adverse signs for performing urethra sparing cystectomy, namely tumor location, preservation of the entire vaginal wall and advanced pelvic lymph node involvement, were disregarded. If one had become aware of the true pathological stage on receipt of the final pathology report, the current mandatory treatment for such a patient would have been systemic combination chemotherapy and careful regular followup, including cytology, urethroscopy and vaginal inspection. Considering the problematic management of this case and the dire prognoses due to disease biology at cystectomy, it is difficult to make any conclusions on the use of an orthotopic neobladder in female patients undergoing cystectomy for bladder cancer truly confined to the bladder. A constellation of such findings occurs in only a small fraction of patients undergoing cystectomy. However, recommendations based on this case cannot be applied to the majority of female patients undergoing cystectomy in whom tumor is confined to the bladder specimen. These women will be good candidates for orthotopic bladder substitution, which does not mean an oncological compromise but a significant benefit in quality of life. Respectfully, Arnulf Stenzl Department of Urology University of Innsbruck Medical School A-6020 Innsbruck Austria 1. Stenzl, A., Colleselli, K., Poisel, S. et al: The use of neobladders in women undergoing cystectomy for transitional-cell cancer. World J Urol, 14: 15, 1996 2. Stenzl, A., Colleselli, K., Poisel, S. et al: Rationale and technique of nerve sparing radical cystectomy before an orthotopic neobladder procedure in women. J Urol, 154: 2044, 1995 3. Lerner, S., Skinner, D., Lieskovsky, G. et al: The rationale for en bloc pelvic lymph node dissection for bladder cancer patients with nodal metastases: long-term results. J Urol, 149: 758, 1993
misprint in my editorial indicated that I discontinue prophylactic antibiotics and imaging in children older than 5 or 6 years who have persistent asymptomatic bacteruria grade III to V. This statement should have been that I discontinue prophylactic antibiotics and imaging in children older than 5 or 6 years with asymptomatic grades of reflux less than III/V (III out of V). It is not my practice to discontinue treatment in high grades of reflux, even in asymptomatic children. While this method may have some merit, there are only preliminary data to support nontreatment. Respectfully, David B. Joseph Department of Surgery, Section of Pediatric Urology Children’s Hospital University of Alabama at Birmingham 1600 7th Ave. S Birmingham, AL 35233-1711 1. Cooper, C. S., Chung, B. I., Kirsch, A. J. et al: The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol, 163: 269, 2000
Reply by Authors. Our approach to the management of asymptomatic high grade vesicoureteral reflux involves eliminating risk factors that contribute to breakthrough infections, which represent the most common indication for antireflux surgery. We concur with the editorial and currently continue all patients with high grade reflux on prophylactic antibiotics in conjunction with directed therapy to address dysfunctional pelvic floor, which we believe is the underlying etiology of breakthrough infection and perhaps reflux in a significant number. We institute a conservative medical program that concentrates on hydration, timed voiding, hygiene and, most importantly, elimination of constipation via an intense bowel management program to compliment our computer game assisted, biofeedback program. With this approach an impressive reduction in breakthrough infection has been demonstrated in patients with voiding dysfunction and vesicoureteral reflux.1 Although plausible in the near future, a paucity of evidence currently exists that supports the discontinuation of prophylactic antibiotics in patients with asymptomatic high grade reflux. 1. McKenna, P. H. and Herndon, C. D. A.: Voiding dysfunction associated with incontinence, vesicoureteral reflux and recurrent urinary tract infections. Curr Opin Urol, 10: 599, 2000
ERRATUM RE: SURVEY RESULTS ON MEDICAL AND SURGICAL FOLLOWUP OF PATIENTS WITH VESICOURETERAL REFLUX FROM AMERICAN ASSOCIATION OF PEDIATRICS, SECTION ON UROLOGY MEMBERS C. D. A. Herndon, F. A. Ferrer
AND
P. H. McKenna
J Urol, 165: 559 –563, 2001 To the Editor. I agree with the authors regarding their response to my comments on the treatment of high grade vesicoureteral reflux. A
VON HIPPEL-LINDAU DISEASE Volume 165, Number 4, page 1207: Sentence 1 in the Case Report is, “An asymptomatic 47-year-old woman was diagnosed as an obligate carrier of a mutant VHL gene (the diagnosis of VHL in her daughter led to retrospective diagnoses in her brother and mother).”