Prognostic Significance of Lymphovascular Invasion in Bladder Cancer after Surgical Resection:A Meta-analysis

Bladder cancer remains a commonly diagnosed malignancy worldwide,bringing huge economic burden and high morbidity for patients. Assessment of prognostic significance of lymphovascular invasion（LVI） is a critical issue in the surgical management of bladder cancer after transurethral resection or radical cystectomy. A systematic search of Pub Med,Embase and Cochrane Library was performed up to Oct 10,2014 to identify eligible studies. Outcomes of interest were collected from studies comparing overall survival（OS）,cancer specific survival（CSS） and recurrence free survival（RFS） in patients with the LVI. Results of studies were pooled,and combined hazard ratios（HRs） with corresponding 95% confidence intervals（CIs） for survival were used as the effect size estimation. Funnel plots were done to show the publication bias,while the forest plots and subgroup analyses were used to limit the heterogeneity. A total of 20 studies（10 663 patients） met the eligibility criteria and were included for this meta-analysis. Our pooled results showed that there were significant differences in OS（pooled HR,1.71; 95%CI,1.52–1.92; P〈0.00001）,CSS（pooled HR,2.25; 95% CI,1.80–2.81; P〈0.00001） and RFS（pooled HR,1.91; 95% CI,1.57–2.32; P〈0.00001） between the patients with LVI and the patients without LVI. There were significant heterogeneities observed in the studies concerning the relationship between LVI and CSS,RFS. There was no clear evidence of publication bias. When tumor stage was beyond T3,LVI lost its predictive value for CSS and RFS. For the patients who had negative lymph nodes,LVI was still an adverse predictor. Our pooled results demonstrate that LVI indicates poor prognosis of patients with bladder cancer after surgical procedures,and it can be of particular importance in clinical practice. However,these results need to be further confirmed by more adequately designed prospective studies.

Laparoscopic radical cystectomy with orthotopic ileal neobladder: report of 33 cases

Background The laparoscopic radical cystectomy (LRC) with orthotopic ileal neobladder is now applied to treat invasive bladder cancer, however, it has not been well codified and illustrated We describe in this paper a technique step by step that we have developed in 33 patients and achieved excellent results Methods The surgical procedure can be divided into eight steps: laparoscopic pelvic lymphadenectomy and mobilization of the distal ureters; exposing Denonvillier’s space and the posterior aspect of prostate; exposing retropubic space and anterior surface of the bladder; dividing the lateral pedicles of the bladder and the prostate; dividing the apex of the prostate; extracorporeal formation of the ileal pouch; extracorporeal implantation of the ureters; and laparoscopic urethra neobladder anastomosis This operation was performed in 33 patients, 29 males and 4 females, with muscle invasive bladder cancer between December 2002 and September 2004 Results The operating time was 5 5-8 5 hours with an average of 6 5 hours; the estimated blood loss was 200-1000 ml with an average of 460 ml The surgical margins of the bladder specimen were negative in all patients There was no evidence of local recurrence at follow up of 1-21 months in all the patients However lymph node metastases were found in one case at 9 months postoperatively Most of patients achieved urine control 1 to 3 months after surgery The daytime continence rate was 94% (31 cases) and nighttime continence rate was 88% (29 cases) Urodynamic evaluation was performed between 3 and 6 months postoperatively for all cases The mean value of neobladder capacity was (296±37) ml The mean value of maximum flow rate was (18 7±7 1) ml/s The mean residual urine volume was (32±19) ml In all cases, excretory urography at 1 to 2 months postoperatively demonstrated slightly dilated upper urinary tracts without ureteral obstruction, which resolved at follow up Cystography showed neobladders being similar in shapes to normal Two small ureteral nipples with intermittently efflux of urine were observed at cystoscopy in most patients Postoperative complications occurred in 6 of 33 patients (18%), including pouch leakage in 2 cases, pelvic infection in 1, partial small bowel obstruction in 2 and neobladder vaginal fistula in 1 Conclusions The LRC with orthotopic ileal neobladder is a feasible option for bladder cancer when radical cystectomy is indicated The extracorporeal formation of the ileal pouch and ureteral implantation through a small lower midline incision can simplify the complexity of the procedures, shorten the duration of surgery and reduce the medical expenses

Orthotopic ileal neobladder similar to original bladder

Objective To report the surgical techniques and results of an 8-year follow-up study of 42 patients with a modified orthotopic ileal neobladder restoring normal anatomical relationship. Methods Total cystoprostatectomy was performed extraperitoneally. A 45-50 cm segment of the ileal loop was isolated, detubularized, and reconfigured into an “M”-shape to form a pouch. Bilateral ureters were implanted by inserting 1 cm distal segment into the pouch. The bottom of pouch was opened and anastomosed with the urethra. Results Forty-two patients were followed up for 6 to 96 months,90.5% of whom were continent in the daytime, and 85.7% at night. Two patients had a difficulty in urination. The average volume of the pouch was (361±48) ml at 12 months postoperation. Urodynamic examination showed the average peak voiding pressure was (86.8±21.4) cmH 2O. The average maximum flow rate (Qmax) was (18.4±6.1) ml/s. No remarkable ureter reflux and obstruction were found. No patient was detected to have urethral carcinoma.Conclusions Extraperitoneal cystectomy can avoid the tumor contamination of the abdomen and intestinal interference of the operative field. The ureter-inserting implantation technique is a simple anti-reflux anastomosis method with less ureter stenosis rate. Isolating the neobladder and ureters from the peritoneal cavity can reduce the postoperative complications, such as adhesive ileus, internal hernia, and urine leakage into the peritoneal cavity. The neobladder is similar to the original bladder in position, volume, shape and anti-reflux ureter connection.