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ABSTRACT
Year : 2016  |  Volume : 8  |  Issue : 5  |  Page : 16-52  

Bladder Cancer


Date of Web Publication18-Dec-2015

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How to cite this article:
. Bladder Cancer . Urol Ann 2016;8, Suppl S1:16-52

How to cite this URL:
. Bladder Cancer . Urol Ann [serial online] 2016 [cited 2020 Jan 25];8, Suppl S1:16-52. Available from: http://www.urologyannals.com/text.asp?2016/8/5/16/172183

Carcinoma bladder: 10 years experience at R.A.F.H

Mansoorul Haq Baqai, M. S. Abomelha, K. Al Otaibi, M. Kourah, A. Al Elaiwai


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

During 1979-1988, at Riyadh Armed Forces Hospital, 80 patients with Carcinoma Bladder were managed by the Department of Urology. These included 69 males and 11 females. Their ages varied from 27-88 years with a mean of 56.9 years. There were 60 cases of transitional cell carcinoma, 17 squamous cell and 3 adenocarcinoma. Basically, they were divided into Group A (25) or Superficial Tumours (G1-2, T1-2) and Group B (55) or Deep Tumours (G34, T3-4).

Group A was mainly treated by transurethral resections and followed with check cystoscopies with good results. Group B was further divided into clinically operable and non-operable tumours.

Non-operable tumours were treated with palliative radiotherapy with poor results. In the operable tumours group some patients refused surgery and therefore treated with radiotherapy alone and acted as control. Others were treated with radical surgery with much better results. As more and more patients are accepting the advice of radical surgery, our results are improving accordingly. The results in general are discussed.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Transitional cell carcinoma urinary bladder

M. Milad, T. Zein, F. Ayyat, S. Rabadi


Department of Urology, Dhahran Health Centre, Aramco, Dhahran, Saudi Arabia

A retrospective study of thirty-four patients with bladder tumour was done at Dhahran Health Centre from 1981 to 1988. Twenty-five of these were superficial, six had muscle invasion and three presented with metastasis. Age ranged from twenty-six to eighty years with 24% below the age of forty years. Male to female ratio 15:1. Clinical presentation was gross hematuria in 60%, 22% microscopic, 16% presented with urinary retention and 2% had non-specific symptoms. 60% had suspected risk factors ranging from smoking to working in industrial chemical plants. Twenty-three are still alive at the completion of the follow up. Two are dead and seven lost to follow up or refused treatments with a survival rate of 68%, considering all non-complaints as non-survivals. Of those superficial tumours: twenty-three were treated with transurethral resection and three underwent partial cystectomy because of position of tumour or obstruction of ureteral orifice. Multiple biopsies were done on these cases before surgery. All had intravesical chemotherapy. Three had recurrence, two out of these were treated and one lost to follow up. None had progression of the disease. Two of the recurrences had Grade II and the third had Grade III tumour.

A review and comparison of the literature is conducted.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Prophylactic MIP and BCG immunotherapy of recurrent superficial bladder tumours: Preliminary report

El-Housseiny I. Ibrahiem 1,2 , M. A. Ghoneim 1,2 , V. Nigam 1,2 , C. Brailovsky 1,2 , M. M. El-Hilali 1,2

1 Urology and Nephrology Center, Mansoura University, Mansoura, Egypt, 2 McGill University, Montreal and CHUS, Sherbrooke, Quebec, Canada

Our objective in this work is to study the efficiency of a newly developed synthetic immuno-adjuvant (MIP) in reducing the rate of recurrence of superficial bladder tumours and to compare it with the BCG. Forty-seven patients with recurrent superficial transitional cell carcinoma (T.C.C.) of the bladder were randomly divided into 3 groups: 1-control (15 patients); they underwent transurethral resection (TUR) only. 2 - BCG (17 patients) they were treated by TUR and BCG. 3 - Maltose tetrapalmitate (MTP) group (15 patients): they were treated by TUR and MTP. The mean period of follow up was 22.93 months for the control, 24.4 for MTP and 28.0 for BCG group. The recurrence rate/100 pt month was 11.34 in the control, 7.4 in the BCG and 7.19 in the MTP group. The recurrence index/month (RI/m) was 0.113 for the control, 0.070 for BCG and 0.072 for MTP group. The recurrence rate and RI/m are significantly reduced in the treated groups (P<0.005) compared to the control. There was no significant difference between BCG and MTP groups. Invasive carcinoma developed in 60% of patients in the control group, 29.4% in the BCG and 20% in the MTP. These invasive carcinoma required cystectomy or definitive radiotherapy. BCG caused irritation of the bladder mucosa while MTP did not have any side effects. The work is still in progress.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Pattern of bladder carcinoma in Assir region

S. D. Shetty, A. Ibrahim, K. P. Patil, S. Al-Kotob, R. Awad, N. K. Hussein


Departments of Urology and Pathology, College of Medicine, King Saud University (Abha Branch), and Assir Central Hospital, Abha, Saudi Arabia

On reviewing 7251 cancer cases treated at KFSH El-Akkad et al. found that the highest proportion of bladder cancer among males was from Assir Region and attributed this to the endemicity of Schistosomiasis. We have reviewed all Genito-urinary malignancies presenting to the 2 major hospitals in the region from 1407 till date. Among a total of 40 cases, 24 (66%) were bladder cancers, of which 15 (62.5%) were transitional cell carcinoma (TCC), 8 (33.3%) were squamous cell carcinoma (SCC) and 1 (6%) was adenocarcinoma. In all SCC cases, the tumor was deep (Ts, T4) and was associated with unilateral or bilateral hydronephrosis. 66.6% of TCC was deep infiltrating type (T3, T4). Histologically, more than 85% of both TCC and SCC were moderate to poorly differentiated tumors and all SCC cases were associated with schistosomiasis.

It appears that although schistosomiasis is endemic in Assir Region, most of the bladder cancer cases seen in our hospitals are unexpectedly TCC.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Prevalence of bladder carcinoma in Jizan region

Akhileshwar Jha, Anupam Bhargava


Department of Urology, King Fahd Central Hospital, Jizan, Saudi Arabia

Geographical differences in the incidence of the bladder cancer is well known but reason is not fully established. In our retrospective study in Gizan area for the period of 5 years, we have found a statistically significant difference in the incidence and histopathological pattern, compared to the available literature.

In our studies, 13% of the patients had adenocarcinoma in to the studies made in the Schistosomal endemic area in Egypt, where it was 5%. The details of the prevalence and histopathological patterns are analysed and discussed.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Adenocarcinoma of urinary bladder with urethral metastasis

Anupam Bhargava, Akhileshwar Jha


Department of Urology, King Fahd Central Hospital, Jizan, Saudi Arabia

Pure adenocarcinoma of the urinary bladder is infrequent and constitutes about two percent of all epithelioid tumors. [1]

Urethral metastasis are rare. We report a case of primary urinary bladder adenocarcinoma with early urethral metastasis following urethral mucosal injury.

Reference:

1. Koss LG. Tumors of the urinary bladder. Atlas of Tumor Pathology. Second Series. Washington, D.C.: Armed Forces Institute of Pathology; 1975. p. 54.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Signet-ring cell carcinoma of bladder: Case report and review of literature

Y. Purnanandam


Department of Urology, King Saud Hospital, Ministry of Health, Jeddah, Saudi Arabia

Among the less common malignancies of bladder, the most prevalent is adenocarcinoma. It has been reported not only in the common form but also less common variants like signet-ring cell carcinoma. The characteristic feature of this carcinoma is the mucous glandular differentiation and production of mucin. This type of cancer occurs rarely and shows very few reports in the literature. In this presentation, we aim to report one such case of signet-ring cell carcinoma, an adenocarcinoma and review of literature with guidelines for management.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Radical T.U.R. and radiotherapy for treatment of invasive T3 bladder tumours

Ayman Kashif Al-Ghatta, Abdullah Fallatah


Department of Urology, King Fahd Hospital, Jeddah, Saudi Arabia

Total cystectomy and urinary diversion is a mutilating operation, incurable and unacceptable in a high proportion of the patients. Our aim in this small group of advanced bulky bladder tumours is to present the results of an alternative method to control the tumours locally and let these patients live happily with a functional bladder. The methods of treatment done in this group are as follows:

  1. Removing the bulk of the tumour by transurethral resection in one or more sessions
  2. Destroy the tumour cells in the deep infiltrating parts of the tumours, as well as micro-extension of the perivesical and pelvic lymphatic by radical dose of radiotherapy
  3. The combination of No. 1 and No. 2 will hopefully reduce the incidence of local recurrence which constitutes the major cause of treatment failure.


The initial results are encouraging, that unrespective of the primary treatment, the average overall 17.4 months survival rate is 100%. Good prognostic factor has shown in all of our patients at first check cystoscopy after completion of their T.U.R. and radiotherapy. T.U.R. as primary therapy for advanced bladder tumours is inadequate to control the local tumours but it's effectiveness role can help a majority of the cases to enhance the effectiveness of the radiotherapy and to preserve their bladder without the need for cystectomy. Salvage cystectomy or chemotherapy or both for persistent unresponsive or distant metastasis tumours.

Presented at the: 6 th Saudi Urological Conference

National Guard King Khalid Hospital - Jeddah

27-28 November 1991

Management of bladder tumours

M. A. Ghoneim


Faculty of Medicine, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

From the therapeutic point of view, tumours of the bladder will be considered under 3 categories; superficial tumours, ca-in-situ, and infiltrating tumours. For superficial tumours; the standard treatment was and still by T.U.R.B. The indications of and methods for adjuvant treatment will be presented. These will include intravesical chemotherapy and/or immunotherapy, photodynamic therapy...etc. The dilemma of and the controversies in classification and management of ca-in-situ will be critically analysed. The role of B.C.G. therapy in particular will be emphasized. Evaluation of cystectomy, radiotherapy and chemotherapy used as single agents or in a multimodal fashion for the treatment of infiltrating tumours will be discussed. Future prospects for the management of bladder tumours will be also presented.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Management of advanced locally invasive bladder cancer: R.K.H. experience

M. H. Baqai, M. Qasim, M. S. Abomelha, K. E. Al-Otaibi


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Radical cystectomy for the treatment of locally advanced bladder carcinoma T3-4 Nx Mo has always been a controversial subject, 5 years survival being <30% with all of its associated morbidity and mortality. Recent trend has shifted towards chemotherapy with or without radiotherapy with encouraging results and added benefit of bladder conservation. A protocol was devised at Riyadh Armed Forces Hospital in the form of two cycles of chemotherapy (Carboplatin, Methotrexate and Vinblastine - Day 1 and Day 22) followed by a course of radiation 4000 cGy to the bladder and true pelvis. Patients with complete remission were given a boost with two more cycles of carboplatin and 2000 cGy to bladder. If partial or no response was seen alternative methods were offered. A total of 23 cases were included in this study. One patient (4%) did not respond. 7 patients (30%) had partial response whereas 15 patients (66%) had complete remission 13/15 (87%) disease for a period of 3-30 months, and 2/15 (13%) developed metastases at 6 and 24 months with local disease still under control in one.

We conclude that locally invasive advanced bladder carcinoma can be managed with combined chemo and radiotherapy with comparable results to cystectomy and with added benefit of bladder conservation.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

The epidemiological features of bladder tumour among native Saudi Arabians at the Riyadh central hospital

S. Kattan, A. Youssef, A. Al Jasser, R. Al-Iriyan, V. C. Onoura, M. Patil


Department of Urology, Riyadh Central Hospital, Riyadh, Saudi Arabia

In a retrospective study, the records of 54 Saudi patients constituting 35.2% of the total number of patients with bladder tumours presenting to Riyadh Central Hospital, over a seven year period from 1985 to 1992 were reviewed.

81% of the patients were habitant of the Central Province of Saudi Arabia, the mean age of patients was 60 years ± 14.8 years with a male:female ratio of 5:1. Gross hematuria was the main presenting symptom in approximately 90% patients. More than 45% of patients presented 6 months or more after the onset of symptoms. 76.9% of tumours were transitional cell carcinoma, 19.2% were squamous cell carcinoma and 3.85 were poorly differentiated. 28.8% were superficial tumours while 71.1% were at least muscle invading. Hydronephrosis either unilaterally or bilaterally was presenting in 50% of cases and 31.1% had evidence of regional or distant metastasis at time of initial presentation. The majority of the tumours were of high grade (Grade II or III) in nature. This study shows that high grade muscle invasive transitional cell carcinoma is the most frequently encountered bladder tumour in the Central Province of Saudi Arabia. Delay in the patient presentation, associated with aggressive biological behaviour of the tumour in this region resulted in high percentage of incurable disease.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Spectrum of bladder cancer in Hafr Al Batin area

B. Akintan


Department of Urology, King Khaled General Hospital, Hafr Al Batin, Saudi Arabia

All cases of histologically proven bladder cancer admitted to King Khaled General Hospital over the past 5 years (1407-1412) were reviewed. Cases included are those whose initial diagnosis was made at this centre.

We are interested especially in mode of presentation, diversity of ethnicity vis a vis, histopathologic types, management and eventual outcome.

Findings reveal a low incidence of bladder tumour when viewed against total hospital admission. An unpleasant observation is the delay in presentation of most of the cases giving rise to grossly abnormal radiological changes. This peculiar situation renders treatment for cure in most cases impossible. It is extremely frustrating for the referring Consultant to be left totally in the dark about the outcome of referred cases. In almost all cases, there was no formal reply to consultations and so the fate of the patient were never know. The sample cases to be presented in detail will illustrate some of these peculiar problems.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Bilharziasis and bladder carcinoma in Gizan region of Saudi Arabia

A. Jha, A. Bharghava, A. Chatterjee, V. P. Pathak, K. S. Abdul Wahab, K. Zachariah


Department of Urology, King Fahad Central Hospital, Gizan, Saudi Arabia

The Gizan region of Saudi Arabia has high incidence of bladder cancer. Out of 136 cases studied over a period of 10 years, in K.F.C.H., Gizan, 88.2% were males, 11.8% females, 41.9% Yemeni and 58.1% Saudi, of that histopathologically, 42.64% were T.C.C., 44.85% were S.C.C. and 12.5% adenocarcinoma, a statistically significantly higher percentage than reported in world literature. Cause for which remains obscure and needs further study although factors are considered.

Bilharziasis was present in 47.05% of total cases, statistically significantly higher in Squamous Carcinoma cases (75.4%) compared to T.C.C. (22.4%) and Adenocarcinoma (35%) in our study.

Results of study are analysed and compared with the world literature specially with studies conducted in the Bilharzial endemic areas.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Prognostic factors in primary non-urachal adenocarcinoma of the urinary bladder: A clinical, histopathologic and flow cytometric

A. A. Shaaban, B. Tribukait, M. A. El-Baz, M. A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Flow cytometric DNA analysis was carried out retrospectively on paraffin-embedded archival material of 93 primary pure non-urachal adenocarcinoma of the urinary bladder treated between 1981 and 1990. Tumors were classified according to histopathologic grade, stage, nodal pathology and flow cytometric DNA ploidy pattern and fraction of cells in the S-phase. The incidence of grossly aneuploid tumors was 88%. Mean follow up was 24.1 ± 21.5 months. The crude overall survival was 62% and 50% at 2 and 5 years, respectively. Prognosis had significant correlation with tumor stage, grade and nodal pathology. The DNA ploidy pattern and fraction of cells in S-phase had no relation to stage, grade and prognosis. Our results demonstrated that the DNA ploidy pattern and fraction of cells in S-phase are not prognostic parameters in non-urachal adenocarcinoma of the bladder due to the very high incidence of aneuploidy.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

T-cell activation and impaired cell mediated immunity in patients with carcinoma of urinary bladder with schistosomiasis

S. Raziuddin, S. Shetty, A. Ibrahim


Department of Clinical Immunology, Department of Urology, College of Medicine, King Saud University and Asir Central Hospital, Abha, Saudi Arabia

Patients with schistosomiasis of the urinary bladder (SB) associated with carcinoma of the bladder (SCB) or carcinoma of the prostate (SCP) have a variety of immunologic abnormalities, including the presence of HLA-DR+, interleukin-2 receptor+ (IL-2R+) and gamma/delta positive T cells in circulating blood. This study demonstrated that HLA-DR+, IL-2R+ and yd+ antigens are selectively expressed on majority of CD4+ T lymphocytes of patients with SCB. Expression of T cell activation antigens and highly depressed response of this T cell subset (CD4+ 5 cells) to phyto-hemagglutinin and concanavalin A stimulations seems to be the characteristic feature of patients with SCB. In addition patients T cells (SCB) demonstrated a highly depressed response in autologous (AMLR) and allogeneic (MLR) mixed lymphocyte reaction. The immunoregulatory role of HLA-DR+, IL-2R+, gamma/delta + CD4+ helper/inducer T cells and the AMLR and MLR abnormalities we have identified in patients with SCB may be important and could play a role in the pathobiology of these diseases in humans.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Transurethral ultrasonography in staging of bladder cancer

B. A. Kamal


Department of Urology, King Faisal University, Al Khobar, Saudi Arabia

This study was done on 103 cases of bladder carcinoma diagnosed by cystoscopy and bladder biopsy in order to study the efficacy of transurethral ultrasonography in staging of bladder cancer. The group of 103 patients were found to have 137 tumours (some patients had multiple tumours). 39 tumours were excised in the course of cystectomy, 67 tumours were removed in the course of transurethral resection and thirty one tumours were excluded from the study because of incomplete histological staging. Stage O and A (TA and TI) were merged together. The accuracy of transurethral ultrasonography in staging O and A was 100%.

Stage B1 tumours were staged with 95.7% accuracy. Stage B2 were staged with a 96.8% accuracy. As for stage C and D tumours, they were staged with an accuracy of 70% and 50% respectively. The overall accuracy of transurethral ultrasonography was 92.6%. Transurethral ultrasonography was found very helpful. Also, monitoring transurethral resection of bladder carcinoma with accuracy of 89.5%.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Cytokine profile in patients with carcinoma of urinary bladder with schistosomiasis

S. Raziuddin, A. Ibrahim


Department of Clinical Immunology and Department of Urology (Surgery), King Saud University, School of Medicine and Asir Central Hospital, Abha, Saudi Arabia

Cytokines, such as tumor necrosis factor-alpha (TNFa) products of activated immune system are the important mediators that participate in a variety of cellular responses and pathogenesis of various immune disorders including malignancy. Carcinoma of the urinary bladder is the most common malignancy worldwide. In some patients schistosomiasis (Schistosoma haematobium) has been associated with carcinoma of the urinary bladder that affects relatively a young age group. We here demonstrate that serum levels of TNF-a are highly elevated in patients with schistosomiasis of urinary bladder (SB), schistosomiasis with carcinoma of urinary bladder (SCB) and carcinoma of urinary bladder without schistosomiasis (CB). The highly purified monocytes from bladder cancer (i.e. SCB and CB) cultured without exogenous stimuli release TNF-a in the culture supernatant. The findings that monocytes are the potent producers of TNF-a in this malignancy may be a key observations to implicate these cells in the pathophysiology of this disease. Furthermore, it was shown that serum TNF-a levels correlated with clinical staging of disease with higher levels in T3 and T4 advanced stage patients and low levels in T1 and T2 low stage patients. These results suggest that TNF-a levels might be one of the factors contributing to the progression of disease.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Carcinoma of the urinary bladder in Saudi Arabia: Clinical experience

M. S. Abomelha, A. Shaaban, S. Orkubi, M. T. Said, K. Al Otaibi


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

We present 235 patients with bladder cancer treated at Riyadh Armed Forces Hospital between 1979 and 1994. Transitional cell carcinoma (TCC) was present in 174 patients (74%). Their ages ranged from 32 to 90 years (mean 64.2 ± 16.2) and the male-to-female ratio was 8:1. Squamous cell carcinoma (SCC) was found in 47 patients (20%), in a relatively young age group. The ages ranged from 33 to 85 years (mean 53.7 ± 14.4) and the male-to-female ratio was 4.2:1. TCC was papillary in 53% solid in 40%, mixed in 5% and 2 patients had carcinoma in-situ. The lesions were multifocal in 33 cases (19%) and involved the trigone bladder neck or prostatic urethra in 35 (20%). On the other hand, SCC showed solid nodular fungating masses in 44 patients (94%), malignant ulcers in 2 and fibrillary lesion in 1. Multifocal tumors were found in 6 patients (13%) and involvement of the trigone, bladder neck or prostatic urethra in 6 cases (13%). Evidence of bilharziasis was noted in 66 patients (28%), 19 patients with TCC (11%) and 39 with SCC (83%). The remaining cases comprised 11 undifferentiated tumors (4.7%) and 3 primary adenocarcinomas (1.3%). The majority of TCCs (60%) and almost all non-transitional cell cancers were muscle-infiltrative. Most of the neoplasms were of high grade.

Since most of the cases of bladder carcinoma are advanced at the time of diagnosis (70%) the importance of early detection is evident. Furthermore, SCC has particular clinico-pathologic features quite different from that seen with TCC.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

The bladder tumor antigen (BTA) test in bladder carcinoma: Preliminary report

A. A. Shaaban, S. A. Orkubi, M. T. Said, M. S. Abomelha


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

The Bard bladder tumor antigen (BTA) test is a latex agglutination test which detects the presence of basement membrane complexes in urine of patients with bladder cancer. We evaluated this test compared to voided urine cytology in 17 patients who underwent 21 diagnostic and follow up cystoscopies for bladder carcinoma. Tumors were diagnosed in 11 cases. Of these cases, 9 (82%) were correctly diagnosed with the BTA test compared to 5 (45%) with voided urine cytology. The remaining 10 cases had no evidence of malignancy by urine cytology, cystoscopy and random biopsies, one false positive BTA test was encountered. The result of this study indicated BTA test sensitivity of 82% and specificity of 90%.

Our preliminary results with a small number of patients indicate that the BTA test is simple and non-invasive diagnostic test, adjunct to cystoscopy in diagnosis of bladder carcinoma. Compared to voided urine cytology, the BTA test is more sensitive and less skill demanding.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Management of invasive urinary bladder carcinoma with vesical preservation

A. Fallatah, A. Shehab, M. Haggag 1 , M. Abu Zaid 2


Department of Urology, King Fahd Hospital, 1 Department of Oncology and Nuclear Medicine, Sulaiman Fakeeh Hospital, 2 Department of Urology, Al-Salama Hospital, Jeddah, Saudi Arabia

Eighty-three patients with histologically proven muscle invasive carcinoma of the urinary bladder were treated by endoscopic transurethral resection of bladder tumor (T.U.R.B.) followed by radical radiotherapy (R.T.). Vesical neoplasm received 60-65 GY over 6 weeks, while 40-50 GY in daily fractions were delivered for the whole pelvis. Seventy patients completed treatment protocol, 47 had transitional cell carcinoma (T.C.C.) while 23 showed squamous cell cancer (S.C.C.). They were followed-up for a period ranging between 12 to 42 months using cystoscopy, urine cytology and bladder biopsies every 3 months during the first year and twice yearly for a second year. Complete responders (C.R.) were followed conservatively while those with partial response (P.R.) were further treated with T.U.R.B. Tumor progression was treated aggressively using auxiliary means as in nonresponders (N.R.). Results were analyzed in relation to tumor response to treatment, patients direct survival and bladder preservation. An overall C.R. was achieved in 31 patients (44.3%), P.R. in 8 (11.4%) and N.R. in 31 cases (44.3%). T.C.C. had C.R. in 55.3% of cases as compared to only 21.7% in S.C.C. Tumor response to treatment correlated significantly with tumor staging. An overall 1 and 2 years direct survival was achieved in 60% and 44.9% of patients. T.C.C. cases had the highest survival chances, 70.3% and 65% at 1 and 2 years respectively. Bladder preservation could be achieved in 81% and 68.2% after 1 and 2 years for all living patients. We concluded that T.U.R.B. followed by R.T. is reliable bladder sparing technique that did not compromise either tumor clearance nor patient survival. An adjuvant systemic chemotherapy should be tried in a subpopulation of high stage, high grades S.C.C. and T.C.C. patients.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Bladder tumors and schistosomiasis

A. M. Peracha, A. H. Kardar, E. Lindstedt, S. Kattan


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Aim: To evaluate the types of bladder tumors associated with schistosomiasis in Saudi patients, their management and outcome.

Materials and Methods: 38 cases of schistosomiasis and bladder tumor managed at KFSH&RC between 1989-1995 were studied retrospectively. Age ranges from 27-75 years (mean 53). M:F ratio is 4:1. Gizan is the most common endemic area. Unilateral hydronephrosis was present in 9 patients (24%).

Results: Squamous cell carcinoma was the most common histological type, 16 patients (42%) followed by transitional cell carcinoma, 7 patients (18%), adenocarcinoma, 1 patient (2%) and sarcoma, 1 patient (2%). Cystectomy was performed in 21 patients (55%) with urinary diversion by means of rectosigmoid valved pouch in 8 patients, orthotopic bladder substitute in 5 patients, ureterosigmoidostomy in 3 patients, Kock-Ghoniem pouch in 2 patients, ileal conduit in 2 patients and cutaneous ureterostomy in 1 patient. Neoadjuvant chemotherapy was given to 4 patients. Radiotherapy was given to 15 patients (39%), 5 (33%) underwent salvage cystectomy later. In cystectomy patients follow-up ranges from 3-73 months (mean 22). Three patients were lost to follow-up. Tumor recurrence/metastases were confirmed in 8 patients (44%). Ten patients (56%) remain recurrence free.

Conclusion: In this group of patients, squamous cell carcinoma was the most common tumor followed by transitional cell carcinoma. Cystectomy was the preferred treatment, with good results.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Bladder cancer 5 year review, Dhahran health center

Twaik Zein, Moheb Milad, El Sayed Hussein, Luay Hajjar, Hisham Soliman


Department of Urology, Dhahran Health Center, Dhahran, Saudi Arabia

A 5 year retrospective review of bladder tumor was conducted at DHC from 1988 to 1993. The total number of cases were 40, male to female ratio was 12:1. Five of the patients were less than 30 years and 5 were between the ages of 31 and 45, i.e. 25% of the patients were below 45 years of age. The youngest patient was a 23-year old male. Gross hematuria was the presenting symptom in 31 cases (77.5%), microhematuria in 2 cases (5%) and obstructive uropathy in 7 patients (17.5%). The pathology was squamous cell carcinoma in 4 cases so they were excluded from the study. Transitional cell carcinoma was superficial in 31 cases (77.5%), (56%) of them had no lamina propria invasion. Cytology was positive in 19 cases (47.5%) of the total and in 35% only of the superficial tumors.

All patients were strictly followed up with physical examination and laboratory studies including urine cytology and cystoscopy. Of the patients with superficial disease, 15 were treated with intravesical chemotherapy. Out of 5 patients that presented with muscle invasion, one had radical surgery and 4 had definite radiation therapy. Seven patients had muscle invasion, one was treated with definite radiation therapy and the other with transurethral resection only due to medical reasons. All patients that underwent definite radiation therapy were followed up and had no progression over the study period.

It was found that TCC occurs at an earlier age group with male to female ratio more than the one reported in the literature to the disadvantage of males.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

High dose rate (HDR) brachytherapy, an alternative method in the treatment of bladder cancer

T. Merdad 1 , V. BeBoe 2 , G. Soete 2 , F. Keuppens 2


1
King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, 2 Department of Urology and Radiotherapy, Free University Hospital of Brussels, Belgium, Europe

Objectives: We evaluated the early results of high dose rate (HDR) Brachytherapy in the treatment of solitary bladder cancer (T1-T3).

Materials and Methods: Between July 1992 and July 1995, 16 patients with bladder cancer (solitary tumor with base not larger than 5 cm and absence of carcinoma in situ), underwent treatment with interstitial HDR radiotherapy (4 patients with pT1, 5 with pT2, 6 with pT3a and 1 with pT3b). Low dose external beam irradiation of 3 × 3.5 Gy was given preoperatively to prevent tumor seeding. A suprapubic cystostomy with implantation of 2 to 6 hollow nylon catheters at the base of the tumor was performed. Postoperatively treatment planning was followed by 15 × 3 Gy HDR irradiation with an Iridium 192 source through the implanted catheters. The patients were kept in bed during one week and prophylactics for thrombosis was administrated. During the follow up (4-41 months), cystoscopy was performed on a 3 month basis.

Results: The pT1 (4), the pT2 (5) and 2 of the pT3a (6) patients are currently alive and free of disease. From the remaining 4 patients, 2 died from intercurrent disease at 29 and 30 months postoperatively. The 2 other patients developed progressive disease, 1 with metastasis at 26 months and the other with local and distant treatment failure. Both received chemotherapy. The patient with pT3b died after 7 months from intercurrent disease. All patients developed irritative bladder symptoms, rapidly disappearing after removal of the catheters. However, 2 patients still experience urgency due to radiation cystitis.

Conclusions: Due to the patient selection for this treatment, comparison with cystectomy or external beam radiotherapy can not yet be made. The results are comparable with low dose (LDR) irradiation with the advantage that HDR requires only a few minutes isolation whereas LDR patients are isolated during 4-6 days. Another advantage is that eventual subsequent radical cystectomy will not be jeopardized by radiation sequel.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Preliminary results of phase II trail of intravesical installation of bacillus calmette guerin and interferon alfa 2b on alternate weeks in the prevention and treatment of superficial transitional cell carcinoma of urinary bladder

S. Bazarbashi, A. Peracha, A. Kardar, M. Mansi, T. Merdad, E. Lindstedt, A. Ezzat, T. Sundin, The Genitourinary Cancer Working Group


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: BCG is considered the drug of choice for the treatment of carcinoma in situ (Tis) of the urinary bladder and for the prevention of the recurrence of other superficial transitional cell carcinoma of urinary bladder. The toxicity is sometimes severe. The mechanism of action of BCG is not well understood but is thought to be mediated through the release of interferon.

Methods: Between June 1994 and December 1995, 15 patients with superficial TCC of urinary bladder were entered into a prospective phase II trail using alternating intravesical BCG and IFN. All patients underwent cystoscopy and transurethral resection of their bladder tumors within 1-3 weeks prior to starting therapy. Six patients had a one centimeter index tumor left for response assessment. Eligibility criteria included histologically confirmed TCC of urinary bladder, with either recurrent tumor, stage (T) a grade (G) 2, T1G1 or primary/recurrent TaG3, T1G2, T1G3 or (Tis), no prior exposure to BCG or IFN, adequate renal, hepatic and bone marrow function, performance status ≤3 and signed informed consent. All patients received 108 mg of intravesical BCG alternating on weekly intervals with 100 million units of intravesical IFN (Intron A, Schering-Plough USA) for a total of 8 weeks. Repeat cystoscopy was performed 4 weeks following end of therapy and every 3 months thereafter.

Patient Characteristics: Median age 58 years (range 38-77), 13 males, 2 females. Pretreatment stage/grade are as follows: TaG1 = 2, TaG2 = 4, TaG3/Tis = 1, T1G2 = 6, and T1G3 = 2.

Results: With a median follow up of 9.1 months, 8 patients developed recurrences. Stage/grade at recurrence were as follows: TaG2 = 3, T1G2 = 3, T2G3 = 1, and one patient developed metastatic disease and died. Median time to recurrence was 36 days (range 8-111). Four of the six index tumors completely disappeared. No patient experienced grade III or IV toxicity.

Conclusion: Alternating intravesical installation of BCG and IFN is an effective and well tolerated treatment for the prevention of superficial bladder cancer. Accrual on this protocol will continue for better evaluation of this therapy. Comparison with the standard intravesical BCG alone is warranted.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Primary squamous cell carcinoma of the urinary bladder

A. A. Shaaban, S. A. Orkubi, M. T. Said, M. Mecci, M. S. Abomelha


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

This study is a clinicopathologic report on 47 patients with primary squamous cell carcinoma of the urinary bladder. Patients ranged in age from 33 to 85 years (mean 53.7 ± 14.4) and there were 38 males and 9 females (M:F = 4.2:1). Endoscopic evaluation revealed exophytic nodular fungating lesions in 44 patients, malignant ulcers in 2 and fibrillary keratinized neoplasm in 1. The tumors were solitary in 41 cases (87%). Involvement of the trigone, bladder neck or prostatic urethra was noted in 6 cases (13%). Almost all neoplasms were invasive at the time of diagnosis and in 27 cases (57%) the tumors were fixed or metastasizing. The tumors had a moderate to poor degree of cellular differentiation in 87% of cases. Evidence of schistosomiasis was noted in 39 patients (83%).

Radical cystectomy and urine diversion were undertaken in 17 patients, partial cystectomy and intestine-cystoplasty in 3 and laparotomy only in 3. Palliative radiotherapy was given in 18 patients and no active treatment in 6. For patients who received definitive surgical treatment, the crude 5-year survival rate was 46%.

We conclude that almost all cases of squamous cell carcinoma are invasive at the time of diagnosis and therefore, the prognosis is exceedingly poor. The importance of detection of the disease at earlier states is evident. There is significant association between schistosomiasis and squamous cell carcinoma. Radical cystectomy is the treatment of choice when the tumor is operable.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Continent urinary diversion using small-bore conduits

S. B. Barker


Department of Urology, King Faisal Military Hospital, Khamis Mushayt, Saudi Arabia

Continent urinary diversion, usually after cystectomy, is now a relatively simple alternative to a wet stoma. Experience with Mitrofanoff type diversion since 1987 is discussed with special reference to appendix conduits (324 patients). The problems with establishing catheterisation and the continence and complication rates are highlighted.

Presented at the: 6 th Saudi Urological Conference

National Guard King Khalid Hospital - Jeddah

27-28 November 1991

Modified Mainz pouch for bladder augmentation and continent diversion

D. Urguhart-Hay, A. Tayeb, P. A. Calcat


Department of Urology, Al Hada Military Hospital, Taif, Saudi Arabia

A Mainz pouch is a low pressure urinary reservoir constructed of caecum and ileum with non-reflux ureteric implantation and a water-proof stoma produced by isoperistaltic ileo-ileal intussusception. It is an excellent procedure for either continent urinary diversion or bladder augmentation. Our experience with a slightly modified technique using ileo-ileal and ileo-caecal intussusception confirms the experience of Thuroff and his colleagues who described the technique in 1986. Of the five patients on whom a Mainz pouch diversion has been performed, all are continent and the one patient in whom a Mainz pouch was used to replace his malignant bladder is dry by night and day with normal intervals of bladder evacuation. The modification to the ileal intussusception has made the procedure simpler, more reliable, and although our patient numbers are few, a superior technique, we believe, to that used in the Mainz technique. It is a procedure we commend in the management of the neurogenic bladder when simpler methods are not effective, and in patients in whom bladder augmentation or replacement is necessary for whatever reason.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

The valved S-shaped rectosigmoid pouch for urinary diversion

T. Sundin, M. Mansi


Department of Surgery, Section of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Recently, Kock et al. [1] introduced the modified rectal bladder in which an intussuscepted colorectal valve prevents urine to reflux to the proximal colon and the rectum is augmented with an open sheet of ileum in order to improve the reservoir function and anal continence. We used the same principle in 12 cases so far, but instead of augmentation with ileum, we split the rectosigmoid for a distance of 30 cm. and after creating a proximal intussusception valve, the split segment was reconfigured to an S-shaped pouch. The ureters were implanted into the pouch with reflux preventing techniques and temporary transverse colostomy was used to protect the construction. Having had previous experience with the modified react bladder, we found the S-shaped rectosigmoid pouch procedure to be simpler and faster. Also, with no intestinal anastomosis proximal to the colostomy, the postoperative course is smoother. The early functional, urodynamic, metabolic and clinical results are encouraging and equal to those obtained by the modified rectal bladder. The intussusception valve has been effective in prevention of reflux from the pouch to the proximal colon. All patients are continent day and night with evacuation of 3-6 hours.

Reference

1. Kock NG, Ghoneim MA, Lycke KG, Mahran MR. Urinary diversion to the augmented and valved rectum: preliminary results with a novel surgical procedure. J Urol 1988;140:1375-9.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Mansoura urology and nephrology center: Experience with the urethral Kock pouch

A. A. Shaaban, M. A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

In 210 men a urethral Kock pouch was constructed as a neobladder after radical cystectomy. A total of 136 patients was followed for a minimum of 1 year and is fully evaluable. Of the patients, 92% are completely continent during the day, while 73% are dry at night. Also, 8 patients had an excellent response to imipramine hydrochloride. Stability or improvement in the configuration of the upper tract was noted in 244 renal units (90%). A total of 28 renal units showed evidenced of deterioration due to reflux (16) and an anastomotic stricture (12). Stability of the antireflux nipple valve was ensured by creation of a window in the mesentery of the corresponding bowel segment and by anchoring the valve to the wall of the pouch by an additional row of staples. On the basis of this favorable outcome the procedure is recommended for male patients for whom cystectomy is indicated and in whom the urethra can be preserved.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

A new antireflux ureteral reimplantation technique into an ileal neobladder

H. Abol-Eneim, M. A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

A new antireflux uretero-ileal re-implantation technique for ileal bladder substitutes is presented. This procedure entails creation of an extramural serous lined tunnel. Following detubularization of the bowel segment, the adjacent flaps are approximated by continuous 4/0 vicry sutures 1 cm. away from the cut edges. The ureters are laid in the thus fashioned trough. Buttonholes are created in the bowel flaps and a mucosa-to-mucosa uretero-ileal anastomosis is carried out. The mucosal edges of the flaps are then approximated by one layer of 4/0 vicry sutures, resulting in closure of this artificial tunnel.

The technique was used in 8 experimental dogs. Follow up was carried out for 12 up to 30 weeks. Assessment by intravenous urography and ascending studies provided evidence that the procedure efficiently provides a non-obstructing unidirectional flow of urine.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

The urethral Kock pouch as a bladder substitute

M. A. Ghoneim, A. A. Shaaban


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

The video demonstrates step by step the creation of urethral hemi-Kock's pouch for bladder substitution. It starts with the terminal phase of the cystectomy and transection of the urethra. Then a 45 cm. long segment of the distal ileum is isolated. The antimesenteric border are sutured together. A reflux-preventing valve is constructed from the proximal 1/3. The intestinal plate is then folded on itself and closed with a single layer of continuous 3/9 vicry. The pouch is inverted between the two mesenteric leaves so that its posterior surface becomes anterior. A hole is created in the most dependent part of the pouch, which is then sutured to the urethral stump. Finally, the ureters are anastomosed to the inlet of the pouch by a stented end-to-side anastomosis.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Total bladder replacement by the urethral Kock pouch: Preliminary report

Atallah A. Shaaban, S. A. Orkubi, M. T. Said, A. Al Ghamdi, K. Al Otaibi, M. S. Abomelha


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Between May 1992 and June 1993, bladder substitution was performed in 13 patients in Riyadh Armed Forces Hospital, of which 8 cases had been provided with a urethral Kock pouch after radical cystoprostatectomy for invasive bladder carcinoma. The final stage of the operation is done carefully to preserve the urethra and periurethral musculature. The technique of creation of Kock pouch entails isolation of a 45 to 50 cm. long segment from the distal ileum. The distal two thirds are detubularized and double-folded for construction of the reservoir while the proximal third of the ileal segment is preserved for formation of an anti-reflux intussusception ileo nipple valve. A hole is made in the most dependent portion of the reservoir for ileo-urethral anastomosis around a 20F silastic urethral catheter. Uretero-ileal reimplantation is done using the standard end-to-side technique with stenting. There was no postoperative mortality. Morbidity included wound sepsis in one patient and prolonged ileus in one that were treated conservatively. All patients are completely continent during the daytime. Night time continence is achieved gradually 2-4 months after surgery. Follow up IVP had shown the functional integrity of the upper urinary tract after six months in 4 patients. One patient developed metastatic disease 5 months after surgery.

We conclude that the urethral Kock pouch is an ideal bladder substitute in terms of imitating the normal bladder functions.

Presented at the: 8 th Saudi Urology Conference

King Fahd Military Medical Complex

9-10 November 1993

The staple stabilised ileo-caecal valve: A new antireflux method for reconstruction

S. Nouri, S. Barker, G. Ismail


Department of Urology, Armed Forces Hospital, Khamis Mushayt, Saudi Arabia

One of the more common complications of urinary reconstruction after cystectomy is ureteric stenosis or persistent reflux causing upper tract deterioration. The staple stabilised ileo-caecal valve has been effective as an outlet valve [1] and we have tried to demonstrate how effective it is as an inlet valve.

The new ureteric re-implantation technique has been used in both substitution cystoplasty with preservation of urethral voiding, and more importantly, with modified rectal bladders [2] where an effective antireflux valve is essential to prevent ascending infection.

The results at one year follow up have been excellent and will be presented together with pouchography and upper tract studies to confirm antireflux without obstruction.

This new technique is easy and rapid to perform. It combines the simple uretero-ileal anastomosis, often used with wet ileostomies and associated with very low obstruction rates, and the added advantage of keeping the anastomosis away from the mixed facio-urinary stream associated with recurrent tumour in ureterosigmoidostomy.

References

1. Davidson T, Barker SB, Mansson W. Tapering of intussuscepted ileal nipple valve or ileocecal valve to correct secondary incontinence in patients with urinary reservoir. J Urol 1992;147:144-6.

2. Kock NG, Ghoneim MA, Lycke KG, Mahran M. Urinary diversion to the augmented and valved rectum: Preliminary results with a novel surgical procedure. J Urol 1988;140:1375-9.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Urothelial bladder augmentation

K. Fouda-Neel, M. Abdul-Aaly, S. Ahmed


Department of Urology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia

Bladder augmentation is usually undertaken to increase bladder capacity and/or to reduce intravesical pressure. Gastrointestinal segments are generally used for this purpose but are associated with major short term and long term complications. These may be avoided by undertaking a URO-THELIAL lined augmentation which was performed in 13 of our patients (neurogenic bladder 9, posterior urethral valves 4, auto augmentation 9, uretero-cystoplasty 6).

A satisfactory result was achieved in six auto-augmentations with improved bladder function and capacity and spontaneous resolution of vesicoureteral reflux in one. Two unsatisfactory results were managed by uretero-cystoplasty and one is scheduled for entero-cystoplasty. The 6 uretero-cystoplasties (including the two failed auto-augmentations) were successful in terms of stabilization of the upper urinary tract and improved bladder function. Urothelial techniques of bladder augmentation should be considered in all patients requiring augmentation, the main advantage being that the problems associated with gastrointestinal segments are avoided and their subsequent use is not precluded.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Orthotopic bladder substitution past experience and current trends

Mohamed A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

In this presentation, our past experience with the Hemi-Kock's Pouch for ORTHOTOPIC Substitution will be critically reviewed, with emphasis on long-term functional outcome.

Furthermore, areas of current interest will be presented:

1. A uretero-ileal anastomosis; should we employ an anti-refluxing technique in low pressure reservoirs?

2. The evolution of a new anti-refluxing uretero-ileal anastomosis. The extramural subserous tunnel

3. ORTHOTOPIC substitution in women: Is it feasible?

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Rational management of urinary diversion

Burchardt


Department of Urology, State Hospital, Langen-Debstedt, Germany

Since 1960, we have been observing an increase of bladder cancer. In our clinic approximately one fifth of the patients suffer from this tumour at the present time. We anticipate that due to increasing age in our country, this trend and its problems will continue. That is the reason why cystectomy, urinary diversion and/or bladder reconstruction are routine in urology clinics also outside academic hospitals.

We propose radical cystectomy in case of patients with infiltrating cancer clinically confined to the bladder. Younger men and in future women too, will obtain an ileal neobladder, older patients and up to now women an ileal conduit with or without urethrectomy.

Patients with advanced cancer and with irritating bladder symptoms or debilitated patients get an ileal conduit only, uretero-cutaneostomies of one or both ureters in the navel. Especially the amount of high stage bladder cancer will increase and we need experience with more patients.

We will demonstrate our indication considering age and the stage of this tumour in nearly 400 patients within a period of 14 years, which lead to a routine procedure with operating times tolerable for patients and growing more actual in respect to cost.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Further experience with the valved S-shaped rectosigmoid pouch for continent urinary diversion

Abdul Hafeez Kardar, Torsten Sundin, Eric Lindstedt


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

The valved S-shaped rectosigmoid pouch is a low pressure reservoir constructed by detubularization and S reconfiguration of 30 cm of the intact bowel. Continence is dependent on the anal sphincter. The pouch is functionally isolated from the proximal colon by an intussusception valve and the ureters are implanted into the pouch by an antireflux technique. The construction is protected by a tube caecostomy for about 10-15 days (transverse colostomy for 4-6 weeks in the first 15 patients). The procedure has been performed in 42 patients during the last 5 years. The indications were: bladder carcinoma (34 patients), giant vesicourethrovaginal fistula (3 patients), bladder exstrophy (3 patients), urethral carcinoma (1 patient), neuropathic bladder (1 patient). There was one early death due to mesenteric artery thrombosis. Early complications constituted prolonged ileus (4 patients) and small bowel obstruction requiring surgical intervention (1 patient). A late complication was the sliding of the nipple valve in 4 patients (9.5%), which was revised successfully (twice in 1 patient). All patients but one (98%), are continent and dry during the day and night with evacuation intervals of 3-6 hours. No patient complained of constipation or abdominal distension. Mild hyperchloremic acidosis was noted in 6 patients with slightly decreased renal function and 4 of them are on alkali. Cystometry of the pouch showed a capacity of 450 ml to 1200 ml (mean 700). The mean pressure at maximum capacity was 22 cm water (range 10-32). The use of tube caecostomy instead of temporary transverse colostomy has significantly shortened the hospital stay and obviated the need for re-admission for colostomy closure.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Routine bone scan prior to radical cystecomy: Is it useful?

A. M. Percha, J. Powe, A. H. Kardar, M. Aslam, H. Al Zahrani, T. Merdad, E. Lindstedt, S. G. Kattan, K. A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: The practice of performing Bone Scan prior to radical cystectomy is erratic and in spite of few earlier studies advising against, it is still being performed frequently. In this retrospective study, we assessed the need and usefulness of routine bone scan at a single center in Saudi Arabia.

Patients and Methods: Charts of all the patients who underwent cystectomy from 1979 to 1996 were reviewed. The bone scans of the patients who developed bone metastases were reviewed again in retrospect to determine if there was any evidence of bone metastases in the pre-operative study.

Results: Total of 164 patients underwent radical cystectomy during this period. Pre-operative bone scan was performed in 118 (72%) patients and in all of them it was reported as showing no evidence of bone metastases. These patients had no bone pain and their serum calcium and alkaline phosphatase were normal. Eighteen (11%) patients developed bone metastases from 0.24 to 4.96 years (mean 1.3081) after the cystectomy. There were 15 males and 3 females, 12 patients had transitional cell carcinoma, 5 patients had squamous cell carcinoma and 1 patient had adenocarcinoma. Twelve of these patients had pre-operative bone scan and these were reviewed again. None of them had any suspicion of bone metastases.

Conclusion: We did not find routine bone scan to be of any benefit in the pre-operative evaluation of bladder carcinoma when radical cystectomy is contemplated and it did not prove to be cost effective.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Does squamous cell carcinoma of the bladder carry a worse prognosis?

A. M. Peracha, A. H. Kardar, M. Aslam, E. Lindstedt, S. G. Kattan, G. H. Mohamed, T. Merdad, K. A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: Baseline characteristics and survival analysis data were compared in patients who underwent cystectomy for Squamous Cell Carcinoma (SCC) and Transitional Cell Carcinoma (TCC) of the bladder at King Faisal Specialist Hospital and Research Centre in Saudi Arabia. This was to determine the prognosis of these two distinct bladder cancers.

Patients and Methods: Charts of 156 patients operated upon between 1979 and 1996 were reviewed retrospectively. Histology was SCC in 67 (43%) and TCC in 89 (57%) patients. Radical cystectomy was performed in 60 (90%) and 72 (81%) patients, salvage cystectomy in 1 (1%) and 13 (15%) patient and partial cystectomy in 6 (9%) and (4%) patient in SCC and TCC respectively. Mean follow up was 1.7 years (8 days to 18.6 years).

Results: Male to female ratio was 3:1 in SCC and 17:1 in TCC groups of patients, p=0.001. Mean age was 49.30 SD + 12.22 years in SCC and 55.82 SD + 11.35 in TCC groups of patients. Tumor grades were G1=5 (8%), G2=43 (64%) G3=19 (28%) in SCC and G1=1 (1%), G2=22 (25%), G3=66 (74%) in TCC patients, p=0.001. Tumor stages were Pa=2 (3%), P1=1 (1.5%), P2=5 (7.5%), P3a=17 (25%), P3b=35 (52%), P4=7 (10%) in SCC and Pa=2 (2%), P1=15 (17%), P2=14 (16%), P3a=15 (17%), P3b=32 (36%), P4=11 (12%) in TCC patients, p=0.001. Lymph nodes were positive in 14% and 29% patients in SCC and TCC respectively. Local tumor recurrence was 18 (27%) in SCC and 12 (13.5%) in TCC patients, p=0.042. Overall 5 and 10 years survival was 37 and 19% in SCC and 38% and 26% in TCC groups.

Conclusion: Though there were some statistically significant differences in few baseline characteristics in the two groups of patients there was no statistically significant difference in overall survival for age, sex, different grades or stages of the tumor in both groups. Thus squamous cell carcinoma has not worse prognosis than invasive transitional cell carcinoma of the bladder, if managed by radical cystectomy.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000

(09-12 Dhu Al Qa'dah 1420)

Orthotopic neobladder substitution vs ureterosigmoidostomy: Comparasion of complications

M. Aslam, A. H. Kardar, E. Lindstedt, S. Kattan, H. Al Zahrani, T. Merdad, F. Al Modhin, A. Al Zahrani, M. Al Otaibi, K. Al Ghamdi, M. Al Mandil, M. A. Chaudhary, K. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: The objective in continent urinary diversion is to preserve the upper tract and maintain continence. In ureterosigmoidostomy (URS) and orthotopic neobladder (OTN) continence depends upon the anal sphincter and the urethral distal sphincter, respectively. We report the comparable complications of OTN and URS.

Materials and Methods: In this retrospective study we reviewed the medical records of patients who underwent URS from 1975-1985 and OTN from 1980-2000. The parameters studied were recurrent pyelonephritis, upper tract dilatation, deterioration in renal function, metabolic acidosis, ureteric reimplantation anastomotic stricture, continence and risk of malignancy. Comparative analysis was made by Fisher's exact test (p<0.05 was considered significant).

Results: 31 patients aged 10-75 years (mean 45.3) underwent URS and were followed for 3-216 months (mean 54.6 months); 32 patients (all bladder cancer) aged 22-73 years (mean 54 years) underwent OTN and were followed for 3-144 months (mean 48 months).

Comparison and significance of complications

Urinary diversion Recurrent pyelonephritis (%) Metabolic acidosis (%) Renal function deterioration (%) Upper tract dilatation (%) Ureteric anastomotic stricture (%)

URS 9 (29) 22 (77.4) 13 (41.9) 18 (58.1) 1 (3.2)

OTN Nil 13 (40.6) 4 (12.5) 7 (21.8) 2 (6.25)

P <0.001 <0.5 <0.5 <0.01 Not significant

One patient developed adenocarcinoma of the colon in the URS non developed malignancy in the reservoir in OTN. Continence figures: In URS 18 were continent with nocturnal incontinence and in 13 there was no documentation for the determination of continence. In OTN 14 (43.75%) were fully continent, 9 (28%) were daytime continent with nocturnal incontinence, 3 (9.3%) were continent with stress leak and 6 (18.75%) were totally incontinent.

Conclusion: The complication rate was much higher in ureterosigmoidostomy than in orthotopic neobladder substitution. We suggest careful selection of patients, meticulous operative technique and vigilant follow up for the successful treatment of complication in both types of urinary diversion.

Presented at the: 14 th Saudi Urology Conference

King Fahd Military Medical Complex - Dhahran

13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)

Pattern of recurrence of high grade T1 TCC of the bladder: A prognostic factor for tumor progression

M. Al Otaibi, S. Kattan, H. Al Zahrani, E. Lindstedt, K. Hanash, A. Kardar, M. Aslam, T. Merdad, M. Khuthila, M. Al Mandeel


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To determine if the pattern of recurrence of high grade T1 TCC bladder (T1, G2-3) is of a prognostic significance for disease progression.

Materials and Methods: 48 patients were diagnosed at presentation to KFSH & RC ad TCC bladder (T1, G2-3) from 1992 to 1994 and their charts were reviewed retrospectively. Pattern of recurrence including the time to 1 st recurrence and the recurrence rated where determined.

Results: The time to 1 st recurrence was significantly shorter in patients who had tumor progression, with mean f 4.3 months for T1 and G2 and 3.75 months for T1 G3, while it was 9.3 months for T1 G2 and 14.5 months for T1 G3 who did not have progression. The progression was 26.7% in patients who had <2 recurrence/year and 88.9% on those who had >2 per year.

Conclusion: The pattern of recurrence is of a prognostic factor in tumor progression of high grade T1 TCC of the bladder. Patient with time to 1 st recurrence of <6 months and those with >2 recurrence/year are considered to be at high risk for disease progression and should be monitored and treated very closely.

Presented at the: 14 th Saudi Urology Conference

King Fahd Military Medical Complex - Dhahran

13-15 February 2001

(19-21 Dhu Al Qa'dah 1421)

Contemporary radical cystectomy for invasive bladder cancer: Surgical aspects and results

Hassan Abol-Enein


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Radical cystectomy and urinary diversion is the gold stander treatment for invasive bladder cancer. Between 1976 and 2000, 2716 patients underwent radical cystectomy and different forms of urinary diversion.

Hospital mortality rate was 1.7%, morbidity including wound infection, urinary leakage, ileus, DVT was observed in 9.4%. Tumor cell type was SCC in 50% TCC in 30% adenocarcinoma in 9.5% and mixed in 10.5%. Two thirds of the tumors were PT3, the incidence of nodal involvement was 20%. Urinary diversion included ileal loop conduit in 26% rectal diversion in 40%, orthotopic ileal bladder substitution in 31% and continent cutaneous reservoir in 3%.

Kaplan-Meier curves showed 5-10, 15 and 20 year disease free survival of 53.8%, 44.4% 41.7% and 39.4% respectively.

Operative procedure and surgical tricks will be presented.

Presented at the: 15 th Saudi Urological Conference

King Fahd Hospital - Madinah Al Munawarah

7-9 May 2002 (24-26 Safar 1423)

Superficial bladder tumors: Analysis of prognostic factors and constructon of a predictive index

B. Ali-El-Dein, O. Sarhan, A. Hinev, H. I. Ibrahiem, A. Nabeeh, M. A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Introduction and Objective: This study was performed to assess in a prospective way the prognostic factors that may predict tumor recurrence and progression. At the same time a predictive index is constructed.

Patients and Methods: Between July 1991 and July 1997, we included 377 patients (302 men and 75 women; mean age 55.4 years) in 2 prospective studies. The patients underwent complete transurethral resection of histologically proven pTa and pT1 transitional cell carcinoma of the bladder (TURBT). Following TURBT, the patients were allocated to 6 groups which received adjuvant intravesical sequential bacillus Calmette-Gurein "BCG" + epirubicin, BCG alone, epirubicin 50mg, epirubicin 80 mg, Adriamycin 50mg and no adjuvant therapy, respectively. Factors that may affect treatment failure (recurrence and/or progression) were studied by a univariate as well as a multivariate analysis. These included tumor stage, histologic grade, DNA ploidy, multiplicity, size, tumor configuration, history of recurrence, associated carcinoma in situ, recurrence at the first 3-month check cystoscopy and the use of adjuvant therapy. The regression coefficients (B) determined by Cox regression analysis were used to construct a predictive index. The algebraic sum of the regression coefficients of the factors with independent and significant association with disease-free survival for each case represented a proportional hazard score (Y).

Results: Follow up ranged from 5 to 96 months with a median of 60. On univariate analysis tumor stage, grade, DNA ploidy, multiplicity, history of recurrence, tumor configuration, recurrence at the first 3-month check cystoscopy and the type of adjuvant therapy significantly affected disease-free survival. Factors that independently and significantly affected disease-free survival on multivariate analysis were tumor stage, grade, DNA ploidy, multiplicity, recurrence at the first 3-month check cystoscopy and the type of adjuvant therapy. The range of hazard score (Y) values for the factors affecting disease-free survival was 0.0 to 4.6731. These ranges were divided equally into 3 risk categories with statistically significant difference regarding their survival as estimated by Kaplan-Meier curves and log rank test (p<0.001).

Conclusions: Multivariate Cox regression analysis showed that tumor stage, grade, DNA ploidy, multiplicity, recurrence at the first 3-month check cystoscopy and the type of adjuvant therapy had independent and significant impact on disease-free survival. After exclusion of the type of adjuvant therapy, a predictive index was created for treatment failure (recurrence and/or progression) based on the results of this multivariate analysis. This predictive index divided the patients into 3 risk groups with different treatment and follow up strategies.

Presented at the: 15 th Saudi Urological Conference

King Fahd Hospital - Madinah Al Munawarah

7-9 May 2002 (24-26 Safar 1423)

King faisal specialist hospital and research centre experience of cystectomy and urinary diversion in patients with bladder cancer

A. M. Peracha, E. Lindstedt, S. Kattan, A. Kardar, M. Aslam, T. Merdad, H. Al Zahrani, K. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To analyze the long term results and the prognostic factors affecting survival amongst patients with bladder cancer, following cystectomy and urinary diversion at a tertiary care hospital in Saudi Arabia.

Methods: One hundred and sixty-four patients operated upon from 1972 to 1996 were studied. Age ranged from 21 to 75 years, mean 52.21 (SD=12.80). Male to female ratio was 6:1 Mean follow up was 2.32 years (ranged 8 days - 18.6 years).

Results: Cystectomies performed were Radical 137 (83.5%), Salvage 14 (8.5%) and Partial 13 (8%). Uretero-sigmoidostomy was performed in 38 (25%), rectosigmoid pouch in 35 (23%), cutaneous ureterostomy in 29 (28%), orthotopic neobladder in 24 (16%) and ileal conduit in 20 (13%) patients. Histology was transitional cell carcinoma (TCC) in 89 (54%) squamous cell carcinoma (SCC) in 67 (41%), adenocarcinoma in 7 (4%) and sarcoma in 1 (1%) patient. Pathological stages were Pa=5 (3%), P1=17 (10%), P2=19 (12%) P3a=34 (21%), P3b=69 (42%), P4=20 (12%). Bilharzial eggs were present in 76 (46%) and lymph nodes were positive in 20 (21%) specimen. Overall 5 and 10 years survival is 38% and 22% respectively. Tumor stage and nodal status had statistically significant impact on this survival, where as tumor grade did not influence survival.

Conclusion: Radical cystectomy and urinary diversion is the best available treatment for TCC (muscle invasive), SCC and adenocarcinoma. It provides low morbidity and mortality, offers good locoregional disease control and 5-years overall survival. Patient with extravesical tumor growth carry particularly poor prognosis (p≤0.05). There is no statistically significant difference in overall survival amongst patients with or without associated bilharziasis or in-patients with TCC or SCC.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23-25 February 1999

(7-9 Dhu Al Qa'dah 1419)

Long term results of two types of urinary diversion to sigmoid colon: A retrospective study

M. Aslam, A. H. Kardar, A. Peracha, E. Lindstedt, S. Kattan, T. Merdad, H. Al Zahrani, K. A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction and Objectives: Various modifications of ureterosigmoidostomy have been adopted to overcome the complications associated with this procedure. Comparison of long-term complications of ureterosigmoidostomy and valved S-shaped rectosigmoid pouch [1] is presented.

Methods: In this retrospective study, medical records of patients who underwent ureterosigmoidostomy (group I) between 1975-1985 and rectosigmoid pouch (group II) between 1989-1997 were reviewed. The parameters studied included recurrent pyelonephritis, deterioration of renal function, metabolic acidosis and ureteric stenosis upper tract dilatation.

Results: There were 34 patients included in group I and 46 patients in group II. Thirty-one patients (age range 10-75 years, mean 45.3) in group I and 37 patients (age range 11-77 years, mean 49.5) in group II were available for evaluation. Follow up ranged 3-216 months (mean 54.6) in group I and 15-81 months (mean 31) in group II. Nine patients (29%) in group I and 1 (2.7%) in group II developed recurrent pyelonephritis. Renal impairment took place in 13 (42%) in group I and 3 (8.1%) in group II. Metabolic acidosis developed in 24 (77%) patients in group I (in spite of alkali replacement) and in 6 (16.2%) patients in group II. Development of ureteric stenosis/dilatation of upper tract was observed in 18 (58%) in group I and 4 (10.8%) in group II. One patient in group I developed secondary adenocarcinoma of the colon.

Conclusion: According to this study the valved S-shaped rectosigmoid pouch (low pressure reservoir) may have significantly less long term complications as compared to ureterosigmoidostomy.

Reference

1. Sundin T, Mansi MK. The valved S-shaped rectosigmoid pouch for continent urinary diversion. J Urol 1993;150:838-42.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hosital Program

23-25 February 1999

(7-9 Dhu Al Qa'dah 1419)

The role of positron emission tomography in lymph node staging of patients with bladder carcinoma

S. Kattan, S. Hussain, J. Powe, E. Lindstedt, K. Hanash, H. Al Zahrani, A. H. Kardar, T. Merdad, A. Peracha


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: The sensitivity and specificity of various radiological modalities for lymph node staging in patients with bladder cancer had not been satisfactory. The role of the positron emission tomography (PET Scan) in lymph node staging in these patients is not known. A prospective study was thus designed to compare the sensitivity and specificity of PET Scan and computerized axial tomography (CT scan) in lymph node staging of patients with bladder cancer.

Methods: 16 patients (13 male, 3 female), their ages ranging between 37 to 85 years were included in study. All patients had bladder carcinoma. The histological type was transitional cell carcinoma in 15 patients and squamous cell carcinoma in 1 patient. The local stage of the tumor was PT1 in 12.5% PT3a in 25% PT3b in 37.5% and T4 n 25% of the patients. All patients were staged for lymph node status by undergoing CT Scan of the abdomen and pelvis, whole body PET Scan utilizing 18 flurodeoxyglucose (FDG). All patients underwent staging pelvic lymphadenectomy at the time of surgery except for one patient where the histological status of lymph node was ascertained by CT Scan guided biopsy.

Results: Histologically proven lymph node metastasis was detected in 31.2% of cases. The sensitivity and specificity of PET Scan for lymph node staging of the right pelvic and iliac lymph node group were 50% and 83% respectively compared to sensitivity of 100% and sensitivity of 75% for CT Scan for the same group of lymph nodes. For the left pelvic and iliac lymph node group the sensitivity and specificity was 100% and 77% for PET Scan respectively and 66.7% and 92.3% for CT Scan respectively. However, when all groups of lymph nodes were studied collectively the sensitivity and specific was 80% and 73% of PET Scan and 100% and 73% for CT Scan respectively.

Conclusions: PET Scan has comparable results with CT Scan for lymph node staging in patients with bladder cancer. Further larger studies are required to establish its role in staging of patients with bladder carcinoma.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospital Program

23-25 February 1999

(7-9 Dhu Al Qa'dah 1419)

Long term results of orthotopic bladder substitution after radical cystoprost atectomy for invasive bladder cancer

I. Shoukry, A. Tawfik, A. Meshref


Department of Urology, King Fahd Centre, Cairo University, Cairo, Egypt

From March 1987 to March 1995, 73 male patients underwent orthotopic detubularized ileal bladder substitution after radical cystoprostatectomy for invasive bladder cancer. Their ages ranged between 30 to 69 years with an average of 48.2 years. Two techniques were used: Urethral hemi-Kock in 36 patients and W-shaped bladder with subserous tunnel in 37 patients. Only one postoperative mortality occurred in urethral Kock group, due to myocardial infraction.

Patients were followed every 3 months in the first year, then every 6 months for the second year, then yearly thereafter. Follow up included clinical evaluation of continence, renal function (intravenous urography and ultrasonography) and reflux (ascending cystogram). Only patients followed up for 6 months or more were included in the evaluation (52 patients).

Of the 52 patients, 26had urethral Kock and 26 had W-shaped bladder with extramural tunnel. Of the urethral Kock's group, 45 of 52 (86.5%) renal units were stationary or improved. Three renal units (5.8%) showed mild back pressure changes, while 4 units (7.7%) showed moderate back pressure changes. Of the W-shaped group, 45 of 50 (90%) renal units (2 patients had a solitary kidney) were stationary or improved. Three renal units (6%) showed mild back pressure changes, while 2 renal units (4%) showed moderate back pressure changes.

Complete continence by day was achieved in 92% of the urethral Kock group, with only one case of stress incontinence (3.8%). Complete continence by day was achieved in 92.3% of the W-shaped group, with only 2 cases of stress incontinence (7.7%). In the urethral Kock group nocturnal enuresis was encountered in 3 patients (11.5%), while 4 patients (15.4%) had occasional wetting by night. In the W-shaped group, nocturnal enuresis was encountered in only one patient (3.8%), while 5 patients (19.2%) had occasional wetting by night.

Both techniques have a good long term functional results as regards continence and preservation of upper urinary tract function. Orthotopic bladder substitution should be offered as a primary choice for patients after radical cystoprostatectomy.

Presented at the: 11 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998

(27-29 Shawwal 1418)

The second generation bladder tumor antigen test in the monitoring of transitional cell carcinoma of the urinary bladder: A preliminary report

Z. Nakshabandi, M. S. Abomelha, S. A. Orkubi, M. T. Said, A. A. Shabban


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

The second generation Bard Bladder Tumor Antigen (BTAstat) test is a rapid immunochromatic test using monoclonal antibodies. It is indicated for the qualitative detection of bladder tumor antigen in human urine as an aid in the diagnosis and follow up of bladder cancer patients. We evaluated this test compared to voided urine cytology in 20 patients who underwent 21 diagnostic and follow up cystoscopies for bladder carcinoma. This presentation will be limited to patients with TCC. 13 patients with history of TCC of the urinary bladder were analyzed. Of these 13 patients, 7 had positive histopathology and 6 had negative histopathology. Of the 7 patients with positive histopathology, 5 (71%) were correctly diagnosed by BTAstat test in comparison to only 2 (29%) diagnosed by voided urinary cytology. One false positive and two false negative BTAstat test sensitivity of 71% and specificity of 83%.

Our preliminary results with a small number of patients indicate that the BTAstat test is simple, one step non-invasive diagnostic test, and an adjunct to cystoscopy in diagnosis of bladder carcinoma. Compared to voided urine cytology, the BTAstat test is more sensitive and less skill demanding.

Presented at the: 11 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998

(27-29 Shawwal 1418)

Uretersigmoidostomy: Long term follow up results

M. Aslam, A. H. Kardar, K. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: Urinary diversion to uretersigmoidostomy has been in use for about one and a half centuries. Due to its associated complications and popularization of otrhoptic bladder/continent diversions, the number of uretersigmoidostomy procedures has significantly fallen. In this retrospective review we studied the results of uretersigmoidostomy after long term follow up.

Materials and Methods: During 1975 to 1985 a total of 34 patients underwent uretersigmoidostomy. One patient died in the post-operative period and two patients did not come back for follow up. The review included the indications for diversion, recurrent pyelonephritis, renal function, metabolic status, continence and the secondary colonic carcinoma.

Results: There were 17 male and 14 female patients, the age ranges were between 10 and 75 years (mean 45.38). The indications included invasive bladder malignancy in 18, vesicovaginal and/or urethra-vaginal fistula in 10 and extrophy of bladder in 3 patients. The follow up ranged between 3 and 216 months. One patients developed adenocarcinoma of the colon at the anastomotic site, recurrent pyelonephritis was noted in 7 patients. The deterioration of the renal function in 7 and metabolic acidosis in 17 patients in spite of instructions for regular intake of alkali. The records were not very helpful about the incidence of incontinence.

Conclusion: (1) Ureterosigmoidostomy is associated with a variety of metabolic and inflammatory complications. (2) A selected group of patients may still enjoy years of complication free continent urinary diversion.

Presented at the: 11 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998

(28-29 Shawwal 1418)

Local urethral recurrence after radical cystectomy and orthotopic bladder substitution in women: A prospective study

Bedeir Ali-El-Dein, Mohamed Abdel-Latif, Albair Ashamallah, Mona Abdel-Rahim, Mohamed A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Introduction and Objectives: To study the pathological outcome and incidence of urethral recurrence after radical cystectomy and orthotopic bladder substitution in women, in a prospective way.

Methods: Between January 1995 and December 2001, 145 women (mean age 50 + 8.5 years) underwent standard radical cystectomy and orthotopic substitution for bladder cancer. Histopathologic examination of the cystectomy specimens was assessed by a single pathologist. Clinically evident pelvic lymphadenopathy, bladder neck and/or vaginal wall involvement or positive intra-operative frozen section from the urethra was considered as contraindications.

Results: One patient died postoperatively from massive pulmonary embolism. Follow up ranged from 12 to 97 months (mean 36; median 55.8). Pathologic stage was P11, P2 (superficial muscle invasion), P3a (deep muscle invasion), P3b (perivesical fat infiltration) and P4a in 12, 19, 56, 44 and 4 patients, respectively. Grade was G1 in 61 patients, G2 in 62 and G3 in 22. Lymp nodes were positive in 28 cases and negative in 117. Histopathology of the trigone revealed carcinoma in situ (CIS) in 11 cases, squamous metaplasia in 7 and was free in the remaining cases. At follow up, isolated urethral recurrence developed in 2 patients (1.4%); in whom the definitive pathology was P3a N1 (positive iliac lymph nodes) M0, grade 2 squamous cell carcinoma in one case and P3b N0M0 tumor associated with trigonal CIS in the other. Local pelvic recurrence developed in 18 patients, distant metastasis in 6 and both in 10. Oncologic failure was positively correlated with high stage, high grade and positive lymph nodes.

Conclusions: The rate of urethral recurrence after radical cystectomy and orthotopic bladder substitution in women is low and acceptable and thus justifies the continued performance of the type of diversion. Proper selection of cases is mandatory. Close follow up for oncologic failure in this group of patients after cystectomy is necessary.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Early and late complications after radical cystectomy and orthotopic bladder substitution in women: A prospective study

Bedeir Ali-El-Dein, Albair Ashamallah, Atallah A. Shaaban, Mohamed El-Azab, Mohamed A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Introduction and Objectives: To study the early and late complications and their treatment after radical cystectomy and orthotopic bladder substitution in women, in a prospective way.

Methods: Between January 1995 and December 2001, 145 women (mean age 50 + 8.5 years) underwent standard radical cystectomy and orthotopic substitution for organ confined bladder cancer. Early post-operative and late complications were reported. In addition, treatment of these complications was stated.

Results: One patient died postoperatively from massive pulmonary embolism. Oncologic failure in the form of local recurrence and/or distant metastasis developed in 34 patients (23.4%), 6 patients died from unrelated diseases and 3 were lost to follow up. 101 patients were eligible for evaluation. Follow up in these patients ranged from 12 to 97 months (mean 36; median 55.8). Out of these, 20 patients developed early complications in the form of DVT in 3, prolonged ileus in 4, wound infection in 7, a benign poucho-vaginal fistula in 4, poucho-cutaneous fistula in 1 and uretero-ileal urine leak in another patient. DVT, prolonged ileus and wound infection were successfully treated conservatively, uretero-ileal leak by prolonged stenting and poucho-cutaneous fistula by open revision. The poucho-vaginal fistulas were repaired, through a vaginal approach 3 months after the operation, with a good continence outcome. Late complications included urinary stones in the pouch (5), kidney (2) and ureter (1) and these were treated by endourologic measures in all but 1. Uretero-ileal stricture occurred in 14 out of 201 reno-ureteral units (7%) and ileo-ureteral reflux in 11/201 (5.5%). Reflux was conservatively treated and 6 units with uretero-ileal stricture in 4 patients were successfully treated by endo-urologic measures. Open surgery was performed for 8 units in 7 patients.

Conclusions: Most complications after radical cystectomy and orthotopic bladder substitution in women were minor and conservatively treated. Endo-urologic measures were successful for the majority of calcular complications and for early stricture. Vaginal repair of poucho-vaginal fistula is possible with good outcome.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Secondary malignant involvement of gynecological organs at radical cystectomy specimens in women: Is it mandatory to remove these organs routinesly?

Bedeir Ali-El-Dein, Mohamed Abdel-Latif, Ahmed Mosbah, Ibrahim Eraky, Atallah A. Shaaban, Noheir M. Taha, Mohamed A. Ghoneim


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Introduction and Objectives: To report on the incidence of concomitant secondary malignancy of gynecological organs (uterus, ovaries and vagina) and the incidence of benign lesions affecting these organs in female radical cystectomy specimens.

Methods: Between January 1983 and December 2001, 2555 cases of radical cystectomy were carried out. Out of these 609 were females. The pathological findings of gynecological organs at female cystectomy specimens were reviewed. These data were correlated to different tumor characteristics and survival.

Results: Mean (range) age for female patients was 46.6 + 9 (20-73) years. Mean follow up was 4.3 + 4.2 (range = 0.5-19) years. Involvement of gynecological organs was documented in 16/609 patients (2.6%). Benign ovarian lesions were detected in 49 cases (8%); simple serous cyst in 31, dermoid cyst in 1, hemorrhagic cyst in 3, bilharzial granuloma in 6 and corpus albicans in 8. Benign uterine lesions were diagnosed in 30 cases (5%); endometrial hyperplasia in 20, endometriosis in 4 and fibroids in 6. No primary genital cancers were detected in this study. Gynecologic organ involvement was more frequent in high-grade tumors and transitional cell cancer type than low grade and squamous cell type (p = 0.01 and 0.05, respectively). Posterior wall tumors were more frequently associated with genital involvement than other sites, although the difference was not statistically significant.

Conclusions: Evidence has been provided that the risk of secondary malignant involvement of genital organs in female cystectomy specimens was very low. This low risk, together with the low risk of primary cancers of genital organs in this group of patients does not strongly support the routine removal of the uninvolved gynecologic organs during radical cystectomy in women. On the other hand, preservation of these organs, if proper selection were conducted, would provide a better functional outcome and a better quality of life.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Sequential intravesical immunochemotherapy for stages ta and T1 transitional cell carcinoma of the bladder: An update

B. Ali-El-Dein, O. Sarhan, A. Nabeeh, E. I. Ibrahiem


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Objectives: To present an update of our experience with sequential immuno-chemotherapy using bacillus Calmette-Guerin (BCG) and epirubicin in superficial bladder tumors. In addition, the question of whether to start with BCG or epirubicin is answered.

Methods: Between January 1993 and December 2001, 156 patients with histologically proven Ta and T1 bladder transitional cell carcinoma were included in a prospective randomized study. Following transurethral resection of the bladder tumor (TURBT), patients were randomly assigned to 1 of 2 groups. Patients in group 1 received weekly doses of 150 mg BCG alternating with 50 mg epirubicin for 6 weeks. Maintenance was carried out by a monthly dose of BCG alternating with epirubicin, to complete 1 year of treatment. Patients in group 2 received the same protocol, but with a reversed order with epirubicin being used initially.

Results: 149 patients, 114 men and 35 women with a mean age of 55 years, were evaluable. 7 patients were excluded due to severe side effects. Mean and median follow up was 42.8 and 43 months, respectively. In the whole series recurrence rate was 18.1%, recurrence rate per year was 0.06, mean interval to first recurrence was 29 months and progression rate was 12%. Side effects developed in 40 patients (25.6%) and were mostly in the form of mild cystitis (26 patients). The 2 groups of therapy were comparable regarding recurrence rate, recurrence rate per year, progression rate and side effects.

Conclusions: The sequential therapy is effective in recurrence prophylaxis of superficial bladder tumors. The side effects were less frequent than in our historical controls treated with BCG alone. It does not matter to start with epirubicin or BCG in this regimen.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

5-ALA blue light guided turbt as a bladder sparing procedure in superficial bladder cancer: A tumor clearance procedure

Ziad Tarik Al-Naieb


Department of Urology, Baghdad University, Baghdad, Iraq

In 150 patients with STCC 30% with rec. Tumors and 70% primary tumors, 5-ALA was used prior to surgery and resection was guided by photodynamic xenon / blue violet light. The resection was carried out until complete disappearance of the red signal from the tissue. The results, complications and success rate will be discussed.

In the procedure we used, it seems that the PDD&T with 5-ALA is a procedure of choice in multiple superficial bladder tumors and also for T2 tumors. A possible bladder sparing procedure in the future.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

BCG complications in the treatment of bladder cancer

Ahmed Y. Al Zahrani, Mohammed S. Abomelha, Mohammad T. Said


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Objective: To evaluate BCG local and disseminated complications associated with the treatment of the carcinoma of the urinary bladder.

Methods: A retrospective assessment of immediate and late complications of BCG-immunotherapy carried out on 39 patients (33 male, 6 female with median age of 64 years) who received 51 BCG courses.

Results: No mortality was recorded and major complications were minor. Cystitis was the most common side-effect making almost two-thirds of the BCG complications. There were 5 episodes of urinary tract infection and one case of septicemia proven by urine and blood cultures treated successfully. No acute systemic reaction occurred and at no time we were forced to cancel the treatment. Patients who developed hematuria or UTI, the treatment are delayed until such complication has been treated. There were three late complications observed, which were in the form of bronchitis, bladder contracture and TB-peritonitis, all of which were managed successfully.

Conclusions: Majority of BCG complications are self-limited conditions. BCG-immunotherapy is generally safe and tolerated well, but could be associated with significant complications in a minority of patients. The key to successful treatment of BCG complications is the awareness of their possibility, even years after the treatment has been given.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Predictors of outcome after radical cystectomy for bladder cancer: Long term follow up

Alaa A. Mokhtar, Khalid I. Al Othman, Naser Elkum, Tajammul Fazili, Kamal A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction and Objectives: To evaluate different prognostic factors which may affect disease specific survival in patients with bladder cancer after radical cystectomy.

Methods: Between July 1975 and December 2000, 229 patients underwent radical cystectomy and urinary diversion for bladder cancer in King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia. 175 patients have available records for review. Retrospective chart review was done. Demographic, clinical and pathological variable which may affect disease specific survival in bladder cancer patients were reviewed. Univariate and multivariate analyses were done with disease specific survival as end point.

Results: The patients mean age was 54 years (21-90), 140 male (80%) and 35 female (20%). Median follow up was 1.5 years (range 29 days - 19 years). Five year disease specific survival was (44%). On univariate analysis, patient's age, lymph node status, pathological staging and presence of hydronephrosis were significant predictors of disease specific survival. However, only lymph node status (p≤0.009), pathological staging (p≤0.04) and presence of hydronephrosis (p≤0.03) were significant predictors of disease specific survival in multivariate analysis.

Conclusion: Lymph node status, pathological staging and ureteral obstruction are significant prognostic factors in bladder cancer patients after radical cystectomy. These factors may help to define bladder cancer patient groups who require further therapy or enrollment in controlled trials to examine additional therapy.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Prognostic variable which predict the outcome after radical cystectomy for squamous cell carcinoma, long term follow

Khalid I. Al Othman, Alaa A. Mokhtar, Naser Elkum, Tajammul Fazili, Kamal A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction and Objectives: To evaluate different prognostic variables which may affect disease specific survival in patients with squamous cell carcinoma after radical cystectomy.

Methods: Between July 1975 and December 2000, 60 patients underwent radical cystectomy and urinary diversion for squamous cell carcinoma of the bladder in King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, Saudi Arabia. Retrospective chart review was done for demographic, clinical and pathological variables which may affect disease specific survival. Univariate analysis was done with disease specific survival as the end point.

Results: The patients mean age was 45 years (21-72) with 40 male (67%) and 20 female (33%). Median follow up was 1.4 year (47 days - 17 years). Five year disease specific survival was (48%). On univariate analysis only lymph node status was a significant predictor of disease specific survival (p≤0.0001). Age of the patient, pathological staging, presence of hydronephrosis, grade of cancer and history of schistosomiasis were not significant predictors for cancer death.

Conclusion: Lymph node status is a strong predictor of survival in patients with squamous cell carcinoma of the bladder. Additional therapy needs to be studied in controlled trials to improve the outcome of this group of bladder cancer patients.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

An artifical neural network to predict recurrence and progression of superficial bladder tumors after transurethral resection

Mohamed A. Gomha, Bedeir Ali-El-Dein, Osama Sarhan, Adel Nabeeh, I. El-Housseiny


Department of Urology, Mansoura Urology and Nephrology Center, Mansoura, Egypt

Objective: To use an artificial neural network to predict outcome after transurethral resection of superficial bladder tumors (free, recurrence or progression of tumor).

Materials and Methods: 410 patients with superficial bladder tumors (65 Ta and 345 T1) underwent transurethral resection (TURBT). These were 359 males and 51 females with a mean age of 56 + 11 years. Intravesical adjuvant therapy was given in 81.5%. All had follow up period >6 months with a mean + SD of 44 + 33.6 months (range = 6-169). At last follow up, 55.4% were free of tumors, 30.7 had tumor recurrence and 13.9% had tumor progression to muscle invasion. 12 variables were used as inputs to an artificial neural network for prediction of recurrence or progression. These were age and sex; tumor stage, grade, size, macroscopic picture, multiplicity, associated CIS, DNA, history of previous resection and the results of cystoscopy at 3 months after TURBT; and type of adjuvant intravesical therapy. PREDICT software program (Neural Ware Inc., 2002) was used to construct a 3-layer feed-forward neural network, with back-propagation of error algorithm. A neural network was trained on randomly selected 286 patients (70%) to predict status at follow up (free of tumors, recurrence or progression to muscle invasion). Performance of the trained net was tested on the remaining 124 patients (30%) with determination of accuracy of correctly predicted classes and the overall accuracy. The relevant variables influencing construction of the ANN were determined using contribution analysis.

Results: Evaluating the performance of ANN on the independent test set revealed prediction accuracy of 78.2%, 71% and 76.5% for patients who remained free of tumors, those with tumor recurrence and those with tumor progression respectively. The overall prediction accuracy is 75.8%. Results of check cystoscopy at 3 months, stage of tumor (Ta vs T1) and macroscopic picture of tumors are the most influential variables, in descending order, to predict outcome after TURBT.

Conclusion: Artificial neural network can predict recurrence and progression after transurethral resection of superficial bladder tumors with reasonable accuracy. ANN may help to guide early cystectomy in those who are predicted to have tumor progression.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Orthotopic neobladder substitution: A retrospective review of long term follow-up in the kingdom of Saudi Arabia

Muhammad Aslam, Hassan Al Zahrani, Said Kattan, Ali Bin Mahfooz, Khalid I. Al Othman, Alaa Mokhtar, Raouf Seyam, Khalid Al Ghamdi, Kamal A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: Urologists have sought to develop an acceptable form of urinary drainage whose bladders had to be removed for malignancy. Simon in 1852 attempted to create a bladder substitute (a rectal bladder) in a patient with bladder extrophy, subsequently numerous techniques have been expounded with evolutionary progress in the development of bladder substitute procedures. The aim of orthotopic bladder substitution is to create a low pressure reservoir, preserve the upper tract and keep the distal urethral sphincter intact to maintain continence. We report a retrospective review of long term follow up from our centre.

Patients and Methods: We retrospectively reviewed the records of patients who underwent radical cystectomy and orthotopic neobladder reconstruction between 1980 and 2000. Parameters studied were prolonged ileus, bowel anastomotic leakage, pulmonary embolism, pneumonia, prolonged catheter drainage for reservoir leakage, reoperation, perioperative mortality, ureteral and urethral anastomotic strictures, neobladder fistulae, reservoic capacity and pressure, recurrent UTI's, deterioration of renal function, upper tract dilatation, metabolic acidosis, reservoir spontaneous rupture, stones (upper tract and reservoir), post-operative insertion of nephrostomy tube, pelvic recurrence, impotence, continence, risk of malignancy in the reservoir, quality of life and patient satisfaction.

Results: The 32 male patients all with bladder cancer were age 22-73 (mean 54 years). Follow up mean 48 months (range from 3-144 months). 2 (6%) developed prolonged ileus, wound infection occurred in 2 (6%) and 1 (3%) developed pulmonary embolism. None underwent reoperation, and there was no perioperative mortality. There was no bowel anastomotic leakage and none suffered from pneumonia or spontaneous rupture of reservoir. 4 (12%) had prolonged catheter drainage, 7 (21%) developed urethral anastomotic stricture and 2 (6%) developed ureteric anastomotic stricture. Recurrent UTI's found in 21 (66%), deterioration of renal function in 4 (12%) and upper tract dilatation occurred in 7 (21%). Reservoir fistulae in 3 (9%) and metabolic acidosis in 13 (40%). 8 (25%) developed pelvic recurrence, and 17 (53%) complained of impotence and 6 out of these underwent penile prosthesis insertion. Only 8 (25%) had urodynamic assessment evaluation, reservoir capacity ranged from 300 to 500 cc (mean 312 cc) with a pressure of 15 to 22cm of H2O.

Continence Figures Were: Fully continent 14 (43%), nocturnal incontinence 9 (28%), stress leakage 3 (9%), totally incontinent 6 (18%). 2 (6%) developed upper tract stones (1 renal, 1 ureteric), 2 (6%) underwent nephrostomy tube insertion postoperatively. Vit B 12 deficiency was not assessed in anyone of them. Normal quality of life and overall satisfied were 26 (81%).

Conclusion: Orthotopic neobladder substitution is not a complication free procedure. We suggest strict adherence policy for careful patient selection, only an experienced and committed urological team to perform this procedure to accomplish minimal complications, and a regular long term follow up to treat complications successfully to achieve high patient satisfaction.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Local staging of bladder carcinoma: Role of endorectal MRI

Adil Hamoodi Al Qaysi, Riyadh A. S. Fadhil, Raji H. Al Hadithi


College of Medicine, Al Nahrain University, Baghdad, Iraq, Department of Urology, Al Riyadh Care Hospital, Riyadh, Saudi Arabia

Aim of the Study: To investigate prospectively the sensitivity, specificity and accuracy of an endorectal MRI in local staging of bladder carcinoma.

Patients and Methods: The study included 53 patients with proven bladder carcinoma (45 men and 8 women, mean age 62.2 years, range 29-78 years). An endorectal MRI had been performed for all the patients. All of the patients underwent total cystectomy. Postoperative histophathological staging were performed and compared with the results of the preoperative MRI staging. Other parameters (immunohistochemical markers and trace elements levels were investigated as part of the paper).

Results and Discussion: Forty-nine cases were transitional cell carcinoma and 4 cases were squamous cell carcinoma. Twelve cases were T2b tumors, 1 case was T3a and 40 cases were T3b tumors. MRI understaged one case of T2b as 2a and understaged one case of T3a as 2b. The overall accuracy was 98%.

Conclusion: Endorectal MRI is very sensitive and promising technique in local staging of bladder carcinoma.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Intravesical sequential chemo-immunotherapy in superficial transitional cell badder cancer: Prospective randomized phase III study

Hisham El Shawaf, Khaled M. Galal 1 , Saleh Mansour 2

Department of Radiotherapy and Oncology, Cairo, Egypt, 1 Department of Urology, Ain-Shams University, and Saudi German Hospital, Jeddah, Saudi Arabia, 2 Department of Radiotherapy and Clinical Oncology, Mansoura University, Mansoura, Egypt

Objectives: Superficial bladder cancer constitutes about 80% of incident cases. Most superficial tumors have a propensity for recurrence after transurethral resection; some are at high risk of progression to muscle invasion. Bacillus Calmette Guerin (BCG) is commonly used as adjuvant intravesical treatment. A number of anticancer agents and new drug classes (gemcitabine) have been tested and approved for intravesical treatment of superficial bladder cancer. In an attempt to improve the efficacy, intravesical chemotherapy and BCG have been combined as sequential treatment.

Patients and Methods: 35 patients with (pTa/pT1) bladder tumors that initially treated with transurethral resection (TURBT) were randomized into three groups. Group (A) patients received intravesical 2 gm of gemcitabine in 100 ml saline once weekly for 6 consecutive weeks. Group (B) received 150 mg of BCG diluted in 50 ml saline once weekly for 6 consecutive weeks. Group (C) received sequential combination of weekly intravesical 2 gm of gemcitabine in 100 ml saline for 6 consecutive weeks then 6 weekly intravesical 75 mg of BCG diluted in 50 ml saline. After median follow up period of 17 months, recurrence or progression was assessed as terminal events of the study.

Results: High risk cases that may have either multiple bladder lesions or more than grade 1 or associated with CIS were present in 72.7%, 66.7%, and 66.7% in arm A, B, and C respectively. The most common local side effects were dysuria, hematuria, frequency and cystitis either bacterial or chemical. Systemic toxicities included neutropenia, thrombocytopenia, fever and malaise. Patients treated with intravesical chemo-immunotherapy had higher incidence of systemic toxicities. Disease-free was present in 36.4%, 66.7% and 75% of cases, however, recurrence was present in 45.5%, 25% and 16.7% of cases in group A, B and C respectively.

Conclusions: In spite of the small number of patients included in the study, our preliminary report suggest that intravesical chemotherapy or chemo-immunotherapy could be reserved for resistant or recurrent cases after failure of BCG treatment. Stratification of cases according to prognostic factors is useful to identify optimal effective intravesical treatment as the maximal benefit of intravesical treatment on prevention of recurrence or progression of the disease was experienced in high risk cases. Moreover, high risk patients who received either BCG alone or as combined sequentially with gemcitabine had higher incidence of disease-free cases, with lower incidence of recurrence and progression when compared to gemcitabine group. The frequency of systemic side effects was insignificantly more frequent in the sequential group.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Initial experience with orthotopic ileal W-neobladder with serous lined extramural tunnel for ureteral re-implantation

Hasan Farsi, Hesham Saada


Urology Department, King Faisal Specialist Hospital, Jeddah, Saudi Arabia

Purpose: Orthotopic bladder substitution following cystectomy has recently been introduced at our center. We analyzed our preliminary results and clinical evaluation of orthotopic ileal W-Neobladder using a serous-lined extramural tunnel as an antireflux procedure.

Materials and Methods: From January 2004 to November 2004, standard radical cystectomy and orthotopic ileal W-shaped Neobladder were performed for 8 male patients for invasive bladder cancer. The ureters were re-implanted using a serous-lined extramural tunnel for reflux prevention as described by Abol-Enein and Ghoneim. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes.

Results: There was no perioperative mortality. Early postoperative complications were encountered in 5 patients including deep vein thrombosis in 1, prolonged ileus and transient diarrhea in 2, urethero-ileal leakage in 1, wound infection and dislodged ureteral stents in 1, cutaneous skin parathesia of the left thigh in 1, and severe hypoalbuminea with scrotal lymphydema in 1 patient. Late complication was observed in one patient in the form of unilateral ureterorenal reflux. Cancer recurrence was not reported in any of our patients. In all cases, stabilization or improvement of renal function was achieved. No metabolic complications were observed. All of our patients had ED and required intracorporeal PGE1 injection. All patients were continent day and night except 2 patients with nighttime occasional enuresis.

Conclusion: Ileal W-Neobladder with a serous-lined extramural tunnel is a safe, reliable form of lower urinary tract reconstruction. The method can be carried out with ease and its versatility has been realized and it's now used routinely whenever orthotopic substitution is required.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Clinical outcome after radical cystectomy for squamous cell carcinoma of the bladder: Is there a difference between bilharzial and non bilharzial cancer?

Alaa Mokhtar, Khalid Al Othman, Naser Elkum, Muhammed Al Musa, Muhammed Aslam, Kamal Hanash


Urology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Purpose: Squamous cell carcinoma of the bladder occur in association with or without bladder bilharziasis. The aim of this study is to evaluate if there is a difference in the outcome between squamous cell carcinoma with or without bladder bilharziasis.

Materials and Methods: Between 1979 and 2003, 97 patients with SCC of the bladder underwent radical cystectomy. A retrospective chart review was done. Cancer specific survival was the end point. Clinical and pathological prognostic factors were studied in both groups.

Results: Out of 97 patients we had 71 patients with complete records. Patients were divided to bilharzial SCC (b-SCC) and non bilharzial SCC (nb-SCC) based on clinical and histological evidence of bilharziasis in the bladder. Median follow up period was 3.2 year (0.5-17 year). The 5 year cancer specific survival for b-SCC and nb-SCC was 39% and 51% respectively, which is statistically not significant. On multivariate analysis only pathological staging (P=0.02) and lymph nodes involvement (P<0.0001) were statistically significant. Presence of bilharziasis was not statistically significant prognostic factor.

Conclusion: There is no significant difference in cancer specific survival between b-SCC and nb-SCC after radical cystectomy. Bladder bilharziasis was not poor prognostic factor for survival. Only pathological staging and lymph nodes involvement were significant prognostic predictors for cancer specific survival.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Prostatic adenocarcinoma in patients underwent radical cystoprostatectomy for bladder cancer

Khalid Al Othman, Alaa Mokhtar, Muhammed Al Musa, Muhammed Aslam, Nasser Elkum, Kamal Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Purpose: We studied the incidence of prostatic adenocarcinoma in patients underwent radical cystoprostatectomy for bladder cancer and compared it to similar series in western countries, aiming to have a better estimation of prostatic cancer prevalence in our society.

Materials and Methods: A retrospective chart review was done on 141 male patients underwent radical cystoprostatectomy for bladder cancer at KFSH&RC between 1975 and 2000. Cases with prostatic adenocarcinoma were identified.

Results: Of 141 male patients underwent radical cystoprostatectomy for bladder cancer only 9 patients (6%) had incidental finding of prostate cancer.

Conclusion: Compared to higher incidence of prostate cancer in cystoprostatectomy specimens seen in western countries (35% - 47%), it seems that we have lower incidence of prostate cancer (6%) which is generally correlate with the incidence of prostate cancer in normal population.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Superficial bladder tumors: An update

Bedeir Ali-El-Dein


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Instruction and Objectives: SBT is a heterogeneous tumor category ranging from the relatively benign TaG1 to the life-threatening T1G3 and CIS. The main stay of diagnosis and treatment of SBT is TURBT. BCG therapy is the most effective adjuvant therapy in this tumor category. The dose and schedule of maintenance BCG has yet to be optimized. Second look TURBT in T1G3 is now becoming a routine in this high risk SBT. Cystectomy may be indicated in some tumors, as a primary option or after failure of conservative treatment.

Patients and Methods: In this lecture, a review of the indications of cystectomy in SBT and a report of Mansoura experience will be made. A comparison of early versus delayed cystectomy for SBT will be discussed. In addition, survival following cystectomy for primary invasive TCC of the bladder versus invasive tumors on top of superficial disease will also be among our experience. Furthermore, the necessity and proper timing of second look TURBT in T1G3 tumors are addressed. Moreover, comparison of 2 different schedules of maintenance BCG for SBT is made in a prospective way.

Results: In Mansoura experience, the 3-year cancer-specific, 5-year and 10-year actuarial cancer-specific survival were comparable in the groups of early and delayed cystectomy for SBT; 87% vs 81%, 80% vs 70% and 73% vs 66%, respectively (log rank p = 0.19). Again, the 3-year cancer-specific and 5-year actuarial cancer-specific survival were comparable in the groups of primary invasive TCC and in invasive tumors on top of superficial disease; 52% vs 47% and 47% vs 44%, respectively (log rank p = 0.7). In addition, the time between the first TURBT and cystectomy (12 or less vs more than 12 months) and number of TURBTs did not significantly affect cancer-specific survival.

Recurrence and progression rates were comparable between the group of maintenance BCG using 3-weekly doses compared to the group of monthly maintenance; 8/34 (23.5%) and 9/50 (18%) for recurrence and 3/34 (8.8%) and 4/50 (8%) for progression, respectively. Toxic and side effects were more frequent in group 1 than in group 2; 17/34 (50%) and 10/50 (20%), respectively (p = 0.004). On second TURBT, 17/30 patients (56.7%) were free of tumor and received BCG therapy. Out of these only 1 (5.9%) developed recurrence during follow up. 9 patients (30%) showed residual tumor (G3pT1 in 6 and G3pT + CIS in 3). These were randomized either to receive BCG (6) or to undergo early radical cystectomy (3). 3 of the 6 patients treated with BCG (50%) developed recurrence + progression. The other 4 patients showed muscle invasive disease and underwent radical cystectomy.

Conclusions: Although tere was a trend towards better survival in early cystectomy, both early and delayed cystectomy for SBT has been found to be statistically comparable regarding survival. Conservative treatment should be adopted for most cases in this tumor category. However, the necessity to separate this tumor category into bad and good cases by clinical prognosticators or biomarkers is imperative. Survival has been found to be comparable following cystectomy for primary invasive and invasive bladder transitional cell carcinoma on top of superficial disease. Monthly BCG maintenance is as effective as and less toxic than multiple 3-week courses in recurrence prophylaxis of T1 bladder TCC. The significant risk of detecting a muscle invasive disease (13.3%) or residual tumor (30%) strongly recommends the routine performance of second TURBT in grade 3 stage T1 bladder TCC. Recurrence of T1G3 on second TURBT is a poor prognostic sign with a high rate of further recurrence or progression.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Issues in the management of high risk superficial bladder cancer

Michael A. S. Jewett


Department of Surgical Oncology, Division of Urology, University Health Network (Princess Margaret Hospital), University of Toronto, Ontario, Canada

Most superficial stage T1 urothelial bladder cancers are high grade and appear to grow rapidly with the potential to not only recur but progress to invasion, metastases, and death. The elements of treatment success which we define as disease-free survival with a high quality of life, including bladder sparing where possible, will be discussed. The sequential steps in the assessment, decision-making, and treatment of T1 patients will be discussed following the appended algorithm for the management of stage T1 urothelial tumors presenting as new or recurrent tumors after previous management of lower stage tumors. Virtually all are high grade histologically and present a serious risk of progression in stage by invasion or metastases. Timely and aggressive management of these tumors is essential to minimize the risk for the patient. Urologists, in particular, are in a position to make a significant impact on the overall outcome of patients in this. Urologists, pathologists, and radiologists must work together to not only diagnose new or recurrent tumors but also to accurately assess individual risk of progression and stratify patients for treatment. The technique of resection is important to be complete but also to safely provide sufficient tissue for staging and grading. Random and directed biopsies are frequently indicated. Immediate adjuvant chemotherapy should be used more frequently. In my opinion, re-resection is mandatory, if the surgeon cannot guarantee that a complete TURBT has been performed or when muscle is not present in the pathological specimen. Clinically useful prognostic factors have been defined to stratify patients by risk of progression. Substaging of T1 tumors has been described but remains controversial. Extravesical tumor extension can occur, particularly after BCG (Bacille-Calmette-Guerin) therapy with an initial complete response, and it should be screened for. The most difficult decision is whether to initiate intravesical therapy or to recommend radical therapy, usually with cystectomy. Initial intravesical therapy should be BCG but careful follow up is necessary with the intent to recommend cystectomy for persistent or recurrent tumor, although some patients can be managed by salvage intravesical therapy.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Advancement of bladder cancer treatment over the past three decades

Mohammed S. Abomelha


Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

The incidence of cancer in Saudi Arabia is one of the lowest in the world (ASR 70/100000 populations). Amongst the genito-urinary cancer (GUC), the bladder cancer is the most common in our country, although prostate cancer is the most common in men.

Over the past 3 decades the incidence, clinical presentation, histological pattern and treatment modalities have made a lot of changes. These changes were the results of health awareness, better health care, prevention and improvement of treatment offered to our patients.

The incidence of bladder cancer has been stabilized at 3.4% of all cancers. Histological wise, there is 50% dropped in the incidence of squamous cell carcinoma due to schistosomiasis prevention campaign. On the other hand, the number of superficial bladder cancer increased by 15% due to health care improvement. Patients' quality of life improved due to better offered treatment modalities.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Therapeutic role of radical cystectomy in locally advanced bladder cancer

Armen G. Aprikian


Division of Urology, The Montreal General Hospital and Royal Victoria Hospital, McGill University, Montreal, Canada

Bladder cancer is the fifth most common cancer diagnosed. Prognosis for this disease is dependent on tumor stage and grade. Radical cystectomy has been the standard treatment for muscle-invasive disease, with combined-modality approaches using chemotherapy increasing. Neoadjuvant chemotherapy in transitional cell carcinoma of the bladder appears to improve survival. This is an important development in the management of muscle-invasive bladder cancer. There is an improved absolute 5-year survival of 5% for T2-T4 disease. Whether all patients in whom radical cystectomy is contemplated should receive neo-adjuvant chemotherapy is debatable.

Radical cystectomy is the gold standard to which all other local therapies including multimodality bladder-preserving strategies must be compared. Refinements in surgical technique coupled with the expanded application of continent urinary diversion have resulted in good functional outcomes in properly selected patients. Cystectomy combined with regional lymphadenectomy can be performed with low morbidity, provides excellent local control, and can result in durable disease-free survival even among patients with pelvic lymph node metastases. There is an increasing body of evidence supporting a more extended lymphadenectomy at the time of cystectomy. An extended dissection may provide a survival advantage in patients with node-positive tumors (p stage), the number of lymph node removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy with evidence of lymph node metastases. Finally, evidence indicates that surgeon and hospital volume of cases is directly related to morbidity and post-operative mortality after cystectomy.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

The choice of urinary diversion in patients undergoing radical cystectomy

Atallah A. Shaaban


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Radical cystectomy for bladder cancer is the most frequent indication for urinary diversion. The ideal bladder substitute should approximate the normal bladder functions, and cancer control should not be compromised. The choice of urinary diversion depends on different patient factors (general, oncological, urinary, and intestinal) and the surgeon experience.

Ureterosigmoidostomy was the earliest form of urinary diversion reported by Simon in 1852 in an exstrophy patient. The lessons taught with its experience were highly stimulative. A lot of modified rectal diversions were utilized with generally disappointing results.

Bricker popularized the ileal loop conduit which is the most common type of urinary diversion. Ileal conduit is simple, safe, with lowest rates of complications and reoperations and it is particularly suitable for high-risk patients.

Continent cutaneous urinary diversion was developed by Gilcrist and modified later by Kock and other investigations. This procedure is practiced in limited centers.

Orthotopic bladder replacement into the native urethra was evolved by Camey and the general principles of reconstruction were optimized by Kock. Candidates for orthotopic substitution should be healthy with adequate renal and hepatic functions. Men with prostatic urethral involvement and women with tumor extension into bladder neck should be excluded. The use of antireflux procedures is associated with higher incidence of uretero-ileal anastomotic strictures than direct methods. Although daytime continence is generally satisfactory, nocturnal enuresis remains a concern in 15-40% of cases.

The ideal bladder substitute remains to be developed even though orthotopic neobladder is the current gold standard.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Serous lined principle in continent urinary diversion

Hassan Abol-Enein


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

The ileal continent urinary diversion entails creation of compliant reservoir with an adequate outlet for voluntary urination. The optimal outlet is the external urethral sphincter which allows voiding through the native urethra. The issue of creation of an antireflux system for ureteral implantation in low pressure reservoirs is a matter of controversy. So far it seems necessary to protect the upper tracts from reflux of the infected urine during the high pressure episodes in the reservoir. A prospective controlled randomized study should be conducted to verify this controversy. Serous lined extramural tunnel is the technique which can be utilized for reflux prevention and construction of continent outlet. It is versatile technique suitable for all diversion and conversion procedures. It provides a competent non obstructing unidirectional valve, technically simple, easy to catheterize and allows endoscopic retrograde instrumentation. It is associated with a low complication rate and minimal need to revisional surgery.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Ureterointestinal strictures following urinary diversion

Hassan Abol-Enein


Department of Urology, Urology and Nephrology Center, Mansoura, Egypt

Ureterointestinal anastomotic stricture is an important complication following urinary diversion. Most of the strictures can be seen up to 5 years following the surgery. The etiology may be due to technical or non technical factors. Irradiation injury and ischemia are among the important causes. It may be symptomatic but usually it is asymptomatic. Endourologic treatment should be the primary option of treatment. It can treat 60-70% of cases. Repeated endourologic treatment is not associated with more improvement. Open surgery is the optimal treatment after failure of endoscopic treatment. Exclusion of malignancy is a must to ensure a satisfactory outcome. Results of early treatment are much better than delayed intervention. Regular and continuous follow up is important to pick up early cases.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Long-term outcome of ureteral implantation in orthotopic colonic substitution

Ismail Khalaf


Department of Urology, Al Azhar University, Cairo, Egypt

Introduction and Objective: Long-term data on the results of ureteral implantation in orthotopic colonic substitution is an important aspect in the evaluation of the outcome of any continent diversion after radical cystectomy. This study reports the outcome of different ureterocolonic anastomotic techniques done with orthotopic sigmoid neobladder, as regards the occurrence of anastomotic stricture, reflux and renal backpressure or function deterioration.

Methods: Computerized database of 120 patients undergoing continent orthotopic sigmoid neobladder substitution after radical cystectomy were analyzed for the outcome of their ureteral implantation. Techniques used included transcolonic Goodwin tunneled anastomosis for 141 ureters, direct only in teniectomy trough for 50 ureters, and direct nipple technique for 25 ureters. Evaluable cases included those who can be followed up for a period of at least one year, develop no tumor recurrence and should have a compliant neobladder. Preimplantation normal ureter-caliber was present in only 60% of cases, while in the remaining cases ureters were abnormal, being either dilated, atonic, thick or fibrous.

Results: Period of follow up ranges between 1-14 years with a mean of 3.7 years. Successful implantation outcome with no stricture or reflux or renal backpressure was noted in nearly three fourths of the cases. Anastomotic stricture occurred in 18.5% of Goodwin-tunneled technique, in 14% of onlay teniectomy technique, and in only 4% of direct nipple technique. Meanwhile, uretro-renal reflux was noted in only 7.8% of tunneled technique, in 16% of teniectomy, and in 12% of direct nipple. Moreover, renal back pressure was noted in 23% of tunneled technique including unilateral loss of function in 3%, while it occurred in 22% of teniectomy and in only 8% of direct nipple.

Conclusions: Antireflux ureteral implantation in orthotopic continent neobladder can result in affection of renal integrity in about one-fourth of cases. This finding may disfavor the use of antireflux tunneled technique in orthotopic colonic neobladder replacement.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Predictors of upper tract and local recurrence after radical cystectomy for bladder cancer in saudi patients

Mohammed Al Mousa, Alaa Mokhtar, Khalid Al Othman, Naser Elkum, Kamal A. Hanash


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Purpose: To evaluate different prognostic factors which may predict local recurrences in patients with bladder cancer after radical cystectomy.

Materials and Methods: Between 1981 and 2000, 229 patients underwent radical cystectomy and urinary diversion for bladder cancer at King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia. 175 patients have available records for review. Retrospective chart review was done demographic, clinical and pathological variables, which may relate to recurrences in bladder cancer patients, were reviewed. Statistical analyses were done with local recurrence was end point.

Results: Of the 175 patients 36 patients (20.6%) had pelvic local recurrence, 2 patients (1.2%) had urethral recurrence and 1 patient (0.6%) had upper tract recurrence. Median follow up was 18 months (range 29 days - 19 years) for the entire groups and median time to recurrence for the patients who develop pelvic local recurrence was 10 months (range 47 days - 69 months). On univariate analysis, lymph node status, area of residency, and histopathological type were significant predictors of local recurrence.

Conclusion: Lymph node status, area of residency, and histopathological type are significant predictors for pelvic local recurrence in bladder cancer patients after radical cystectomy. These predictors may help to define bladder cancer patient groups who require further therapy or enrollment in controlled trials to examine additional therapy. Upper tract and urethral recurrence are rare and may not require close follow up.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006

(21-24 Muharram 1427)

Urinary bladder tumor and environment

Eyad Al Aqqad


Department of Urology, Queen Rania Urological Center, Royal Medical Services, Nablus, Palestine

Bladder cancer is the second most common genitourinary tumor and is significant cause of morbidity mortality. Its constitutes the 3 rd urological illness after urinary stones and prostate tumors.

These tumors are very often preceded by modifications preneoplasiques largely induced by environmental factors, tobacco being a chief one.

The impact of these factors varies from an individual to another according to a genemique profile that makes it more or less responsible to these factors and by consequent to cancer. The environment factors especially tobacco, the professional and iatrogenic factors are recognized currently as risk factors important for the development of bladder tumors.

Tobacco addition counts at least 50% of the environmental factors in the etiology of bladder tumors. Trials of neoadjuvant chemotherapy have failed to show a survival advantage in case of advanced and metastatic bladder cancer.

The current tumor, node, and metastasis staging system is insufficient to predict outcome in patients with bladder cancer irrespective of the treatment they received. The role of prevention of bladder tumors is very important.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Use of the new marker NMP22 bladder check decreases the frequency of check cystoscopy in the follow up of patients with TCC of the urinary bladder

A. Allam, B. Hathout, S. El-Nisf


Department of Urology, Farwania Hospital, Kuwait City, Kuwait

Aim of the Work: To assess the sensitivity and specificity of urinary NMP22 qualitative assay in the detection of recurrence of TCC during follow up period compared to radiological investigations, urine cytology and check cystoscopy; and if it can be relied on for follow up of certain cases to decrease the frequency of check cystoscopies.

Patients and Methods: 38 patients known to have UB cancer undergoing routine follow up were subjected to abdominal-pelvic ultrasonography, NMP22 BladderCheck test, urine cytology followed by check cystoscopy +/- biopsy. The result of those tools was compared regarding its sensitivity and specificity in detecting recurrence of UB cancer. On the light of these results, the accuracy of the NMP22 BladderCheck was evaluated.

Results: BNO22 BladderCheck could detect 19 out of 20 cases of bladder cancer recurrence (95% sensitive). The only missed case was under treatment with local BCG which probably affects the accuracy of the test. NMP22 was superior to urine cytology in term of sensitivity, while both diagnostic modalities were equal in term of specificity (88.89%).

Conclusions: NMP22 BladderCheck is a simple in-office test which proved in the current study to be highly sensitive in detecting recurrence, it can change the classical regimen for follow up of bladder cancer cases; reducing the number of check cystoscopies for these patients thus reducing morbidity and improving the quality of life beside its economic impact. However, this conclusion should be proved in a wider scale of patients.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Pattern of bladder cancer treatment in Saudi Arabia

B. Al Saywid, M. Zimaity, M. Rimawi, A. Abusamra


Department of Urology, King Abdulaziz Medical City, Jeddah, Saudi Arabia

Aim of the Work: Bladder cancer management often entails facing multiple controversial decisions by the urologist. A recent consensus conference laid management guidelines for some of these difficult decisions; they were published recently. We conducted a practice pattern survey to assess the treatment patterns of bladder cancer by urologist in Saudi Arabia and to determine if the pattern is in line with current recommendations.

Patients and Methods: A two-page structured questionnaire on bladder cancer management was distributed to all urologists who attended the 19 th Saudi Urological Conference in Riyadh, Saudi Arabia, during the period of Feb. 27 th to March 1 st 2007; and also distributed to all urologists who attended Jeddah Urology Club meeting which was held on March 4 th 2007, Jeddah Saudi Arabia.

Results: 328 physicians received the questionnaire; of these, 146 urologists returned the surveys (44.5%) response rate), 24 were incomplete, and thus 122 surveys were used for analysis. Board Certified Urologists were one hundred and eight (108), and fourteen (14) respondents were in residency training program in Saudi Arabia. 84% of urologists have more than 5 years of experience. 54.6% of urologists perform less than 5 transurethral resection of bladder tumor (TURBT) per month. 86 participants (73 urologists and 13 residents) did not use intravesical chemotherapy post TURBT in all the times. For the role of re-TUR in 2-4 weeks post initial TURBT, 80 participants are applying this role (65.5%). In the case of recurrent T1G3 post initial 6 weeks of BCG course, 45% recommended, a 2 nd BCG course (6 weeks), while 30% chose immediate cystectomy. 76% of all participants perform Radical cystectomy less than 5 annually. More than 50% of all participants never used neoadjuvant chemotherapy. Only 26% of all participants perform extended pelvic lymph node dissection during the Radical Cystectomy. 28% of all participants still performing ileal conduit as a sole urinary diversion.

Conclusion: The practice patterns of Urologists in Saudi Arabia for bladder cancer appear quite varied, depending on their training base, patient demographics and geographic location of practice. Despite the wide acceptance of immediate post-TURBT intravesical chemotherapy, this adjunctive modality does not appear to be a routine therapy for a significant proportion of many board certified urologists. In addition, Neoadjuvant chemotherapy and extended pelvic lymphadenectomy at the time of cystectomy has also not been embraced as routine care. Reasons for not incorporating these approaches into standard practice, including barriers to their acceptance and performance, may be multifactorial.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Radical cystectomy in the female, how I do it?

Hassan Aboul Enein


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Radical cystectomy entails removal of the bladder, perivesical fat, draining pelvic lymph nodes, female genital organs, all in bloc. With the era of orthotopic neobladder in female, preservation of a good urethral stamp to improve continence, some vaginal tissues to keep the nerves to maintain sexual life are critical. The way and extent of lymphadenectomy, preparation of the pelvis to receive the neobladder, bloodless, ligatureless cystectomy will be demonstrated.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14-16 April 2009

Radical cystectomy and orthotopic ileal W-neobladder: Functional results and follow up report

H. Farsi, A. Nassir, R. Rami Salawi, H. Saada


Surgery Department, Urology Section, King Faisal Specialist Hospital, Jeddah, Saudi Arabia

Objective: Orthotopic ileal urinary bladder replacement is an established method after radical standard cystectomy. The detubularized orthotopic ileal reservoir has been used worldwide ever since because of its technical simplicity, its reduced risk, and its good functional results.

Patients and Methods: We assess our experience and long follow up results of 22 patients who underwent radical cystectomy and orthotopic ileal neobladder reconstruction.

Results: The mean (range) follow up was 26 (4-39) months. Early complications in 5 patients were treated conservatively. The incidence of daytime and nighttime continence was 93.3% and 67%, respectively.

Conclusion: Radical cystectomy followed by the construction of orthotopic W-shaped ileal neobladder results in a near-normal-functioning orthotopic reservoir that can be safely offered to suitable patients.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14-16 April 2009

Long-term prognostic value of the combination of the eortc risk group calculator and molecular markers in non muscle invasive bladder cancer patients treated with bacillus calmette-guerin

Sultan Saud Alkhateeb 1,2 , Mischel Neill 1,2 , Sas Bar Moshe 1,2 , Bas Van Rhijn 1,2 , David Kakiashvili 1,2 , Neil Fleshner 1,2 , Michael Jewett 1,2 , Michel Petein 1,2 , Claude Schulman 1,2 , Sally Hanna 1,2 , Peter Bostrom 1,2 , Thierry Roumeguere 1,2 , Shahrokh Shariat 1,2 , Sandrine Rorive 1,2 , Alexandre Zlotta 1,2

1 Department of Urology, Princess Margaret Hospital, University Health Network, 2 Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

Introduction: To evaluate the long-term prognostic value of the combination of the EORTC risk calculator and different molecular markers in predicting the outcome of intermediate and high-risk non-muscle invasive bladder cancer (NMI-BC) treated with intravesical BCG.

Methods: This study included 42 patients presenting with intermediate to high risk NMBC treated with transurethral resection (TUR) and BCG. TUR samples were analyzed for the molecular markers p53, p21 wafl/cip, Bel-2, CyclinD1 and metallothionein 9 (MMP9) using immunohistochemistry. Frequency of positivity measured as a percentage was assessed alone and in combination with EORTC risk group in relation to outcome in terms of recurrence and progression using univariate analysis and Kaplan-Meier survival curves.

Results: The overall recurrence rate was 61.9% and progression rate was 21.4% and median follow up was 88 months. In univariate analysis, CyclinD1 and EORTC risk-group were significantly associated with recurrence (p-value 0.03 and 0.02, respectively) while none of the markers showed a correlation to progression. In combining marker status to EORTC risk groups, high-risk group and positive MMP9, Bel2, CyclinD1 and p21 were significantly associated with recurrence (log rank p-values <0.001, 0.03, 0.02 and 0.006, respectively) and high-risk group with positive MMP9 and p21 were significantly associated with progression (log rank p-values 0.01 and 0.04, respectively).

Summary and Conclusion: Molecular markers have a long term prognostic value when combined with EORTC scoring system and they may be used to improve the predictive accuracy of currently existing scoring system. Larger series are needed to confirm these findings.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Transitional cell carcinoma of bladder in young age group

Naif Al Hathal, Khalid Al Othman


Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objective: To identify the probable risk factors, natural history and outcome of bladder urothelial cancer in young age group.

Materials and Methods: A retrospective chart review study of all patients 30 years old and less who were diagnosed to have bladder transitional cell carcinoma at King Faisal Specialist Hospital and Research Centre from 1975 to 2006. Demographic, clinical and pathological data were analyzed. Transurethral resection of bladder tumor (TURBT), any adjuvant therapy given, initial pathological stage and follow up disease recurrence or progression were studied.

Results: Twelve (12) patients were identified to have urothelial bladder cancer aged less than 30 years old (6-29), 10 male and 2 female. Two (2) patients (16%) had papillary urothelial neoplasm of low malignant potential (PUNLMP) at initial diagnosis, 8 patients (68%) were diagnosed to have low grade superficial bladder cancer and 2 patients (16%) had high grade bladder cancer invasive to lamina propria. None had muscle invasive bladder cancer at initial presentation. All had normal upper tract screening. Four (4) out of twelve (12) patients (33.3%) had recurrence of tumor and one patient (8%) had progression to muscle invasive bladder cancer whose initial pathology was high grade bladder cancer with invasion only to lamina propria (T1G3). None of the 2 patients with PUNLMP had any recurrence over average follow up of 5 years. Two (2) out of 8 patients whose initial pathology was low grade superficial bladder cancer had recurrence with same stage and grade. Both patients whose initial histology was high grade bladder cancer with lamina propria invasion (T1G3) had more than one recurrence; furthermore, one had progression to muscle invasive bladder cancer.

Conclusion: Urothelial bladder cancer in young age group is mostly superficial with less recurrence and progression rates than older patients. More studies are needed with larger population number to clarify such disease entity.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Patients with non primary PT1 non-muscle invasive bladder cancer treated with bacillus calmette-guerin are at higher risk of progression compared to primary T1 tumors

Sultan Saud Alkhateeb, Bas W. G. Van Rhijn, Antonio Finelli, Theodorus van der Kwast, Andrew Evans, Sally Hanna, Rati Vajpeyi, Neil Fleshner, Michael Jewett, Alexandre Zlotta


Department of Urology, Princess Margaret Hospital, University Health Network, and Mount Sinai Hospital, University of Toronto, Toronto, Canada

Introduction: Few studies have examined the prognostic significance of prior tumor resection(s) in T1 non-muscle invasive bladder cancer (NMI-BC) treated with intravesical Bacillus Calmette-Guerin (BCG). The aim of this study is to examine this issue by comparing the prognosis of primary versus non-primary T1 NMI-BC treated with BCG.

Methods: Patients with pT1 NMI-BC treated with BCG were identified and their pathology was reviewed. Patients were then stratified into primary versus non-primary tumors and their outcome was compared using univariate, multivariate and Kaplan-Meier survival analyses and Cox regression model adjusting for various clinical and pathological features including, age, gender, tumor size, multifocality, pathological grade and associated carcinoma in-situ (CIS).

Results: We had a total of 191 patients, 95 (49.7%) with primary and 96 (50.3%) with non-primary tumors. Their clinical and pathological characteristics were comparable. For the primary versus the non-primary group, progression rates were 24.2% vs 39.6%, respectively (HR 2.07, 95% CI 0.98 - 3.71, multivariate p-value 0.03) and the 5-year progression-free survival rates were 71.9% vs 51.5%, respectively (Log Rank p-value <0.001). This difference remained significant in a multivariate Cox regression analysis (HR 2.53, 95% CI 1.40-4.57, p-value 0.002). There was no difference between the two groups in recurrence or disease-specific mortality.

Summary and Conclusion: Non-primary T1 NMI bladder tumors treated with BCG carry a significantly higher risk of progression to muscle invasive disease compared to primary tumors. This information may be used in combination with other prognostic factors to identify patients at high risk of progression when counseling patients.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Surgeon-volume and outcome relation in transurethral resection of bladder tumour

Sultan Saud Alkhateeb, Neil Fleshner, Michael Jewett, John Trachtenberg,

Alexander Zlotta, Antonio Finelli


Department of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada

Introduction: It has been suggested that the presence of detrusor muscle (DM) in the first transurethral resection of bladder tumour (TURBT) may serve as a surrogate for complete\adequate resection in non-muscle invasive bladder cancer (NMBI-BC). The aim of this study is to evaluate whether surgeon-volume of TURBT is associated with the presence of DM since it has not been evaluated before.

Methods: Between 1990 and 2009, we identified all TURBT procedures performed at our institution for bladder cancer and the surgeons performing them. We determined the mean number of TURBT performed per surgeon per year and then developed tertiles of surgeons: low, moderate and high based on their volume (<6, 6-12 and >12 procedures per year, respectively). Clinical and pathological variable assessed included: age and gender, tumour size and multifocality, pathological tumour stage and grade, concomitant carcinoma in-situ (CIS) and whether DM was sampled. We limited our analysis to patients' initial TURBT and compared the outcome (presence of DM) between the three tertiles using univariate analysis and multivariate logistic regression adjusting for the clinical and pathological variables.

Results: The mean number of TURBT's performed by staff was 14.9 procedures (median 15.1) per surgeon per year. Among the 624 patients included in our analysis, the overall rate of DM sampling was 54.0%. There was a significant increase in the rate of DM sampling with time 36.6% vs 45.8% vs 62.8% for the 1 st , 2 nd and 3 rd 7-year periods (p<0.001). When comparing volume tertiles, the DM sampling rate was 47.8% in the low-volume group compared to 53.6% in the moderate-volume group (OR 1.57, 95%, CI 0.98-2-49, p-value 0.056) and 58.2% in the high-volume group (OR 1.71, 95% CI 1.05-2.77, p-value 0.029).

Summary and Conclusion: We demonstrate, for the first time, a volume-outcome relationship in TURBT with a significant correlation between surgeon volume and the presence of DM in the initial resection. If these findings are confirmed in other institutions or on a population level, initiatives can be instituted to address and overcome this quality of care issue.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Prospective phase II study of maximal transurethral resection followed by combination of chemo-radiotherapy for non metastatic invasive bladder cancer

Ahmed Momamed El Taher


Department of Urology, Assiut University Hospital, Assiut, Egypt

Introduction: Evaluation of the efficacy and safety of maximal transurethral resection followed by combination of chemo-radiotherapy for invasive bladder cancer to preserve the bladder and to determine the outcome of this regimen. The study end points were response, disease free survival, overall survival and toxicity.

Methods: After transurethral resection for carcinoma of the bladder, patients received 60 Gy of fractionated radiotherapy over 6 weeks with cisplatin and gemcitabine. Response was assessed after 4-6 weeks after the end of treatment.

Results: This study included 30 patients of whom 27 patients showed complete response, one patient died after 25 settings of radiotherapy and 2 patients showed progressive disease at the cystoscopic re-evaluation. Within a median follow up period of 18 months, another 7 patients developed an infiltrating bladder relapse and they were managed surgically. Anemia and cystitis were observed in 1 and 5 patients, respectively. The value of disease free survival and overall survival were 66.67% and 76.6%, respectively.

Summary and Conclusion: This combination protocol can be offered as a reasonable alternative to radical cystectomy in selected patients with invasive bladder cancer.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Radical cystectomy in female for orthotopic substitution

Hassan Abol-Enein


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Introduction: Radical cystectomy is frequently indicated in treatment of invasive bladder cancer. The quality of cystectomy should be considered and the outcome is dependent on many technical details.

Method: Transperitoneal approach is the usual incision, Bilateral meticulous iliac and pelvic lymphadenectomy is a must. Liberal use ligasure system for pedicle control. This will provide a blood less cystectomy. Careful delicate dissection of the urethral stamp is important. Fixation of vaginal stump to the remnant of round ligament will minimize the vaginal vault prolapsed. Filling the pelvic cavity with a generous omental flap is quite helpful to support the pouch.

Results: This technique has improved the function outcome significantly.

Conclusion: Detailed attention of the surgical technique is critical to ensure a satisfactory outcome.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 2011

Continent cutaneous ileal reservoir

Hassan Abol-Enein


Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Introduction: Continent ileal reservoir is indicated whenever construction of an orthotopic neobladder diversion is not feasible.

Surgical Technique: The technique entails isolation of 40 cm of the terminal ileal for construction of the body of the reservoir. Two additional segments 10 cm each were used for the inlet and outlet. Serous lined principle was used to create unidirectional valves for reflux prevention and continence mechanism. The outlet chiminy is connected to the umbilicus and the ureters were reimplanted using serous lined antireflux mechanism.

Results: This technique is easy to learn, suitable for many indications in adults and children. The rate of continence is as high as 95%.

Conclusion: The technique is quite associated with good functional outcome. It works when other techniques are difficult to use or contraindicated.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 2011

Activated H-ras gene mutations in transitional cell carcinoma of urinary bladder in Kashmiri population

M. Saleem Wani, Arshad A. Pandith, Zafar A. Shah, Arif Hamid, Roohi Rasool, Adfar Yousuf, Mushtaq A. Siddiqi


Sheri-Kashmiri Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Introduction: This study aimed at assessing the frequency of specific-point mutations in the H-ras of RAS gene family of a group of Kashmiri patients with bladder cancer and whether they are linked with the clinicopathological parameters.

Materials and Methods: We examined the paired tumor and normal tissue specimens of 48 consecutive patients with transitional cell carcinoma undergoing TURBT and Radical Cystectomy. The DNA samples were evaluated for the occurrence of H-ras activating mutations in exon 1 and 2 by PCR-SCCP. In addition blood was also collected from all the cases to rule out any germ line mutation.

Results: Specific point mutations of activated H-ras identified in bladder cancer patients represented 14.5% (7 out of 48) comprising of 7 missence mutations. The base substitutions identified in these bladder tumors were diverse and included four transversions (two G T and two AT) and three transitions (A G). 71.4% of the mutations were detected in codon 61 and 28.6% in codon 12. This pattern of mutation is compatible with interactions of the urothelium with more than one class of environmental agent during bladder tumor development particularly smoking which showed a significant association with this study (P < 0.05). No correlation was found between tumor grade and/or stage and the presence of H-ras mutation.

Conclusion: Activation of H-ras mutation showed a significant association with smoking in bladder tumors (P < 0.05). No correlation was found between tumor grade and/or stage and the presence of H-ras mutation.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 2011

Angiosarcoma of urinary bladder report of two cases and review of literature

Nayef Ameje, Mohamed A. Gomha, Samir S. Amr


Department of Urology, King Fahd Specialist Hospital, Dammam, Saudi Arabia

Introduction: Angiosarcoma of urinary bladder is an extremely rare vascular neoplasm, with eighteen reported cases since 1907. Our aim is to review these reported cases of angiosarcoma of urinary bladder in the literature and to report 2 new additional cases.

Materials and Methods: PubMed search was done for angiosarcoma of urinary bladder. The 18 reported cases as well as the medical records of 2 new cases in our hospital (KFSH-Dammam) were reviewed with regards to the patient's age, clinical parameters, diagnostic modalities, management, and outcome.

Results: Only 20 cases of urinary bladder angiosarcoma including our two new cases have been reported since 1907. Two cases have been found with pre-existing bladder hemangioma. One case was found to have history of cutaneous angiosarcoma that represents metastatic deposits in the bladder, so it was not included in our review. Bladder angiosarcoma occurs in middle age and elderly people (Mean age 64.3 years). Men are the majority with male to female ratio 14.6. The vast majority of cases presented with hematuria (75%) and dysuria is the second most common symptom (15%). Some risk factors like exposure to radiation and chemicals have been proposed. Out of the all 20 cases, 6 patients had previous history of radiation for the pelvic area for gynecological or prostate cancer, and 5 cases had history of smoking. Histologically 43% spindle type, 28.5% typical type and 28.5% epithelioid type were found. Although angiosarcoma of the bladder has a poor prognosis in general, there are 2 reported cases who showed longer survival after multimodal therapy reaching up to 6 years. Our 2 cases, one male and one female patient, had no known angiosarcoma related carcinogenic chemical exposure or radiation to the pelvic area, but the male patient had history of smoking. Both our cases presented with hematuria and dysuria, and were diagnosed by the CT scan and cystoscopy with bladder biopsy. Special immunohistochemical staining was essential to make the final diagnosis. The male patient refused surgery initially although the big bladder mass was mobile and respectable. He presented after as an emergency case with acute abdomen and exploration showed rupture of the bladder tumor into the peritoneum, so palliative cystectomy was done. The patient then developed huge abdomino-pelvic recurrence and pulmonary metastases and died 6 weeks after exploration. The female patient was 90 years old and is the oldest patient in all the reported cases. She was not a candidate for any mode of intervention since she had a non respectable mass (T4b) at the time of diagnosis that extend to vagina as a visible mass in the vulval area. She died 3 months after her presentation.

Recommendation: Angiosarcoma of urinary bladder is a rare tumor that has poor prognosis and it needs more cumulative cases or more assessment of the risk factors and the best modality of treatment. The outcome of most of reported cases is dismal although multimodal therapy showed promising results.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 2011

Single centre experience with the management of superficial bladder cancer

Ashraf Almatar, Mohamed A. Gomha, Adel Al Dayel, Ibrahim Al Oraifi, Irfan Khan, Riyad Al Mousa


Department of Urology, King Fahd Specialist Hospital, Dammam, Saudi Arabia

Objectives: To evaluate our experience in KFSHD with the management of superficial bladder cancer and to determine recurrence and progression.

Materials and Methods: Between 2005 and June 2010, 49 patients (pts) were diagnosed as superficial bladder cancer in KFSHD. 9 patients were excluded from the study as they continued treatment elsewhere and do not have follow up data. The remaining 40 patients (33 males and 7 females) had a mean age ± SD of 55 ± 14 years. Patients were initially treated by transurethral resection and peri-operative intravesical Mitomycin C (MMC, 40 mg in 40 ml saline) in the majority of them. They then received induction and maintenance of either MMC or BCG (SWOG protocol) or nothing based or the risk category of their bladder tumors (low risk: Ta, G1, single & < 3 cm; high risk: T1 or G3 or CIS; intermediate risk: all others). Patients were followed up by cystoscopy every 3-6 month and urine cytology. Date of diagnosis is the date of the first TURBT in our hospital, the date of last follow up is the date of last cystoscopy. Time to recurrence is the time between the first TURBT and first cystoscopy that showed recurrence. Recurrence and progression rates were determined. 5 year-recurrence free survival was estimated by the Kaplan-Meier survival analysis.

Results: Mean follow up period was 23 ± 16 months. 11 pts out of 40 had recurrence with recurrence rate of 27.5%. One patient had progression to muscle invasive disease (progression rate: 1/40 = 0.025%) 16 months after receiving intravesical MMC for intermediate risk cancer (multiple Ta G2) and underwent radical cystectomy. The 5-year-recurrence free survival was 55%. Among the 11 patients with recurrence 3 had high risk tumors, one with low risk and 7 with intermediate risk. Among the 3 high risk pts, one had BCG failure and the other 2 had no recurrence on BCG at 6 months. Among the intermediate risk patients, only 2 had MMC but they were uncompliant; after completing induction and maintenance MMC, one was free and one has TaG1 recurrence at last follow up cystoscopy. The remaining 5 patients did not receive intravesical therapy after first TURBT because of variable reasons; then after recurrence 2 patients received MMC, one received BCG (all 3 are recurrence free at last cystoscopy); one (TaG1) continued without intravesical therapy (IT) and one was uncompliant to receive IT. The patient in the low risk group became pregnant and so no treatment was given and when she had low risk recurrence after delivery only immediate MMC instillation was given and follow up showed no recurrence.

Conclusion: Recurrence of superficial bladder tumors occurred at a rate of 27.5% while progression to muscle invasive disease is rare with tailored approach of using intravesical therapy after TURBT. Recurrence can be further decreased if we can ensure patients' compliance, and treat all patients with intermediate risk group with intravesical therapy.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 2011




 

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