12 MARCH 2008

mes

Cystectomy over age 80: Patient selection is key

Caroline Helwick cy in the elderly, but few studies have
JT CORRESPONDENT included patients >80 years old.
"Elderly bladder cancer patients may be
New Orleans—For very elderly patients guided toward alternative and less effective
with bladder cancer, good outcomes with therapies, based on their pi"esumed increased
radical cystectomy are possible primari- predisposition to complications und an
ly through appropriate patient selection, inaease in baseline comorbidities." Dr. PCatz
timely surgical man- noted. "But we are doing more of these oper-
agement, and metic- ations on the very elderly, and. therefore,
/\nierican ulous postoperative Iwe have a] need for infomiation."
College care. These factors The study reviewed the perioperative
of Surgeons are essential to sus- results and long-term survival outcomes
Clinical Congress tain long-term sur- of all patients >80 years of age who under-
New Orleans
vival, according to a went radical cystectomy from 1995 to 2003
retrospective review at the University of Chicago. Of 517
from the University patients in this group, 49 (9%) were at least
of Chicago Medical Center. 80 years old, with a mean
Results ofthe study, led by Gary Stein- age of 83 years. At least Bladder
berg, MD, were presented at the Ameri- two comorbidities were
can College of Surgeons Clinical Con- present in3l (63%) ofthe very elderly. All
gress here by Mark H. Katz, MD, a clin- patients underwent cystectomy with uri-
ical fellow in urologic oncology at the nary diversion performed by a single sur-
University of Chicago. geon. The study excluded patients with
Bladder cancer is a disease of the eld- non-urothelial bladder cancer, benign dis-
erly. While radical cystectomy is standard ease, or additional concomitant surgery.
care for invasive disease, it is a complex
procedure with a significant rate of com- Delays affect risk, compiications
plications. Several studies have demon- Among the patients 80 years of age or old-
strated the operation's safety and efllca- er, researchers found that mean blood loss
At a Glance
Cystectomy in tiie eiderly »
Comorbidities, complications may
increase risk in older patients; pallia-
tjon may be preferable in some,
was 985 mL, blood transfusions were
required in 32 of the 49 patients (76%),
and average length ofthe surgery was 279
minutes. Peri-operative mortality occurred
in five patients (11%).
Intraoperative complications occurred
in two patients (4.7%), while early post-
operative complications (<90 days)
occurred in 24 patients
Cancer \ ^^^^
'^
' ^ i" approximate-
• ly one-third of the cas-
es, these complications included ileal con-
duit or howel leak/fistula, and in anoth-
er one-third, postoperative ileus. Late
postoperative complications were seen
in seven patients (17%). Four patients
(9.5%) died within 30 days. Dr. Katz
reported.
The main histologic subtype was
urothelial carcinoma, seen in 36 patients
(86%). Organ-confined disease was
observed in 21 patients (58%), and non-
organ-confined disease was reported in
15 patients (42%).
After a mean follow-up of 38 months,
;
mean time to deaUi in patients >80 years of
i
age was 19.5 months (range. 6 to 51
ij
months). Overall survival was 44%, and
disease-free survival was 36%. Compar-
ing survival in cases with organ-confined
versus extravesicaJ disease, researchers
showed that overall survival wa.s 62% in
organ-confined disease and dropped to 20%
in patients with extravesical disease (p<.01).
Disease-free survival was 52% versus 13%,
respectively (p=.O2). No differences in .sur-
vival were noted when patients were strat-
ified by number of comorbidities.
"Radical cystectomy in patients age 80
and older is as.sociated with significant short-
and long-tenn morbidity, and local control
and survival are heavily dependent on patho-
logic stage," Dr. Katz concluded.
Treatment or pailiation?
Extravesical disease was common in this
population, and led to poor outcomes in
many cases, he added, possibly because
of reluctance and consequent delay by
Please see CYSTECTOMY, page 13

ter muscle in patients with sphincter insuf-

Muscle progenitor cells restore sphincter function
Within 6 months, 80% of sphincter pressure
is restored in animal model, study shows
Caroline Helwick
UT CORRESPONDENT
New Orleans—Autologous muscle pro-
genitor cells are able to restore otherwise
irreversibly damaged sphincter function,
according to results in an
animal model by investi-
gators at the Wake Forest
Incontinence
University School of Medicine, Winston-
Salem, NC.
"Thirty percent of all women suffer
from urinary incontinence during the
course of life, which
is likely caused by
urinary sphincter
insufficiency, a com-
bination of myoflber
damage, denerva-
tion, hormonal chan-
ges, and other fac-
tors." said Bryan Till-
Dr.THIman
man, MD, PhD.
assistant instructor at Wake Forest's Insti-
tute for Regenerative Medicine. "Multi-
ple treatment modalities, including oper-
ations and injection therapies, have been
tried, but none of these methods is able
to entirely restore normal sphincter mus-
cle function."
Conducted under the direction of
Anthony Atala, MD. lead scientist Daniel
Eberli. MD, PhD, evaluated a novel treat-
ment modality, muscle cell therapy, that
addresses the underlying cause of urethral
sphincter insufficiency. Researchers used
a model of urinary sphincter insufficien-
cy created by microsurgi-
cally excising approxi-
mately 80% ofthe sphinc-
ter muscle in 26 dogs.
Canine muscle progenitor muscle cells
(MPCs) were reproducibly isolated,
grown, and expanded in culture, labeled
with MPC-specific fluorescent markers,
then injected into 12 animals. The remain-
ing 14 dogs served as controls. The aim
was to restore the integrity of the sphinc-
ter, which had already been demonstrat-
ed iti a rat model. Dr. Tillman explained
during a presentation at the American Col-
lege of Surgeons Clinical Congress here.
Urodynamic studies, functional organ
bath studies, and ultrasound and histolog-
ic examinations were performed, and
sphincter function observed over the fol-
lowing 6 months, with the mariners demon-
strating the developing muscle fibers.
Sphincter function restored
"At 6 months, we were able to see restora-
tion of the sphincter mechanism in ani-
ficiency."
Response to the presentation was
strong.
mals receiving the MPC injection," Dr. "This is a beautiful study that exempli-
Tillman reported. fies exciting work." said Howard M. Sny-
Treated animals recovered sphincter der. Ill, MD, professor of urology in sur-
pressure to approximately 80% of nor- gery at the Universi-
mal, while pressures in the control ani- rf, . ^jg^ ty of Pennsylvania
mals dropped and remained at 20% of JF School of Medicine,
normal. In addition, nerve stimulation in Philadelphia. "The
the treated animals produced contraction ' -iiHt e*^ i' functional reconsti-
in the nonnal range by 2 months post-pro- /. V tution of damaged
cedure. Fluoroscopic and CT imaging of V tissue is the Holy
the treated sphincter and controls also ^ ''"'^ ^ ' Grail."
revealed differences of reconstitution.
"Injected cells were able to survive and
Dr.Snyder Dr. Snydernoted
that muscle function
to form mature tissue within the damaged is influenced by a vast number of differ-
sphincter." Dr. Tiilman pointed out. "This ent factors that must be kept in mind when
study demonstrates the feasibility of using conducting experiments such as this, and
autologous muscle precursor cells for the he emphasized that the cells not only be
functional restoration of urinary sphinc- reconstituted, but also functional.OH
' i • '
Histological analysis shows the formation of new muscle tissue at 3 months.
Photo A: Maison's trichrome staining (muscle cells and mucus in red and extra-
cellular matrix in blue) shows the morphologic advances of MPC-injected ani-
mals with reconstruction of the muscle layer. Photos B and C: Immunohisto-
chemical staining for anti-desmin reveals a significantly higher sphincter mus-
cle mass in cell-injected animals (B) versus damage-only animals (C). (Photos
courtesy of Daniel Eberli. MD, PtiD)
 www. urologytimes.com MARCH 2008 13

INFERTILITY have had male factor infertility; that is, ity) in men evaluated for infertility from
continued from page 1 ihey were members of an infertile couple 1987 lo 1998. Infonnation on testis cancer
who could have had only female factors. stage, histology, and cryptorchidism was
California between 1965 and 1998. These records were com- collected. The standardized
"It is no mystery that there has been a Men with male factor pared wiih information from incidence nttio (SIR), which is
dramatic and contintied rise in testiculiir infertility are 3.6 times the California Cancer Reg- the number of obser\'ed cases
germ-cell cancers in U.S. men over sev- more likely to develop testis istry, which included data for 10 regions of cancer divided by ihe expected eases,
j
III.

eral decades," said principal investigator cancer than other meti are. in the Surveillance. Epidemiology, and was used to determine pt>ssible associa-
Thomas J. Walsh. End Results program for the period 1988 Eions between infeilility and te.stis cancer.
MD. clinical instruc- to 2004. Men whose cancer diagnosis pre-
tor in urology work- pies, represents the largest multi-institu- ceded that of infertility were excluded. Strong correlations
ing with Paul Turek. tional cohort of men presenting for infer- Investigators identified all cases of his- Among the cohort of 42.283 male part-
MD. and colleagues. tility care in the United States. Medical tologically confirmed testiculai gerai-cell ners in infertile couples, 44 ca.ses of post-
"While it is more dif- records were abstracted to identify 42.283 cancers occurring allea.st 1 yearafter infer- infertility testicular cancer were identi-
ficult to prove, it male partners. These men may or may not tility evaluation (to address reverse causal- Please see INFERTILITY, page 14
appears that there has
heen a simultaneous
Dr. Walsh
decline in semen
quality and fertility. We wondered whether
these trend.s could be connected."
Seven other case-control and cohort stud-
ies have examined this question, and the
The End of Accidental
five most recent ones have found an asso-
ciation. The largest and Endoscope Laser Damage is in Sight
probably the most reli-
Ameriain able of these studies, Announcing The New Gyrus ACMI Endoscope Protection System (EPS)
Society for by Jacob.sen et al (BMJ
Reproductive 2000; 321:789-92) was
Medicine a Danish study of
32,000 subjects that
Washington
docuinented ^e occur-
rence of testis cancer
following a diagnosis of infertility.
"But evidence from Danish cohorts may
not be generalizable lo U.S. men. and data
from U.S. studies are limited and dis-
crepant." Dr. Walsh cautioned.
The current .study, based on 51,318 cou- Invisio* DUR*-D
Digital Flexible Ureteroscope

CYSTECTOMY
continued from page 12

surgeons in deciding to take these elder-

ly patients into surgery.
"This topic is increasingly important,
and this study highlights the difficulties of
treating this patient group," commented
Raj S. Pruthi, MD. associate professor of
surgery and urology at the University of Our new Endoscope Protection System,
North Carolina, Chapel Hill. "There has
to be a balance between trying to obtain (EPS) when used with our revolutionary
good disease-specific survival and palli-
ation. The incidence ofbladder cancer has EPS automatically Invisio' DUR'-D Digital Flexible Ureteroscope,
shuts down the
risen 40% over the past several decades. laser in less than and the DUR-HL20 Holmiunn:YAG 20W Laser,
We know our patients are getting older, 100 milliseconds
and we need to begin to rethink concepts when retracted can dramatically reduce the number of repairs
regarding age and treatments." into the DUR'-D
He noted that the mortality rate in this Ureteroscope and the cost of doing ureteroscopy by terminating
review seemed high at 11% compared to laser energy before it can damage the working channel.
4.5% seen in most other series. Dr. Katz
agreed, and pointed out that three of the
four patients who died within 30 days of
surgery actually never left the hospital.
Jerome P. Richie, MD, professor of sur- The Vision to See. The Power to Treat
gery and chief of urology at Hiirvard Med-
ical School. Boston, noted that 40% of
the patients had T4 disease on intake.
"Are these really good candidates for
cystectomy?" he asked. "I'm not sure you
For more information, please contact your local Gyrus ACMI sales representative
should he doing cystectoniies on them.
or call customer service at 888.524.7266 or visit www.gyrusacmi.com GYRUSACMI
Perhaps they should be receiving other
Gyrus ACMI, Inc.
treatment." DQ 136 Tumpike Rd, 5outfibofough. MA 01772
© 2008 Cyrus ACMI Inc. ™ a"d S' Trademark and Registered Trademark of Gyrus Group PLC or its www.gyrusa cm i.com
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