Hatem Ahmed Aboulkassem

Background: Laparoscopic radical cystectomy is a challenging surgical procedure; however, it has been largely abandoned in favor of the more intuitive robotic-assisted cystectomy. Due to the prohibitive cost of robotic surgery, the adoption of laparoscopic cystectomy is of relevance in low-resource institutes. . This is a randomized controlled trial comparing laparoscopic radical cystectomy (LRC) to open radical cystectomy (ORC) at a single institute. Each group included thirty patients. The trial was designed to compare both approaches regarding operative time, blood loss, transfusion requirements, length of hospital stay, time to oral intake, requirement of opioid analgesia, and complications.

Results: LRC was associated with less hospital stay (9.8 vs. 13.8 days, =0.001), less time to oral solid intake (6 vs. 8.6 days, =0.031), and lower opioid requirements (23.3% vs. 53.3%, =0.033). There was a trend towards lower blood loss and transfusion requirements, but this did not reach statistical significance. Overall complication rates were comparable.

Conclusion: Laparoscopic radical cystectomy was associated with comparable postoperative outcomes when compared to ORC in the first laparoscopic cystectomy experience in our center. Benefitting from the assistance of an experienced laparoscopic surgeon is recommended to shorten the learning curve.

INTRODUCTION: To evaluate the functional outcomes and quality of life beyond 1 year, in patients treated with radical cystectomy and orthotopic diversion for invasive bladder cancer. To investigate various potential contributing factors on patient's quality of life after radical cystectomy and urinary diversion via orthotopic neobladder.

MATERIALS AND METHODS: This retrospective study was conducted at the National Cancer Institute (NCI), Cairo; including a total of 97 patients who underwent radical cystectomy and orthotopic diversion. Functional and sexual outcome and patient QoL were assessed by ICIQ-SF, IIEF-5 and QLQ-C30 questionnaires. Potential association of patient QoL with pre-and intraoperative variables was studied.

RESULTS: Our results show that preoperative ECOG performance status 0 (P=0.0001), and nerve sparing surgery (P=0.001), were associated with high QoL and functional outcomes. On the contrary, ECOG performance status 2, preoperative comorbidities as ischemic heart diseases (P=0.01), recurrence (0.041), adjuvant chemotherapy (P=0.017) and radiotherapy (P=0.001) were associated with low QoL on univariate analysis. However, only ECOG performance status 2 (P<0.0001), incontinence (P<0.0001), non-nerve sparing surgery (P=0.001) and ureteric stricture (P=0.001) were independent predictors of worse QoL on multivariate analysis.

CONCLUSION: Orthotopic bladder is associated with increased morbidity. Attention should be given to preoprative patient characteristics at the time of patient selection, and intraoperative quality of functional preservation.

LEVEL OF EVIDENCE: 3.

UNLABELLED: We aimed at clarification of reasons for recurrence of urothelial carcinoma after radical cystectomy in a retrospective study that included 189 patients. Presence of lymphovascular invasion even in node-negative cases, high tumor grade, and high nodal stage appeared to be independent predictors for recurrence. This raises the necessity for postoperative multimodality treatment to improve disease-free survival.

BACKGROUND: Radical cystectomy remains the gold standard for local control of muscle-invasive bladder cancer. Despite that, a significant proportion of patients develop disease recurrence. Several predictors for recurrence have been described and the implication of such factors on development of recurrence will help in modification of treatment strategies to improve the prognosis of bladder cancer patients.

PATIENTS AND METHODS: This is a retrospective study carried on patients with muscle-invasive urothelial carcinoma who underwent radical cystectomy at the National Cancer Institute in 3 years; January 2007 to December 2009, and analyzed for the development of recurrence and potential risk factors.

RESULTS: The 3-year disease-free survival (DFS) rate was 56%. Seventy patients (37%) developed disease recurrence during the follow-up period. Of these recurrences, 17 patients (24.3%) developed local and/or regional recurrences, 45 patients (64.3%) developed distant metastasis, and 8 patients (11.4%) developed local and/or regional and distant recurrences. In univariate analysis, lymph node metastasis (P < .001), lymphovascular invasion (LVI) (P < .001), high grade (P = .005), and advanced tumor stage (P = .002) were significantly associated with development of recurrence. In multivariate analysis, lymph node metastasis, LVI, and high grade were significantly associated with tumor recurrence and poor DFS.

CONCLUSION: Lymph node metastasis, LVI, and high tumor grade were independent prognostic factors that affected tumor recurrence and DFS. LVI status should be reported in radical cystectomy specimens to help in risk assessment of patients especially in node-negative cases.

OBJECTIVE: To investigate the causes of groin recurrence in patients with vulval cancer who previously had negative nodes following superficial inguinal node dissection (SIND).

MATERIAL AND METHODS: Forty-one patients with squamous cell carcinoma of the vulva (stage I or II) were operated upon. The primary treatment was wide local excision with 2 cm safety margin and superficial inguinal lymphadenectomy. Six patients had ipsilateral and one patient had bilateral groin recurrence. Those patients were subjected to deep inguinal node dissection (one patient required bilateral node dissection).

RESULTS: The mean age at time of diagnosis was 59 years (range 51-68). The median follow-up period for all patients was 63 months (range 24-71) and that of the recurrent cases was 20 months (range 12-38). The mean depth of invasion of the recurrent cases was 5.5mm (range 5-5.9 mm) and the mean diameter of the primary tumor in recurrent cases was 3.8 cm (range 3-4.5 cm). All recurrent cases had a high grade of the primary tumor. The median interval to recurrence was 21 months (range 12-57). The groin recurrence rate after negative SIND was 17% (7/41 patients).The mean number of nodes resected per groin was eight (range 1-17). The nodes ranged in size from 0.2 to 4.0 cm.

CONCLUSION: Carcinoma of the vulva with the following criteria (size of tumor is greater than 3 cm, depth of invasion greater than 5mm, and high grade tumors) is at high risk of recurrence.

Resection of anterior vaginal wall that occurs with some cases of anterior pelvic exenteration leaves the patient with a small and narrow vagina. This affects their sexual life leading to major psychologic problems, especially in young women. The aim of this study is to evaluate a new technique of vaginal reconstruction following anterior pelvic exenteration with clinical and cytohistologic follow-up. Between March 2002 and November 2004, ten sexually active female patients underwent vaginal reconstruction after radical cystectomy that required en bloc removal of the anterior vaginal wall, with a pedicle graft of greater omentum combined with a vicryl mesh. The mean age of the patients was 38 years. The mean operative time of the reconstructive procedure was 50 min. There were no complications regarding the reconstructive procedure. On follow-up, the neovagina accepted two fingers easily and showed a pink-colored smooth lining. Seven patients reported successful attempts of sexual intercourse. It was concluded that reconstruction of vagina after anterior pelvic exenteration in sexually active women can be done safely with the use of vicryl mesh combined with a pedicled omental graft. It is a simple, reliable, and not time-consuming technique. The long-term follow-up was very beneficial in detection of complete healing, postoperative infections, and hormonal activity of the graft and recurrence of malignancy.

Resection of anterior vaginal wall that occurs with some cases of anterior pelvic exenteration leaves the patient with a small and narrow vagina. This affects their sexual life leading to major psychologic problems, especially in young women. The aim of this study is to evaluate a new technique of vaginal reconstruction following anterior pelvic exenteration with clinical and cytohistologic follow-up. Between March 2002 and November 2004, ten sexually active female patients underwent vaginal reconstruction after radical cystectomy that required en bloc removal of the anterior vaginal wall, with a pedicle graft of greater omentum combined with a vicryl mesh. The mean age of the patients was 38 years. The mean operative time of the reconstructive procedure was 50 min. There were no complications regarding the reconstructive procedure. On follow-up, the neovagina accepted two fingers easily and showed a pink-colored smooth lining. Seven patients reported successful attempts of sexual intercourse. It was concluded that reconstruction of vagina after anterior pelvic exenteration in sexually active women can be done safely with the use of vicryl mesh combined with a pedicled omental graft. It is a simple, reliable, and not time-consuming technique. The long-term follow-up was very beneficial in detection of complete healing, postoperative infections, and hormonal activity of the graft and recurrence of malignancy.

BACKGROUND: It is well recognized that recurrent disease can occur following malignancy in the head and neck region. This is particularly true for basal cell & squamous cell carcinoma, whereby recurrence may occur many years following initial surgery or other modalities. We report here on skin malignancy occurring in the scalp with skull invasion down to the dura mater. Composite resection of scalp, craniectomy, dural resection and reconstruction including a free tissue transfer was analyzed.

PURPOSE: To evaluate our experience in full thickness scalp resection and reconstruction.

PATIENTS AND METHODS: At the National Cancer Institute, Cairo University, twelve patients with locally advanced tumors of the scalp invading the calvarium were treated with wide local excision of the scalp combined with underlying craniectomy and dural resection if needed. Reconstruction was completed using fascial graft for the dura, methyl methacrylate for the skull, and either giant rotational flap or free tissue transfer.

RESULTS: Between 1998 and 2002, twelve patients with locally advanced tumors of the scalp were subjected to this surgery. All patients successfully tolerated the procedure and completely recovered with minimal morbidity with acceptable cosmetic results.

CONCLUSION: With the advent of free tissue transfer to cover large defects in the skull and the availability of polymethyl methacrylate (bone cement) for cranioplasty, large defects in the calvarium can be successfully resected and grafted with satisfactory outcome, improved salvage rate, and prolonged survival.

PURPOSE: Bladder cancer is still the most common solid tumor among adult males in Egypt because of the prevalence of bilharzial infestation, especially in the countryside. In this prospective study, we have recorded the prognostic factors for 180 patients with invasive bladder cancer for whom standard radical cystectomy had been performed to develop a prognostic index (bladder prognostic index) that defines high risk patients who are more vulnerable to disease relapse after surgery and who may benefit from additional therapy.

PATIENTS AND METHODS: The study was performed between January 1997 and December 1999, in which 180 patients with histopathologically proved invasive bladder cancer associated with bilharziasis underwent radical cystectomy or anterior pelvic exenteration. After surgery, patients were regularly followed for a minimum of 2 years.

RESULTS: Our patients included 141 males and 39 females. Squamous cell carcinoma was the most common type (53.3%), and most of the tumors were grade II (61.1%). A total of 173 patients had their tumors operable, while 7 were inoperable. We had 5 (2.8%) operative related mortalities. At 5 years postoperatively, free and overall survival rates for the whole group of patients were 31.44%+/-5.9% and 32.5%+/-6.8%, respectively. Tumor pathologic stage, grade, and nodal affection were the only significant factors with impact on survival (P=0.008, 0.051, and 0.004, respectively). These 3 prognostic indexes were used to design a model to predict an individual patient's risk factor for recurrence. Patients were then assigned to one of the 4 risk groups according to the score achieved in this prognostic index (0=low risk, 1=intermediate risk, and 2 or 3=higher risk). These 4 risk groups had distinctly different rates of disease-free survival, i.e., 91.7%, 53%, 13%, and 7% for low, intermediate, and higher risk groups, respectively.

CONCLUSION: Although this prognostic index appears to be of a significant clinical relevance, it needs to be more validated on a larger number of patients, and it could be a surrogate variable for biologic factors responsible for the heterogeneity of bladder cancer.

PURPOSE: The aim of this study is to evaluate our experience at the NCI, Cairo University in the management of non- metastetic hepatoblastoma (HB). Also to improve survival of children with HB and reduce the operative morbidity and mortality by using preoperative chemotherapy.

PATIENTS AND METHODS: After biopsy and assessment of the extent of disease, all patients were treated with a 6-hour continuous intravenous infusion of cisplatin (PLA) 90mg/m2 on day one followed by doxorubicin (DO) 20mg/m2 per day administered as 1- hour infusion on days 2,3 and 4. After four courses of preoperative chemotherapy, patients were reassessed. Whenever possible, the primary tumor was resected and the treatment was completed with two more courses of chemotherapy.

RESULTS: Twenty children with HB were registered between January 1999 and December 2000, the median age at diagnosis was 12 months (range, 40 days to 11 years). All the 20 patients had received preoperative chemotherapy (PLADO). Fifteen patients (75%) showed partial response with tumor shrinkage and serial decrease of serum alpha-fetoprotein levels. Sixteen patients underwent surgery, fourteen of them had complete resection of the primary tumor (87.5%). The median duration of followup was 26 months (range 1-55 months). The three year disease-free survival was 68.4% and event-free survival was 65%.

CONCLUSION: We can advocate the use of PLADO chemotherapy and delayed surgery to be the standard treatment for children with HB. Other treatment programs should be measured against this standard.