Case Report: Echinocandin-Resistance Candida glabrata FKS Mutants From Patient Following Radical Cystoprostatectomy Due to Muscle-Invasive Bladder Cancer

Invasive Candida glabrata infections are not common complications after radical cystoprostatectomy. Furthermore, resistance to echinocandins arising during the course of a patient’s treatment is rarely recognised. We described a case of development of echinocandin resistance in a patient with muscle-invasive bladder cancer (pT2b N0 M0, high grade) diagnosis, subjected to radical cystoprostatectomy and exposed to echinocandins. A male patient with a previous surgical history after a traffic accident, who was operated on due to bladder cancer, underwent an episode of candidemia and mixed postoperative wound and urinary tract infection caused by C. glabrata and extended spectrum β-lactamase (ESBL)-producing Escherichia coli during hospital treatment. The patient was started on caspofungin. Repeat blood cultures showed clearance of the bloodstream infection; however, infection persisted at the surgical site. Resistance to echinocandins developed within 2 months from the day of initiation of therapy with caspofungin in the C. glabrata strain obtained from the surgical site. The isolates sequentially obtained during the patient’s treatment demonstrated resistance to echinocandins due to the mutation in hotspot 1 FKS2. Although resistance to echinocandins is relatively rare, it should be considered in oncological patients with increased complexity of treatment and intestinal surgery.

The Incidental prostatic adenocarcinoma and transitional cell carcinoma involvement of the prostate gland in patients undergoing radical cystoprostatectomy for bladder cancer treatment in Rajavithi Hospital

Objective: To determine the incidence of incidental prostatic adenocarcinoma and transitional cell carcinoma (TCC) involvement of the prostate gland in patients undergoing radical cystoprostatectomy in Rajavithi Hospital, Secondly, to assess the possible influence of the patient factors and bladder cancer on the pathological findings of the prostate gland. Materials and Methods: We retrospectively reviewed 169 male patients who had undergone radical cystoprostatectomy for bladder cancer between April 2013 and August 2019. Pathologic findings of the prostate gland and urothelial cancer in the prostate gland were catalogued. Information including age, body mass index (BMI), underlying disease, glomerular filtration rate (GFR), pathologic stage, and grade was collected and analyzed to determine any correlations. Results: Incidental prostatic adenocarcinoma and TCC involvement of the prostate gland were found in 15 patients (8.9%) and 29 patients (17.2%), respectively. There were no correlations between patient demographics and pathological findings of the prostate gland. Conclusion: Although the incidence of incidental prostatic adenocarcinoma and TCC involvement of the prostate gland in our research is low, the screening of every candidate for prostate sparing cystectomy with a digital rectal examination, prostate-specific antigen, and transurethral biopsy of the prostatic urethra and bladder neck prior to surgery are recommended.

Hyperchloremic Metabolic Acidosis with Hyperglycemic Hyperosmolar Syndrome after Robot-Assisted Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion: A Case Report

Hyperchloremic metabolic acidosis can be a problem in urinary diversion using the ileum. A 73-year-old Japanese male was hospitalized in emergency due to anorexia and malaise 3 weeks after being discharged from the hospital after getting robot-assisted radical cystoprostatectomy and intracorporeal ileal conduit urinary diversion. The blood analysis revealed metabolic acidosis, elevated chloride ions, and marked hyperglycemia: he was diagnosed with hyperchloremic metabolic acidosis and hyperglycemic hyperosmolar syndrome. We started administering insulin and large amounts of fluid replacement; besides, we inserted a large-diameter open tip catheter into the ileal conduit in hopes of inhibiting urine reabsorption in the intestinal mucosa. His general condition gradually improved, and he was discharged 10 days after his hospitalization.

COMPARISON OF EXTRAPERITONEAL AND TRANSPERITONEAL RADICAL CYSTOPROSTATECTOMY IN TERMS OF FIRST 30 DAYS OUTCOMES

Objective: To compare the first 30-day outcomes of Trans-peritoneal and Extra-peritoneal Radical cysto-prostatectomy. Study Design: Quasi-experimental study. Place and Duration of Study: Armed Forces Institute of Urology, Rawalpindi, from Mar 2015 to Mar 2019.Methodology: A total of 100 patients who underwent Radical cystoprostatectomy were observed in two groups either by extra or trans-peritoneal approach. Patients diagnosed with carcinoma urinary bladder (both muscle and non-muscle invasive) vetted through multidisciplinary meeting, with or without neo-adjuvant chemotherapy were included. Patients undergoing salvage cystectomy or any previous open abdomino-pelvic surgery were excluded. The standard techniques were used for both approaches. Variables under study were recorded for first 30-day-followup period. Results: The mean age was 59.9 ± 7.231 years (range=34-80). In extra-peritoneal group the mean duration of surgery was 5.6 ± 1.16 hours comparing to 7.2 ± 1.34 hours in the trans-peritoneal group. Statistically significant trend was also noted in the favour of extra-peritoneal group for stay in Intensive care in post-operative period (3.00 ± 1.19 days/4.77 ± 1.20, p<0.001) as well total stay in the hospital (6.06 ± 2.8 days/ 11.74 ± 4.17, p<0.001). Overall comparison of total number of complications as per Clavien-Dindo system in both groups was insignificant (p=0.136), however a significant trend in favour of extraperitoneal group was noted with respect to major wound dehiscence as well rate of blood transfusion (p<0.001). Conclusion: Extra-peritoneal approach showed a favourable trend in terms of operative time and early recovery after radical cysto-prostatectomy.

Dynamics of changes in renal function in patients undergoing radical cystoprostatectomy with various variants of heterotopic reservoir

Relevance. Chronic renal failure in patients undergoing radical cystoprostatectomy (RCPE) with various variants of urine derivation is one of the significant problems that requires an interdisciplinary approach. To date, there is an insufficient number of studies comparing a significant decrease in glomerular filtration rate (GFR) between different types of urine diversion after radical cystectomy. Purpose of research. To study glomerular filtration rate (GFR) indicators in patients who underwent radical cystectomy with a heterotopic Bricker reservoir and compare them with similar indicators in patients who underwent radical cystectomy with a « V « shaped heterotopic reservoir. To compare early postoperative complications in patients who underwent radical cystoprostatectomy with the formation of a heterotopic Bricker reservoir and with a modified V-shaped heterotopic reservoir. Materials and methods. To study and compare the dynamics of glomerular filtration rate (GFR), we retrospectively selected patients after radical cystoprostatectomy with heterotypic ileocystoplasty. Patients were divided into two groups: the control group — patients with radical cystoprostatectomy and Bricker ileocystoplasty (n=46), the study group — patients with radical cystoprostatectomy and modified V-shaped heterotopic ileocystoplasty (n=49). Results. At the stage of discharge of patients from the hospital after radical cystoprostatectomy, the level of glomerular filtration rate (GFR) was not statistically significant differences between the study and control group (P=0.3791), including patients with the presence of hydronephrosis (P=0.4664). The difference in glomerular filtration rate (GFR) between the study group and the control group was statistically significant after 6 years of dynamic follow-up. As a result, it can be argued that the dynamics of glomerular filtration rate (GFR) reduction in the study group is lower than in the control group. A particularly significant difference in glomerular filtration rate (GFR) was observed in patients with existing hydronephrosis at the preoperative stage. Conclusion. Modified «V» — shaped heterotopic urine derivation can be recommended for patients who have undergone radical cystoprostatectomy, especially with existing hydronephrosis at the preoperative stage. This method should be used in patients with chronic pyelonephritis against the background of previously diagnosed ureterohydronephrosis, which is a fairly frequent consequence of the invasive nature of the growth of bladder cancer with ureteral obstruction.

Recurrence of Aggressive Urothelial Carcinoma in an Ileal Neobladder without Involvement of Remaining Urothelium

We review a case of a 70-year-old male with a recurrence of urothelial carcinoma in an ileal neobladder without involvement of the remaining urothelium two years after a radical cystoprostatectomy. This case is extremely rare especially due to the lack of recurrence in the urethra or upper urinary tract. Abbreviations BCG: Bacillus Calmette-Guérin; CIS: Carcinoma in situ; CT: Computerized/computed tomography; NCCN: National Comprehensive Cancer Network; PE: Pulmonary embolism; PET: Positron emission tomography; RC: Radical cystectomy; TURBT: Trans-urethral resection of bladder tumor; UC: Urothelial carcinoma. Keywords: Urothelial carcinoma; Ileal; neobladder; Tumor; Recurrence; Metastasis.

Incidental Prostate Cancer in Radical Cystoprostatectomy Specimens is Associated with Worse Overall Survival

BACKGROUND: The impact of incidental prostate cancer (IPC) on oncological outcomes after radical cystoprostatectomy (RCP) specimens from patients with bladder cancer (BC) remains controversial. This relationship has not been well elucidated in Asian countries, where the incidence of prostate cancer has recently shown dramatic increases. OBJECTIVES: This study retrospectively compared pathological features and oncological outcomes between BC patients with and without IPC in the RCP specimens. METHODS: This study included 142 men who underwent RCP for BC. Men who were previously diagnosed with prostate cancer were excluded. Each prostate gland and seminal vesicle was processed as whole mounts and 4-mm close-step sectioning was performed. A single genitourinary pathologist diagnosed IPC. The pathological features and oncological outcomes such as overall survival (OS), bladder cancer-specific survival (BCSS), and progression-free survival (PFS) were compared between patients with IPC (IPC+group, n = 45) and without IPC (IPC- group, n = 97). P values less than 0.05 considered to indicate statistical significance for patients’ characteristics. Because of multi-primary endpoint, P values less than 0.0167 was considered statistical significance for oncological outcomes. RESULTS: We detected IPC in 45 RCP specimens (31.6%). Patients in the IPC- group were significantly younger at surgery than those in the IPC+group (P < 0.001). The pathological features of the RCP specimens did not differ significantly. In multivariable analyses, presence of IPC was significantly associated with worse OS (P = 0.005), but not with either BCSS or PFS (P = 0.038 and 0.326, respectively). In Kaplan–Meier analyses, OS tended to be longer in the IPC- group than that in the IPC+group (NR vs 65 months, P = 0.0017). CONCLUSIONS: Our results suggested significantly better OS in patients without IPC than that in those with IPC.