PEDIATRIC UROLOGY

Does the less aggressive multimodal approach of treating bladder-prostate rhabdomyosarcoma preserve bladder function?
Soler R, Macedo A Jr, Bruschini H, Puty F, Caran E, Petrilli A, Garrone G, Srougi M, Ortiz V
Department of Urology, Federal University of Sao Paulo, Sao Paulo, Brazil
J Urol. 2005; 174: 2343-6

• Purpose: The treatment of bladder-prostate rhabdomyosarcoma has evolved into multimodal therapy, including chemotherapy, radiotherapy and organ sparing surgery with bladder preservation. We investigated bladder function in children who underwent multimodal therapy at our institution and retained the original bladder for at least 6 months after treatment ended.
• Materials and Methods: We evaluated 8 children with bladder-prostate rhabdomyosarcoma treated at our institution between 1999 and 2003 according to inclusion criteria. All patients underwent history, physical examination and urodynamic study at least 6 months after completion of treatment (range 6 to 39 months).
• Results: All patients were treated following the same chemotherapy and radiotherapy scheme. Three patients (37.5%) were asymptomatic and had normal urodynamic studies, and 1 had only dysuria (this patient later underwent continent urinary diversion with transverse colon). The 4 remaining patients had urological complaints, and the urodynamic findings were reduced bladder capacity in 4, overactivity plus sensory urgency in 2, sensory urgency only in 1 and suprapubic pain during filling in 1.
• Conclusions: Among 8 patients 3 had normal urinary function and 4 had minor tolerable alterations. Cystectomy and urinary diversion were later necessary in only 1 patient due to disabling dysuria. The fact that the original functioning bladder was preserved in 7 of 8 patients suggests the feasibility of multimodal therapy. Long-term followup will still be necessary for definite conclusions, since we recognize that the deleterious effects, mainly of radiotherapy, may take longer to become evident.
  
  
• Editorial Comment
  The authors review their experience with an organ-sparing approach to treatment of pelvic rhabdomyoscarcoma in your children. Eight patients were reported from those treated between 1999 and 2003. The results were very encouraging, with only one patient requiring cystectomy during follow-up for dysuria.
  Although high cure rates are possible with aggressive therapy that includes surgical extirpation of the bladder, efforts in recent years have focused on obtaining the same cure rates while preserving the bladder. Data on whether this can be done successfully are somewhat limited. This report is an important follow-up that provides valuable data for the clinician facing a new patient with this problem.
  Despite the positive message however, there are several caveats. First, two patients were excluded. One had an early recurrence (we do not know whether this patient survived) and another is reported as having a “head injury.” Bladder preservation at the expense of survival may not be the best outcome. Second, perhaps even more important, only 3 of the 8 patients were asymptomatic at the time of follow-up, which is admittedly short. Will they stay asymptomatic? What about the 4 remaining with their bladders? Will they develop increasing symptoms over time? Will they ultimately require a cystectomy? Longer follow-up is needed. Despite these questions, the report provides promising and important information.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA