[ACTIVE SURVEILLANCE IN RECURRENT LOW-RISK BLADDER TUMORS].

OBJECTIVES: To report our experience with the active surveillance policy in patients with recurrent low-risk bladder tumors. METHODS: The files of 52 patients who underwent active surveillance instead of immediate surgical resection were reviewed. Different variables concerning tumor growth rate were evaluated. RESULTS: A total of 75 surveillance periods were documented in 52 patients (mean age 75.6 years S.D. 10.45 years, 37 males and 14 females), Mean surveillance period length was 16.5 months (S.D. 16.1). All tumors resected after surveillance were found in stage Ta and in low-grade except one tumor which was high-grade; 70 active surveillance periods ended with tumor resection, and 5 patients were still under surveillance when the research ended; 27 surveillance periods (37.7%) ended because of the growth of additional tumors. Active surveillance therefore spared 27 surgeries. The rate of tumor growth during surveillance depended on the tumor's largest diameter at the beginning of surveillance. If initial tumor diameter was smaller than 5 mm (68 cases), the median tumor growth rate was 1.12 mm3/month (IRQ: 0-6.55). If the initial tumor diameter was ≥5 mm (7 cases), the median tumor growth rate was 137.14 mm3/month (IRQ: 2.21-1787.5, p < 0.05). CONCLUSIONS: Small, recurrent papillary bladder tumors pose minimal risk to the patient. An active surveillance policy, without immediate resection of the tumor is safe, can spare surgeries and can be considered in patients presenting with small papillary recurrence.

The Response of Variant Histology Bladder Cancer to Intravesical Immunotherapy Compared to Conventional Cancer.

BACKGROUND: High-grade urothelial carcinomas (UCs) often show foci of variant differentiation. There is limited information in the literature about the response of these variant urothelial tumors to immunotherapy with bacillus Calmette-Guerin (BCG). We compared the response, to treatment with BCG, of UC containing glandular, squamous, nested, and micropapillary types of differentiation to response of conventional non-muscle invasive high-grade UC. METHODS: A total of 100 patients were diagnosed with variant histology urothelial cancer between June 1995 and December 2013. Forty-one patients with Ta or T1, confirmed by second look biopsies, received immunotherapy with BCG. Fourteen patients in this group were diagnosed with micropapillary differentiation, 13 patients with squamous differentiation, 9 patients with glandular differentiation, and 7 patients with nested variants. The control group included 140 patients with conventional high-grade UC. Both groups have been treated and followed similarly. FINDINGS: Patients with variant tumors had similar clinical features to patients with conventional disease, including age, male to female ratio, stage, the presence of Tis, and median follow-up. Patients with variant tumors had a significantly worse prognosis compared to patients with conventional high-grade UC, including 5-year recurrence-free survival (63.5 Vs. 71.5%, p = 0.05), 5-year progression (≥T2)-free survival (60 Vs. 82.5%, p = 0.002), 5-year disease-specific survival (73 Vs. 92.5%, p = 0.0004), and overall survival (66 Vs. 89.5%, 0.05). INTERPRETATION: A patient with variant bladder cancer treated with intravesical immunotherapy has a 27% chance of dying from this disease within 5 years compared to 7.5% chance for a patient with conventional high-grade UC.

[FACTORS PREDICTING OVERALL AND DISEASE-FREE SURVIVAL AFTER SURGERY FOR INVASIVE BLADDER CANCER].

OBJECTIVES: To evaluate the prognosis of patients who underwent surgery for invasive bladder cancer and to search for prognostic factors. METHODS: The files of all the patients who underwent radical or partial cystectomy for invasive bladder cancer between 1992 and 2014 were reviewed. The effect of various prognostic factors was evaluated by uni- and multivariate analyses. RESULTS: A total of 160 patients were included in the study and were followed for a median period of 25.5 months after surgery. The overall 2 years and 5 years survival rates were 70% and 61.2% respectively. The disease-free 2 years and 5 years survival rates were 64.4% and 61.9% respectively. The overall 2 years and 5 years survival rates of patients with disease limited to the bladder (≥T2N0) were 88.2% and 82.4% and of patients with disease extending beyond the bladder (≤T3N0) 56.5% and 45.7% respectively. Factors that were found to be significantly associated with overall survival were: TNM stage, co-morbidity (Charlson 6-11) and the tumor's diameter. No association was found between: disease presentation, smoking habits, positive cytology, the tumor being primary or secondary, variant histology, the presence of endophytic growth pattern, the presence of CIS, hydronephrosis, positive lymph nodes on pre-operative imaging, surgery type (radical or partial cystectomy) and adjuvant chemotherapy. CONCLUSIONS: The survival rates of the locally treated patients match the reported rates in the literature. Tumors' T stage were found to be the strongest prognostic factor. Tumors' diameter was found to be an independent prognostic factor. This is reported here for the first time in the literature.

Radical cystectomy vs. chemoradiation in T2-4aN0M0 bladder cancer: a case-control study.

BACKGROUND: Muscle-invasive bladder cancer is most commonly treated by radical cystectomy. Patients who are too sick to go through this surgery or who are unwilling to accept the mutilation associated with it are referred to chemoradiation. We compared the results of these 2 modalities using age-matched populations. PARTICIPANTS AND METHODS: Between 1998 and 2008, 33 patients were treated with chemoradiation for biopsy-proven T2-4aN0M0 urothelial bladder cancer. For every patient treated with chemoradiation, an age-matched patient who underwent radical cystectomy on the same year was selected for comparison. Mean radiotherapy dose was 62 Gy (standard deviation = 8.4) and median follow-up of both groups was approximately 36 months. RESULTS: The groups were similar in age, proportion of men, and length of follow-up. However, the Charlson comorbidity index was significantly lower for operated patients (3.45 vs. 4.36, P = 0.01). Furthermore, 2 patients (6%) in the chemoradiation group had salvage cystectomy (one for disease recurrence and another for bladder shrinkage). The 2- and 5-year overall survival rates after surgery were 74.4% and 54.8%, respectively, and after chemoradiation were 70.2% and 56.6% (P = 0.8), respectively. The 2- and 5-year disease-free survival rates after surgery were 67.8% and 63.2%, respectively, and after chemoradiation were 63% and 54.3% (P = 0.89), respectively. Side effects were mild in both groups, with grade 3+toxicity seen in only 2 operated and 4 irradiated patients. CONCLUSIONS: Despite having a significantly higher comorbidity index, patients treated with chemoradiation had similar overall and disease-free survival rates with low toxicity. Treatment with chemoradiation should be considered in patients with T2-4aN0M0 bladder cancer.

Cystoscopic-assisted partial cystectomy: description of technique and results.

BACKGROUND: Partial cystectomy provides oncological results comparable with those of radical cystectomy in selected patients with invasive bladder cancer without the morbidity associated with radical cystectomy and urinary diversion. We describe a novel technique of partial cystectomy that allows accurate identification of tumor margins while minimizing damage to the rest of the bladder. METHODS: During the study period, 30 patients underwent partial cystectomy for invasive high-grade cancer. In 19 patients, the traditional method of tumor identification was used, ie, identifying the tumor by palpation and cystotomy. In eleven patients, after mobilization of the bladder, flexible cystoscopy was done and the light of the cystoscope was pointed toward one edge of the planned resected ellipse around the tumor, thus avoiding cystotomy. RESULTS: Patients who underwent partial cystectomy using the novel method were similar in all characteristics to patients operated on using the traditional technique except for tumor diameter which was significantly larger in patients operated on using the novel method (4.3±1.5 cm versus 3.11±1.18 cm, P=0.032). Complications were rare in both types of surgery. The 5-year local recurrence-free survival was marginally superior using the novel method (0.8 versus 0.426, P=0.088). Overall, disease-specific and disease-free survival rates were similar. CONCLUSION: The use of a flexible cystoscope during partial cystectomy is a simple, low-cost maneuver that assists in planning the bladder incision and minimizes injury to the remaining bladder by avoiding the midline cystotomy. Initial oncological results show a trend toward a lower rate of local recurrence compared with the standard method.

Mixed high and low grade bladder tumors--are they clinically high or low grade?

PURPOSE: The pathological grade of bladder cancer has an immense impact on patient treatment and prognosis. While most bladder tumors show pure high or low grade patterns, some show a mixed pattern. We explored the incidence and clinical significance of this phenomenon. MATERIALS AND METHODS: A total of 642 patients with a mean age of 67.5 years underwent transurethral resection of nonmuscle invasive bladder tumors between June 1998 and December 2008, including 156 and 454 with low and high grade lesions, respectively. In 32 patients (5%) mixed grade tumors were found, defined as low grade tumors with 10% or less of a high grade component. All patients were followed a median of 60 months postoperatively. RESULTS: Mean age, the proportion of men and the proportion of stages Ta/T1 in patients with mixed grade tumors were between those of the high and low grade groups. Five-year recurrence-free survival was similar for high, low and mixed grade tumor types (56.9%, 63.8% and 66.4%, respectively, p=0.252). Five-year progression-free survival was significantly lower in patients with high grade disease (73.9%, p<0.0001) but similar in those with high and mixed grade tumors (99% and 96.9%, respectively, p=0.167). Similarly, disease specific survival was significantly worse in patients with high grade tumors (p<0.0001) but similar in those with high and mixed grade lesions (p=0.679). CONCLUSIONS: Mixed grade is found in about 5% of nonmuscle invasive tumors, representing a patient group with unique clinical features. The clinical course of patients with mixed grade tumors parallels that of patients with low grade tumors.

The natural history of secondary muscle-invasive bladder cancer.

BACKGROUND: The management of patients with high-grade non muscle invasive bladder cancer (NMIBC) brings diagnostic and therapeutic challenges. In the current study, we sought to study the natural history of progression to "secondary" muscle-invasive bladder cancer (MIBC)-cancer that developed during follow up of patients presenting with non-muscle invasive bladder cancer (NMIBC). METHODS: Between 1998 and 2008, 760 patients were treated for bladder cancer. Primary MIBC (>=T2) tumors (present upon presentation) were diagnosed in 114 patients. All patients with high-grade NMIBC were treated with intravesical BCG. Mean follow-up was 44 months. RESULTS: Forty patients (6.1%) developed secondary MIBC after a mean period of 21 months from initial diagnosis of bladder cancer. The 2- and 5-year disease-specific survival rates were better for patients with secondary MIBC (90% and 56% compared to 69% and 42% for patients with primary disease, p=0.03). The Kaplan-Meier curves of the two groups were parallel but displaced by approximately 2 years. CONCLUSION: In the current series, MIBC progression occurred among initially presenting patients with NMIBC in 6.1%. In most patients, the initial diagnosis of NMIBC is correct and muscle invasion occurs after a mean period of about 2 years. This supports a non-radical approach in patients with high-grade T1, Ta or Tis. Meticulous follow-up with liberal biopsy of any suspicious lesion may provide early diagnosis of invasive disease.

Gross hematuria in patients with prostate cancer: etiology and management.

The objective of the study is to assess the etiology and prognosis of gross hematuria (GH) in patients with carcinoma of the prostate (CAP). From 1991 to 2011, 81 men (mean age 74.3 years, SD 6.5) with CAP were hospitalized with GH. Primary treatment of CAP was radical surgery in 13 patients (group 1) and nonsurgical therapy in 68 (group 2), mostly radiotherapy (35 cases) and hormonal treatment (25 cases). The common etiologies of GH in group 1 were bladder cancer (38.5%) and urinary infection (23%). In contrast, CAP itself caused GH in 60% of the patients in group 2. Thirty-nine patients (48%) required transurethral surgery to manage GH which was effective in all cases; nevertheless, the prognosis of group 2 patients was dismal with median overall survival of 13 months after sustaining hematuria, compared to 50 months in group 1 (P = 0.0015). We conclude that the etiology of GH in patients with CAP varies according to primary treatment. After radical prostatectomy, it is habitually caused by bladder cancer or infection. When the primary treatment is not surgical, GH is most commonly due to CAP itself. Although surgical intervention is effective in alleviating hematuria of these patients, their prognosis is dismal.

Subepithelial growth patterns in urothelial carcinoma-frequency and prognostic significance.

PURPOSE: Most urothelial carcinomas are exophytic, but some tumors exhibit subepithelial components, either in the form of endophytic growth pattern (EGP) or as von Brunn's nests involvement (VBNI). The purpose of this study was to investigate the frequency, inter-relations and clinical significance of these forms of subepithelial neoplasia in urothelial carcinoma. PATIENTS AND METHODS: Between June 1995 and December 2007, 760 patients (mean age of 67.5 years) underwent transurethral resection of bladder tumors in our institution, including 478, 157, and 112 patients with stage Ta, T1, and ≥T2 disease, respectively. Isolated or concomitant Tis were present in 137 (18%) patients. Median postoperative follow-up period was 53 months. RESULTS: EGP was found in 86 cases (11.3%) and VBNI in 30 (3.9%) patients. Both forms of subepithelial growth were significantly more common in higher stage and grade tumors and were associated with each other. Multivariate analysis showed that EGP is an independent prognostic factor of stage progression (HR 4.6, P < 0.0001) and disease specific mortality (HR 2.6, P = 0.001) but not of tumor recurrence (HR 1.2, P = 0.51). VBNI was found an independent prognostic factor of tumor progression (HR 5.1, P < 0.0001), but neither of tumor recurrence nor disease specific mortality. CONCLUSIONS: Subepithelial growth is not an uncommon in bladder cancer. It is more frequent in high-grade and high-stage tumors. The findings of this study suggest that subepithelial growth carries a higher risk for stage progression (EGP and VBNI) and mortality (EGP), but not tumor recurrence.

Predicting the risk of high-grade bladder cancer using noninvasive data.

AIM: To examine the hypothesis that the risk of high-grade bladder cancer can be predicted using noninvasively obtained data. PATIENTS AND METHODS: We retrospectively analyzed the database of 431 patients that had transurethral resection of first-time bladder tumors between June 1998 and December 2009. Pre-operative parameters evaluated were: patients' age; gender; sonographic tumor diameter, number and location of tumor inside the bladder; presence of hydronephrosis, and results of urinary cytology. Parameters that showed significance in multivariate analysis were incorporated into the nomogram. RESULTS: Multivariate analysis of the data showed that patient's age, the presence of hydronephrosis, sonographic tumor diameter (risk of a high-grade tumor: 14, 29, 43.3, 55.7 and 69.4% at diameters: 0.5-1.5, 1.6-2, 2.1-2.5, 2.6-3 and >3 cm, respectively), location of tumor in the bladder (risk of high-grade tumor: 28.8, 47, 67.5 and 90.5% in the lateral walls, posterior/base, anterior and dome, respectively), and urinary cytology were all highly significant and independent predictors of high-grade tumors. A nomogram constructed using these variables scored an area of 0.853 in the ROC curve. CONCLUSIONS: The risk of high-grade bladder tumor can be accurately predicted using non-invasively obtained information. This prediction can help to triage patients with newly detected bladder cancer for biopsy.

Is radical cystectomy mandatory in every patient with variant histology of bladder cancer.

Urothelial carcinomas have an established propensity for divergent differentiation. Most of these variant tumors are muscle invasive but not all. The response of non muscle invasive variant tumors to intravesical immunotherapy with BCG is not established in the literature, and is reported here. Between June 1995 and December 2007, 760 patients (mean age of 67.5 years) underwent transurethral resection of first time bladder tumors in our institution. Histologically variant tumors were found in 79 patients (10.4%). Of these 57 patients (72%) of them had muscle-invasive disease or extensive non-muscle invasive tumors and remaining 22 patients (28%) were treated with BCG immunotherapy. These included 7 patients with squamous differentiation, 4 with glandular, 6 with nested, 4 with micropapillary and 1 patient with sarcomatoid variant. The response of these patients to immunotherapy was compared with that of 144 patients having high-grade conventional urothelial carcinomas. Median follow-up was 46 months. The 2 and 5-year progression (muscle-invasion) free survival rates were 92% and 84.24% for patients with conventional carcinoma compared to 81.06% and 63.16% for patients with variant disease (P=0.02). The 2 and 5-year disease specific survival rates were 97% and 91.43% for patients with conventional carcinoma compared to 94.74 % and 82% for patients with variant disease (P=0.33). 5 patients (22.7%) of variant group and 13 patients (9.03%) of conventional group underwent cystectomy during follow-up (P=0.068).Patients with non-muscle invasive variants of bladder cancers can be managed with intravesical immunotherapy if tumor is not bulky (>4 cm). Although progression to muscle invasive disease is more common than in conventional group and occurs in about 40% of the patients, life expectancy is similar to patients with conventional high-grade urothelial carcinomas provided that follow-up is meticulous.

Raman molecular imaging: a novel spectroscopic technique for diagnosis of bladder cancer in urine specimens.

BACKGROUND: Raman molecular imaging (RMI) is an optical technology that combines the molecular chemical analysis of Raman spectroscopy with high-definition digital microscopic visualization. This approach permits visualization of the physical architecture and molecular environment of cells in the urine. The Raman spectrum of a cell is a complex product of its chemical bonds. OBJECTIVE: In this work, we studied the possibility of using the Raman spectrum of epithelial cells in voided urine for diagnosing urothelial carcinoma (UC). DESIGN, SETTING, AND PARTICIPANTS: Raman signals were obtained from UC tissue, then from UC touch preps obtained from surgical specimens and studied using the FALCON microscope (ChemImage, Pittsburgh, PA, USA), with a×100 collection objective and green laser illumination (532 nm). Then, urine samples were obtained from 340 patients, including 116 patients without UC, 92 patients with low-grade tumors, and 132 patients with high-grade tumors. Spectra were obtained from an average of five cells per slide. MEASUREMENTS: Raman spectroscopy of cells from bladder cancer (BCa) tissues and patients. RESULTS AND LIMITATIONS: The Raman spectra from UC tissue demonstrate a distinct peak at a 1584 cm(-1) wave shift not present in benign tissues. The height of this peak correlated with the tumor's grade. The signal obtained from epithelial cells correctly diagnosed BCa with sensitivity of 92% (100% of the high-grade tumors), specificity of 91%, and a positive predictive value of 94% and a negative predictive value of 88%. The signal correctly assigned a tumor's grade in 73.9% of the low-grade tumors and 98.5% of the high-grade tumors. RMI for diagnosis of BCa is limited by the need for specialized equipment and training of laboratory personnel. CONCLUSIONS: RMI has the potential to become a powerful diagnostic tool that allows noninvasive, accurate diagnosis of UC.

What happened to shockwave lithotripsy during the past 22 years? A single-center experience.

INTRODUCTION: From 1985 to August 2007 we have performed 15,324 shockwave lithotripsy (SWL) treatments using the Dornier HM3 lithotripter. We studied trends in the characteristics of treatments and patients. PATIENTS AND METHODS: Patient data were recorded in a computerized database. Changes in characteristics of patients and stones treated during this period were reviewed. RESULTS: A total of 15,324 treatments were performed on 10,734 patients. The following trends were observed: (1) Stone size: A significant increase in the proportion of patients treated for stones up to 10 mm in diameter, no change for stone size of 10 to 20 mm, and a decrease in stones larger than 20 mm in diameter. (2) Stone location: A significant increase in the proportion of patients treated for proximal and distal ureteral calculi, whereas a significant decrease in those with renal pelvic and staghorn stones. (3) Auxiliary procedures: A significant increase in the use of perioperative procedures (stents or ureteral catheters) ranging from 20% during the mid-1980s up to 60% in the year 2007. (4) Presenting symptoms: A significant increase in the percentage of patients referred with pain and a significant decrease in the percentage of patients referred with signs of infection. (5) Repeat SWL: A total of 13% of the patients required a second SWL for the same stone within 90 days of the first procedure. (6) Complication rate: This rate was relatively low, ranging from 1% to 6% per year. CONCLUSIONS: The evolvement of endourological procedures and techniques resulted in a decreased referral of large kidney stones for SWL. Advanced diagnostic modalities increased the diagnosis of renal colic in patients presenting with pain, and consequently their referral rate and timing for SWL treatment. The use of stents increased because of referral of patients with obstructing stones and infection or for prevention of posttreatment obstruction.

Fever after shockwave lithotripsy--risk factors and indications for prophylactic antimicrobial treatment.

PURPOSE: To identify risk factors for fever after shockwave lithotripsy (SWL) and suggest guidelines for prophylactic antimicrobial treatment. PATIENTS AND METHODS: Between 1985 and 2007, a total of 15,324 SWL procedures were performed in our institution using the Dornier HM3 lithotripter. Because stone analyses were not available in the majority of patients, management of stones larger than 2 cm in diameter were excluded from this analysis to minimize the ratio of struvite stones as a possible cause for postprocedural fever. In this analysis, 11,500 SWL treatments were included. Clinical parameters before, during, and after treatments were prospectively registered using a computerized database. Potential risk factors for fever after SWL were evaluated. RESULTS: Fever >38.0 degrees C developed in 161 (1.4%) patients. The risk factors for fever after SWL were: A positive urine culture (P < 0.05), an indwelling nephrostomy tube or stent during the procedure (P < 0.001), lithotripsy of kidney or upper ureteral stones (P < 0.05) and preoperative symptomatic urinary tract infection (UTI) (P < 0.05) or sepsis (P < 0.05). Lithotripsy of mid and lower ureteral stones, stone size, and the use of ureteral catheters during the procedures were not associated with increased risk of fever after SWL. CONCLUSIONS: Fever (>38.0 degrees C) develops in only 1.4% of the patients undergoing SWL. Therefore, prophylactic antibiotic treatment is not indicated in all patients. Selective prophylactic treatment is recommended in patients who present with UTI, kidney or upper ureteral stones, and those for whom a nephrostomy tube or stent is necessary.

The follow-up of patients with non-muscle-invasive bladder cancer by urine cytology, abdominal ultrasound and urine CYFRA 21-1: a pilot study.

AIM: This study aimed to evaluate the accuracy of urine cytology, bladder ultrasound (US), urine cytokeratin 19 fragment assay (CYFRA 21-1) and the combination of these noninvasive modalities in the detection of recurrent bladder cancer. PATIENTS AND METHODS: In a total of 154 patients that were followed with cystoscopy after endoscopic resection of non-muscle-invasive bladder cancer, we performed and analyzed results of 311 observations that included cytology, CYFRA 21-1, US. The urine concentration of CYFRA 21-1 was measured by an immunoradiometric assay. RESULTS: Cystoscopy and biopsy revealed recurrent bladder tumors in 21 patients. Most of the tumors (77%) were less than 10 mm in their largest diameter. Urine cytology, US and urine CYFRA 21-1 resulted in overall sensitivity of 19.1, 52.4 and 71.4% and specificity of 96.6, 99.7 and 68.6%, respectively. Each of these methods used alone yielded false-negative results in patients harboring tumors at high risk of progression. The combination of all three methods had sensitivity and specificity of 90.5 and 67.2%, respectively. All three tests were negative in 197 of 311 observations (63.3%), missing only 2 low-risk tumors. CONCLUSION: The combined use of US, urinary CYFRA 21-1 and cytology appears to be an effective, noninvasive approach for the detection of recurrent bladder tumors.

Extracorporeal shock wave lithotripsy in prepubertal children: 22-year experience at a single institution with a single lithotriptor.

PURPOSE: The sophistication of percutaneous nephrolithotomy and ureteroscopy challenges the efficacy of ESWL for urolithiasis in prepubertal patients. We evaluated our long-term experience with ESWL in these patients and determined its efficiency. MATERIALS AND METHODS: We retrospectively reviewed the charts of all prepubertal patients who underwent ESWL. We evaluated the need for tubing, the 3-month stone-free rate, the need for additional ESWL, and the effect of stone size and location, and cystinuria on the 3-month stone-free rate. RESULTS: Between 1986 and 2008, 119 males and 97 females with a mean age of 6.6 years who had urolithiasis underwent ESWL using the Dornier HM3 lithotriptor. We treated 157 children with renal calculi with an average +/- SD diameter of 14.9 +/- 8.9 mm, of whom 66 (42%) required a tube in the urinary system. The 3-month stone-free rate was 80% and 31 patients (19.7%) needed an additional procedure. Stone location did not affect the stone-free rate but stone size did. We treated 59 patients for ureteral stones with an average stone length of 9.5 +/- 4.8 mm, of whom 41 (69%) required tube insertion. The 3-month stone-free rate was 78% and 13 patients (22%) needed an additional procedure. The 3-month stone-free rate did not depend on stone location or size. The rate was 37.5% in patients with cystinuria and 82.5% in all others (p <0.0001). Six patients (2.8%) had complications. CONCLUSIONS: The 3-month stone-free rate after ESWL in prepubertal patients is 80% and 20% of patients require additional procedures. ESWL is most effective for kidney stones less than 11 mm. ESWL has inferior results for cystine stones compared to other calculi. Complications are rare.

The fate of the seminal vesicle remnant after proximal transection or ligation: an animal model.

PURPOSE: Dissection of the seminal vesicles during radical prostatectomy has the potential to damage the pelvic plexus, thus compromising trigonal, bladder neck and cavernous innervation, and contributing to delayed gain of continence and erectile function. The rate of prostate cancer invasion into the seminal vesicles in currently operated patients is low and in most it may be predicted preoperatively. This situation calls for seminal vesicle sparing radical prostatectomy in select patients, leaving a distal remnant of the seminal vesicles in place. We investigated the fate of the seminal vesicle remnant after proximal transection or ligation in an animal model. MATERIALS AND METHODS: The right seminal vesicle in 36 anesthetized male rats was divided by suture ligation or by transection. The left seminal vesicle served as a control. Six rats per group were sacrificed 1, 2 and 4 weeks after division, respectively. Seminal vesicle morphology was evaluated macroscopically and microscopically. RESULTS: All rats tolerated surgery well and gained weight postoperatively. Transected seminal vesicles were similar in weight and morphology to control contralateral glands. One week after seminal vesicle ligation the remnants became significantly heavier and showed balloon dilatation of the hollow spaces, while the lining epithelium became significantly flattened. Two and 4 weeks after ligation half of the animals showed gland shrinkage and half demonstrated persistent dilatation. CONCLUSIONS: Seminal vesicle transection preserves the gland remnant in a relatively normal morphology, while ligation leads to severe and inconsistent morphological changes. When considering seminal vesicle sparing radical prostatectomy, seminal vesicle transection may be preferred to ligation.

The natural history of bladder carcinoma in situ after initial response to bacillus Calmette-Gúerin immunotherapy.

OBJECTIVES: To explore patterns of recurrence, muscle invasion, and disease specific mortality in patients with bladder carcinoma in situ (CIS) who responded to an induction course with intravesical bacillus Calmette-Gúerin (BCG) immunotherapy. METHODS: Between June 1985 and December 2003, 104 patients (mean age 67 years) were diagnosed with either pure (38 patients) or concomitant (66 patients) CIS. Patients who responded to one (92 patients) or two (12 patients) induction courses of intravesical BCG instillation were included in the study. Response was determined and monitored by routine periodic bladder biopsies. Outcome of patients and the effect of various prognostic parameters were assessed after a median follow-up of 75 months. RESULTS: The 5- and 10-year recurrence-free survival rates were 63% and 54%, respectively. The 5- and 10-year muscle-invasive-free survival rates were 79% and 77%, and the 5- and 10-year disease-specific survival rates were 90.5 and 85.8%, respectively. Median time to recurrence, muscle invasion, and disease-specific mortality was 18, 19, and 40 months, respectively. Pure and concomitant CIS were associated with a similar outcome. The recurrence of nonmuscle-invasive tumor did not increase the risk for muscle invasion or mortality. CONCLUSIONS: Pure and concomitant bladder CIS share similar biologic behavior. Muscle-invasive disease is expected in about 25% of the BCG responders followed for long time periods and disease-specific mortality in 15%. Tumor recurrence, whether nonmuscle-invasive or muscle-invasive, follows a similar time table suggesting that these are not sequential but parallel and independent processes.

Prostatic urothelial carcinoma: is transurethral prostatectomy necessary before bacillus Calmette-Guérin immunotherapy?

OBJECTIVE: To evaluate the efficacy of transurethral prostatectomy (TURP) followed by bacillus Calmette-Guérin (BCG) immunotherapy in patients with prostatic urothelial carcinoma (PUC) and compare the results of studies using combined TURP and BCG with studies in which TURP was not performed. PATIENTS AND METHODS: Patients with bladder cancer and PUC were treated with TURP followed by six weekly intravesical instillations of BCG. Response was determined and monitored by periodic bladder and prostatic urethra biopsies and urinary cytology. Also, the outcome of previous series using similar methodology was compared with the outcome of studies in which TURP was not performed. RESULTS: In all, 20 patients with PUC were treated with TURP followed by intravesical instillations of BCG. The median follow-up was 52.5 months. All patients had an initial complete response (CR). The prostatic urethra 5-year recurrence-free survival rate was 90%. However, bladder and prostatic urethra 5-year recurrence-free survival rate was only 30%. Five patients (25%) died from urothelial carcinoma (UC) after a median period of 58.5 months (two from bladder cancer metastases and three from upper tract metastases). The long-term prostatic urethra CR rate in studies using TURP before immunotherapy was significantly higher than the CR rate in studies using immunotherapy alone (P < 0.001). However, there was no difference when bladder and prostatic urethra CR rates were considered together (P = 0.54). CONCLUSION: In patients with PUC, TURP before BCG immunotherapy eliminates PUC in most cases, and is probably the preferred treatment for this disease. The risk of UC-specific mortality in these patients is high.

Vesical vs. extra-vesical patterns of recurrence after the treatment of urothelial upper tract tumors.

OBJECTIVE: The objective of this study was to define recurrence patterns after nephro-ureterectomy (NU) for urothelial upper tract tumor (UUTT), and to suggest guidelines for follow-up. METHODS: The effects of age, gender, UUTT grade, stage, size, location in the urinary system, and the administration of adjuvant chemotherapy on disease-free survival were assessed retrospectively. RESULTS: Fifty-three patients (mean age 62.7 years) underwent NU for UUTT and were followed with periodic cystoscopy, urinary cytology, and CT of the chest and abdomen. During a median follow-up period of 72 months, 26 patients (49%) developed tumor recurrence. Almost 95% of the recurrences occurred within the first 48 months following surgery. Two distinct patterns of recurrence were identified: vesical and extra-vesical recurrences. Vesical recurrence occurred in 19 patients (35.8%) and did not impair survival. The risk of vesical recurrence was independent of UUTT grade or stage. Patients who had Grades 1 or 2 UUTT developed only low-grade vesical recurrence, while patients with Grade 3 UUTT developed either high- or low-grade vesical recurrences. Extra-vesical recurrence occurred in 8 patients (15.1%); all had an initial Grade 3 UUTT, and were associated with short median survival. CONCLUSIONS: Patients presenting with Grades 1 or 2 UUTT are at risk of developing low-grade bladder tumors. Therefore, cystoscopic surveillance is recommended. Patients presenting with Grade 3 UUTT are at risk of developing both high- and low-grade bladder tumors as well as extra-vesical recurrence. An aggressive multimodality program including cystoscopy, urinary cytology, and CT of the chest and abdomen is advisable.