En Bloc Transurethral Resection of Bladder Tumors: A New Standard?

OBJECTIVE: To assess safety and efficacy, namely pathological assessment of the specimen and recurrence rate, of en bloc transurethral resection (EBTUR) of bladder tumor. MATERIALS AND METHODS: We performed a systematic review of the available literature on PubMed. Seventeen articles, mainly prospective case series, were found. EBTUR is performed with a great variety of equipments, whereas the resection technique is similar. RESULTS: Overall, 895 patients have been submitted to EBTUR, accounting for 1191 lesions. Forty complications (4%) were computed. Only 10 (1%) were grade III, mostly bladder perforation or bleeding. Fifty-nine conversions (6.5%) to conventional transurethral resection (TUR) have been reported because of difficult locations of tumors or failure to extract the specimen. Several series, accounting for 763 patients, report about incidence of detrusor muscle in the specimen. Overall, 731 (96%) cases with detrusor muscle were computed. Tumor stage remained uncertain only in 12 (1.5%) cases. Follow-up data were available for 544 patients. Mean follow-up ranged from 9.3 to 40 months. Recurrence rate varied from 6% to 55%. Most of the recurrence occurred outside primary tumor site. Mean weighted follow-up across all series was 20 months, whereas overall recurrence rate was 23%. CONCLUSIONS: Irrespective of the technique adopted, EBTUR is a safe procedure. The presence of detrusor muscle in the specimen is high if compared with historical series of conventional TUR. Indeed, recurrence rate is comparable. The objective advantage of a proper histological assessment suggests to perform EBTUR instead of conventional TUR, when feasible.

Narrow band imaging and bladder cancer: when and how.

Narrow band imaging (NBI) is an optical enhancement technology for endoscopy. NBI works filtering the standard white light in two bandwidths of illumination of 415 nm, blue, and 540 nm, green. As a result, capillaries on mucosal surface appear brown and veins in connective subepithelial layer cyan, enhancing the contrast among epithelial, subepithelial tissue and its vascularisation. Given that it is a filter, it is safe, does not need any kind of instillation and the vision modality can be switched from NBI to white light and vice versa without any limitations of time. NBI-assisted cystoscopy increases the detection rate of urothelial lesions and enhances visibility of tumour margins with respect to standard white light modality, although it does not need a particular learning curve. NBI exploration of the bladder should be avoided during active bleeding because the light absorption would be excessive impeding an optimal vision. Moreover, it should always be employed in combination with standard white light modality to avoid an excess of false-positive findings, particularly during or immediately after topic treatments. It can be used in office to anticipate bladder recurrences and in the operating theatre to perform a complete tumour resection. As a matter of fact, it is able to reduce the recurrence rate and ameliorate bladder cancer management by identifying high-grade cancerous tissue, especially Cis, undetected by the standard white light modality.

Long-term PSA-free survival and castration-free survival with delayed antiandrogen therapy in patients with one versus two or more positive nodes at prostatectomy.

PURPOSE: To analyze time in relation to biochemical recurrence (BCR) and antiandrogen therapy (ADT) in patients with node metastasis at retropubic prostatectomy (RRP) and to identify prognostic factors of BCR- and ADT-free survival. METHODS: Positive node patients at RRP and extended pelvic lymph node dissection (ePLND) were recruited retrospectively. Neoadjuvant and adjuvant therapy were exclusion criteria. BR was defined as PSA ≥ 0.3 ng/ml or the beginning of salvage radiotherapy or, ADT. RESULTS: Between 1995 and 2008, 70 node-positive patients after RRP were followed without ADT. Overall, BCR-free survival was 77.9% at 2 years and 29.7% at 8 years. The median time to BCR was 59.2 months for patients with only one node compared to 27.7 months for those with ≥2 nodes. The number of positive nodes was the only independent predictor of BCR in Cox regression multivariable analysis. ADT-free survival was 78% at 2 years and 39% at 8 years. The median time to ADT for patients with only one positive node was 115 months, and the 5 years ADT-free survival was 68.8%. Gleason score and the number of positive nodes were the only independent prognostic factors of time to ADT in the Cox regression multivariable analysis. CONCLUSIONS: The prognosis of patients with positive nodes after RRP and ePNLD is good in terms of BCR- and ADT-free survival. After 8 years, 29.7% were still free from BCR, and 39% did not receive ADT. The number of positive nodes was the most important predictor of BCR- and ADT-free survival.

The role of narrow-band imaging in the management of non-muscle-invasive bladder cancer.

Narrow-band imaging is a young optical enhancement technology for endoscopy. It is a filter to the standard white light which increases the contrast between underlying vasculature and epithelial strata of the mucosa, improving the detection of bladder cancer with particular regard to high grade, flat lesions. Narrow band imaging is absolutely safe, may be used any time during a procedure, either during office cystosopy or transurethral resection, and implies a minimal burden for the healthcare provider given the absence of a learning curve and the limited cost of the camera and light source. The ameliorated detection translates into an improved management of the disease and a lower recurrence risk in prospective randomized studies, suggesting the inclusion of the technology in daily clinical practice.

Development and external validation of lymph node density cut-off points in prospective series of radical cystectomy and pelvic lymph node dissection.

OBJECTIVE: To identify lymph node density thresholds and their prognostic role in patients who underwent radical cystectomy and pelvic lymph node dissection, and to validate findings in an external series. METHODS: Between May 2001 and September 2009, data from 750 radical cystectomies carried out at "Regina Elena" National Cancer Institute (Rome, Italy) were collected in a prospectively-maintained database. Once patients who had undergone neoadjuvant treatments and those who had undergone salvage radical cystectomy were excluded from the 210 pN+ patients, 156 patients with urothelial carcinoma were selected for analysis. Optimal cut-off points for age, lymph node count and lymph node density were identified by considering these variables as continuous. External validation of findings was carried out by using data of 154 pN+ patients selected from two prospective series. RESULTS: The optimal identified cut-off points were 11% and 30% for lymph node density, nine and 30 nodes for lymph node count, and 73 years for age. Median cancer-specific survival of patients were significantly different in patients with lymph node density <12%, between 12% and 30%, and >30% (71 months, 24 months and 11 months, respectively; P < 0.001). Cancer-specific survival was independently predicted by lymph node density cut-off points (12-30% vs <12%: hazard ratio 1.51, P = 0.047; >30% vs <12%: hazard ratio 2.89, P < 0.001). In the external series, the prognostic effect of lymph node density according to tertiary distribution of risk based on these lymph node density cut-off points was confirmed at Cox multivariable analysis (12-30% vs <12%: hazard ratio 1.5, P = 0.048; >30% vs <12%: hazard ratio 2.5, P = 0.004). CONCLUSIONS: Lymph node density is the strongest predictor of cancer-specific survival. Identified lymph node density thresholds have shown to be independent predictors of cancer-specific survival in the external validation series.

Safety and efficacy of periurethral constrictor implantation for the treatment of post-radical prostatectomy incontinence.

OBJECTIVE: To assess safety and efficacy of the periurethral constrictor for the treatment of postprostatectomy urinary incontinence. METHODS: Periurethral constrictor is a minimally invasive, low-cost (€ 2000) device based on an adjustable occlusive mechanism. From December 2004 to March 2010 the device was implanted in 66 patients with mild to severe incontinence (3 or more pads per day) through a 3- to 5-cm perineal incision. Median surgical time was 35 minutes (range 25-60). Discharge occurred on day 1 after removing the indwelling urethral catheter. RESULTS: In 4 cases (6%), the device was removed because of infection/periurethral erosion. At 18 months, 62 patients were valuable; continence was recovered totally in 49 cases (79%), partially in 9 (15%) cases, and remained unchanged in 4 (6%). No one needed self-catheterization to empty the bladder. CONCLUSION: Periurethral constrictor improved continence in most of the patients. Nevertheless, a larger series and longer follow-up are needed to confirm safety and to test durability.

En bloc transurethral resection of bladder lesions: a trick to retrieve specimens up to 4.5 cm.

The present technique maintains the integrity of voluminous lesions during extraction. Pathological analysis is consequently improved and a proper evaluation of the surgical margins is also possible. Papillary lesions of up to 4.5 cm are amenable to en bloc resection and extraction, while solid lesions comply less well with the urethra and sometimes are very difficult to extract. Nevertheless, the main limitation of the technique remains that lesions originating from the bladder neck are not amenable to en bloc resection,while particular attention should be paid during resection of lesions involving the ureteric orifice to avoid ureteric stripping.

A randomized prospective trial to assess the impact of transurethral resection in narrow band imaging modality on non-muscle-invasive bladder cancer recurrence.

BACKGROUND: Narrow band imaging (NBI) is an optical enhancement technology that filters white light into two bandwidths of illumination centered on 415nm (blue) and 540nm (green). NBI cystoscopy can increase bladder cancer (BCa) visualization and detection at the time of transurethral resection (TUR). NBI may therefore reduce subsequent relapse following TUR. OBJECTIVE: Assess the impact of NBI modality on 1-yr non-muscle-invasive BCa (NMIBC) recurrence risk. DESIGN, SETTING, AND PARTICIPANTS: Consecutive patients with overt or suspected BCa were included in a prospective study powered to test a 10% difference in 1-yr recurrence risk in favor of cases submitted to NBI TUR. Excluding patients with muscle-invasive BCa, negative pathologic examination, or without follow-up, the study population was composed of 148 subjects randomized from August 2009 to September 2010 to NBI TUR (76 cases) or white light (WL) TUR (72 cases). INTERVENTION: TUR was performed in NBI or standard WL modality. MEASUREMENTS: The 1-yr recurrence risks in NBI or WL TUR groups were compared using odds ratio (OR) point and interval estimates derived from logistic regression modeling. RESULTS AND LIMITATIONS: The 1-yr recurrence-risk was 25 of 76 patients (32.9%) in the NBI and 37 of 72 patients (51.4%) in the WL group (OR=0.62; p=0.0141). Simple and multiple logistic regression analyses provided similar OR points and interval estimates. CONCLUSIONS: TUR performed in the NBI modality reduces the recurrence risk of NMIBC by at least 10% at 1 yr.

Effect of age, family history of prostate cancer, prostate enlargement and seasonality on PSA levels in a contemporary cohort of healthy Italian subjects.

We assessed the joint effect of age at enrollment, age at follow-up, family history of prostate cancer, prostate enlargement and seasonality on prostate-specific antigen (PSA) estimated through log-normal mixed-effects modeling in an Italian cohort of healthy, 45- to 65-year-old subjects over a 4-year period. The median ratio was used as the measure of effect. Median and mean baseline PSA were 0.78 (interquartile range: 0.41-1.50) and 1.27 (95% CI: 1.19-1.35) ng/mL, respectively. A similar median annual increase of 5.7% (95% CI: 4.8%-6.5%) was found for age at enrollment and age at follow-up. Individuals with moderate to severe prostate enlargement had a median PSA ratio of 1.040 (95% CI: 0.919-1.176) and 1.318 (95% CI: 1.128-1.539), respectively. Median ratios of 1.200 (95% CI: 0.026-1.404) and 1.300 (95% CI: 0.915-1.845), respectively, were computed for subjects with only one or more than one prostate-cancer-affected relatives. Regarding seasonality, the highest value was shown in summertime, the lowest in wintertime, and the resulting median ratio was 1.280 (95% CI: 1.117-1.468). Irrespective of age, baseline PSA was in most cases about 1.00 ng/mL with a yearly median variation of about 5% over a 4-year period. Indeed, prostate enlargement, prostate cancer family history and seasonality showed a remarkable impact on PSA measurement. This should be considered when counseling patients with a PSA history.

Late-onset incontinence in a cohort of radical prostatectomy patients.

A cohort of 235 subjects, who underwent radical prostatectomy from 1994 to 2002, completely continent at the 2-year follow up and with the last follow-up visit in 2009, was examined to assess incidence and risk factors of late-onset incontinence. Median follow up was 100 months, range 84-176. At the last follow-up visit, 209 (89%) maintained continence, and 26 (11%) became incontinent. Specifically 14 out of 26 (6%) used one pad and 12 (5%) used two or more pads daily. Incidence of age ≥ 65 years at radical prostatectomy was greater in the subgroup who developed late incontinence, 109/209 (52%) vs 19/26 (73%). Incidence of adjuvant or salvage radiotherapy, of hormonal manipulation and of extraprostatic disease was similar in the two subgroups. Univariate and multivariate analysis did not disclose any difference. Late-onset incontinence is to be expected in about 10% of subjects who became completely continent after radical prostatectomy. The cause is likely to be related to ageing. Patients should be informed about the long-term risk of becoming incontinent.

Genetic polymorphisms of CYP17A1, vitamin D receptor and androgen receptor in Italian heredo-familial and sporadic prostate cancers.

BACKGROUND: Searching for genetic and environmental factors predisposing to prostate cancer, common single-nucleotide polymorphisms in CYP17A1, CYP19A1, VDR genes, and the number of CAG repeats from AR were investigated in Italian heredo-familial prostate cancer (HFPC) patients controlled for dietary intake and life style habits. METHODS: We evaluated differences between HFPC and sporadic cancers, in the pattern of common single-nucleotide polymorphisms in CYP17A1, CYP19A1, VDR genes, and the CAG repeat from AR, controlling for dietary intake and lifestyle habits in a regionwide population. Ninety-five patients with HFPC were identified and 378 sporadic prostate cancers were randomly selected as controls. Dietary intake and lifestyle habits were determined through self-administered questionnaires in all patients. Genotyping of polymorphisms for CYP17A1, CYP19A1, VDR, and the CAG repeat from AR was carried out using pyrosequencing. RESULTS: HFPC cases were significantly younger than controls, whereas similar proportions of localized tumours, favourable histology, and abnormal prostate serum antigen levels (4-19 ng/ml) were detected in the two groups. A statistically evident gene-gene interaction was found: a 5-fold higher probability [odds ratio (OR)=4.83; 95% confidence interval (CI): 1.37-17.02] of HFPC was observed in the subgroup profiling VDR1 T/T genotypes coupled with VDR2 T/T genotype. Among nutrients, an increase in HFPC risk (OR=3.14; 95% CI: 1.12-8.81) was found only for zinc, when associated with the VDR2 T/T genotype. CONCLUSIONS: Significant evidence for positive interactions between VDR1 and VDR2 genotypes was demonstrated, suggesting that high-risk multigenic polymorphism profiles could variously sustain HFPC tumorigenesis.

Laparoscopic radical cystectomy. Where do we stand?

Laparoscopic Radical Cystectomy (LRC) has been proposed since 1999 as a less invasive alternative to Open Radical Cystectomy (ORC). Pioneers of the technique claim that LRC led to faster recovery, shorter hospital stay and more rapid return to daily activities respect to ORC while offering the same functional and oncological results. About 900 cases are published in peer reviewed papers. The greatest series is formed by a cohort of 85 patients. The preferred urinary diversion is the ileal conduit (46%) although in recent series the ileal neobladder is increasingly adopted. Urinary diversion is usually performed extracorporeally through an abdomen incision of about 5-10 used also for the extraction of the specimen. The mean or median follow up of LRC series does not exceed 31 months and the longest follow up reported up to now is 58 months in the series examined. Overall survival rate varies from 72% to 95%. While feasibility of LRC has been demonstrated, cancer control has far from been assured, mainly in consequence of limited follow-up of the series and an unexpected low disease free survival rate. Moreover the advocated advantages related to LRC seem to be related to patients' selection rather than to less invasiveness. Actually when characteristics of the patient and of the disease are similar, outcomes of LRC and ORC, in terms of hospitalization and recovery, are comparable. LRC is currently an experimental procedure which can not be considered at the present time a concrete alternative to ORC.

Cistectomía radical laparoscópica. ¿Dónde estamos? / Laparoscopic radical cystectomy. Where do we stand?

La Cistectomía Radical Laparoscópica (CRL) ha sido propuesta desde 1999 como una alternativa menos invasiva de la Cistectomía Radical Abierta (CRA). Los pioneros en esta técnica reclaman que la CRL tiene una recuperación más rápida, estancias hospitalarias más cortas y un retorno a las actividades diarias más rápido en comparación con la CRA a la vez que ofrece a los mismos resultados funcionales y oncológicos.Se han publicado unos 900 casos en revistas con sistemas de revisión por pares. La serie más larga está formada por una cohorte de 85 pacientes. La derivación urinaria preferida es el conducto ileal (46%) aunque en series recientes la adopción de la neovejiga ileal está aumentando. La derivación urinaria se realiza normalmente extracorpórea a través de la incisión abdominal de unos 5-10 cm utilizada también para extracción de la pieza.La media o mediana de seguimiento de las series de CRL no supera los 31 meses y hasta ahora el seguimiento más largo comunicado en las series examinadas es de 58 meses. La tasa de supervivencia global varía entre 72% y 95%.Aunque la viabilidad de la CRL ha sido demostrada, está lejos de haber demostrado el control oncológico, principalmente como consecuencia del seguimiento limitado en las series y de una inesperada baja tasa de supervivencia libre de enfermedad. Además, las ventajas defendidas de la CRL parecen estar más relacionadas con la selección del paciente que con una menor invasión. Realmente cuando las características del paciente y de la enfermedad son similares, los resultados de la CRL y la CRA en términos de hospitalización y de recuperación son comparables.La CRL es realmente un procedimiento experimental que no puede ser considerada como una alternativa(AU)

Laparoscopic Radical Cystectomy (LRC) has been proposed since 1999 as a less invasive alter-native to Open Radical Cystectomy (ORC). Pioneers of the technique claim that LRC led to faster recovery, shorter hospital stay and more rapid return to daily activities respect to ORC while offering the same functional and oncological results.About 900 cases are published in peer reviewed papers. The greatest series is formed by a cohort of 85 patients. The preferred urinary diversion is the ileal conduit (46%) although in recent series the ileal neobladder is increa-singly adopted. Urinary diversion is usually performed extracorporeally through an abdomen incision of about 5–10 used also for the extraction of the specimen.The mean or median follow up of LRC series does not exceed 31 months and the longest follow up reported up to now is 58 months in the series examined. Overall survival rate varies from 72% to 95%.While feasibility of LRC has been demonstrated, cancer control has far from been assured, mainly in consequen-ce of limited follow-up of the series and an unexpected low disease free survival rate. Moreover the advocated advantages related to LRC seem to be related to pa-tients’ selection rather than to less invasiveness. Actually when characteristics of the patient and of the disease are similar, outcomes of LRC and ORC, in terms of hos-pitalization and recovery, are comparable.LRC is currently an experimental procedure which can not be considered at the present time a concrete alter-native to ORC(AU)

Feasibility of transurethral resection of bladder lesion performed entirely by means of narrow-band imaging.

PURPOSE: To assess the feasibility of transurethral resection (TUR) of bladder lesions performed entirely by means of a narrowband imaging (NBI) modality. PATIENTS AND METHODS: Data from an ongoing prospective randomized trial (NCT01004211) were extracted. Quality outcomes of standard TUR and NBI TUR were compared. Complications were graded according to the Clavien-Dindo system. RESULTS: To date, 33 and 29 subjects were randomized to standard and NBI TUR. No significant differences regarding age, sex, American Society of Anesthesiologists score, rate of multiple lesions, or lesions larger than 3 cm in the two groups were found, whereas rate of TUR for recurrent bladder cancer was greater in the NBI group. All procedures ended with complete clearance of the suspected or overt bladder tumor in the modality assigned. No death or major surgical or medical complications were registered. Overall grade I to II complications rate in the NBI and standard groups was, respectively, 8/29 (27%) and 11/33 (33%) (P = 0.831). Median surgery time was, respectively, 20 and 30 minutes in the NBI and standard group (P = 0.381). Median time to catheter removal was, respectively, 2 and 3 days in the NBI and standard groups (P = 0.288). Median time to discharge was 2 and 3 days (P = 0.173). No patient was readmitted after discharge. Muscle tissue was absent in the specimen of one patient who underwent standard TUR. CONCLUSION: NBI TUR appears to be feasible. The results of the ongoing randomized trial will show whether NBI TUR is able to reduce significantly the 1-year recurrence rate of bladder tumors.

New Italian guidelines on bladder cancer, based on the World Health Organization 2004 classification.

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.

Narrow band imaging for detecting residual/recurrent cancerous tissue during second transurethral resection of newly diagnosed non-muscle-invasive high-grade bladder cancer.

OBJECTIVE: To determine if narrow-band imaging (NBI) can be used to detect high-grade cancerous lesions missed with the white light at the time of a second transurethral resection (TUR) of high-grade non-muscle-invasive bladder cancer (NMIBC). PATIENTS AND METHODS: Consecutive patients with newly diagnosed high-grade NMIBC were enrolled in a prospective observational study. Patients with incomplete resection or absence of muscle tissue in the specimen were excluded. About 1 month after the first TUR, NBI cold-cup biopsies were taken from areas suspicious for urothelial cancer at the end of an extensive white-light second TUR protocol including: (i) resection of the scar of the primary tumour; (ii) resection of any overt or suspected urothelial lesions; and (iii) six random cold-cup biopsies of healthy mucosa. RESULTS: In 2008, 47 consecutive patients were recruited after giving written consent (median age 62 years, range 49-83, 39 men and eight women). Nine patients (19%) had macroscopic or microscopic high-grade NMI urothelial cancer, whereas one was reassessed as having muscle-invasive disease at the white-light second TUR plus the six random biopsies. NBI biopsies were taken in 40 of the 47 patients and detected six more patients with high-grade cancerous tissue (13%). In all 16 of the 47 patients (34%) were found to have residual/recurrent cancer using our extensive protocol of second TUR followed by NBI biopsies. CONCLUSIONS: Adding NBI biopsies at the end of an extensive second TUR protocol in patients with newly diagnosed high-grade NMIBC can lead to the identification of patients with otherwise missed high-grade residual/recurrent urothelial carcinoma.

Predictors of symptomatic lymphocele after lymph node excision and radical prostatectomy.

OBJECTIVES: To identify the prognostic factors of symptomatic lymphocele. METHODS: From January 2004, 359 patients underwent pelvic lymph node excision during radical prostatectomy at our center, of whom, 347 were followed up for > or = 6 months. RESULTS: At a median follow-up of 14.5 months (range 6-54), 44 patients had developed a lymphocele (12.6%). In 26 patients (7.4%), it was symptomatic and required treatment. On univariate analysis, lymphocele was associated with the extension of the lymph node dissection, the number of nodes retrieved, and the presence of nodal metastasis. Patient age, year of surgery, surgeon, anticoagulant or antiplatelet oral therapy before and after the period of low-molecular-weight heparin prophylaxis, American Society of Anesthesiologists score, use of neoadjuvant hormonal therapy, preoperative prostate-specific antigen value, Gleason score, and pathologic stage were not influential. After adjusting for covariates, logistic regression analysis revealed that only the number of nodes was significantly associated with the onset of a symptomatic lymphocele. The risk of lymphocele seemed to increase linearly with the number of nodes retrieved, and the incidence of positive nodes reached a plateau when >10-13 nodes were harvested. CONCLUSIONS: The benefit of more extensive nodal excision during radical prostatectomy should be weighed against the increased risk of lymphocele and its sequelae, including reintervention. In our series, no other factor, including previous anticoagulant or antiplatelet therapy, neoadjuvant hormonal therapy, and surgeon experience, influenced the incidence of symptomatic lymphocele.

Bipolar transurethral resection in saline (TURis): outcome and complication rates after the first 1000 cases.

OBJECTIVE: TURis((R)) is an emerging technique that shows the same efficacy of monopolar resection. However, there is currently little available data on the safety of bipolar devices. We assessed outcome and safety of TURis on a large cohort of patients with at least 6 months' follow-up. PATIENTS AND METHODS: Between January 2006 and October 2007, 1000 consecutive transurethral resection (TUR), 376 transurethral resection of prostate, 480 transurethral resection of bladder neoplasm, and 144 transurethral incision of prostate were performed. All procedures were carried out with a bipolar device in physiologic saline (TURis). The resectoscope used was an Olympus 26F in continuous flow-type Iglesias with continuous aspiration. The loops were all disposable/single use. The incidence of unwanted stimulation of the obturator reflex, TUR syndrome, thermal skin lesion, blood transfusion, urethral strictures, and bladder neck contractures were recorded. RESULTS: None of the patients operated experienced a TUR syndrome or a thermal skin lesion. The median follow-up of the entire cohort was 12 months (range, 6-24 months); 663 patients had at least 1-year follow-up (66.3%). Urethral stricture occurred in 27 patients (2.7%). Four patients developed a bladder neck contracture after transurethral resection of prostate (1%). Early postoperative clot retention occurred in 21 patients (2.1%), and 11 patients needed one or more transfusion (1.1%). Only six patients (2%) submitted to TUR of a neoplastic lesions at the lateral bladder wall experienced an unwanted trigger of the obturator reflex. CONCLUSIONS: TURis offers the patient the same results as monopolar technology guaranteeing maximum safety without increasing the incidence of urethral strictures.