Functional Outcome and Complications following Ileal Neobladder Reconstruction in Male Patients without Tumor Recurrence. More than 35 Years of Experience from a Single Center.

PURPOSE: There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. MATERIALS AND METHODS: Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. RESULTS: Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). CONCLUSIONS: The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.

Preoperatively Dilated Ureters are a Specific Risk Factor for the Development of Ureteroenteric Strictures after Open Radical Cystectomy and Ileal Neobladder.

PURPOSE: We evaluated preoperative ureteral obstruction as a risk factor for benign ureteroenteric anastomosis strictures in patients who underwent open radical cystectomy and ileal neobladder diversion. MATERIALS AND METHODS: A total of 953 patients in whom bilateral ileoureterostomy was performed between January 1986 and March 2009 formed the study population. A nonrefluxing Le Duc technique was applied in 357 consecutive patients and a refluxing Wallace type technique was applied in 596. We defined ureteroenteric anastomosis stricture as the need for specific therapy (eg stenting, dilatation or reimplantation) or as proven loss of renal function. Kaplan-Meier analysis was done to calculate the likelihood of ureteroenteric anastomosis stricture development. RESULTS: Median followup in the study population was 65 months. Preoperatively 109 patients had unilateral or bilateral obstructed ureters. Unilateral or bilateral obstruction developed in 107 of the 953 patients (127 reno-ureteral units, including 63 on the right side and 64 on the left side). Of the reno-ureteral units 98 had benign and 29 had malignant ureteroenteric anastomosis strictures. The overall stricture rate due to any cause in preoperatively obstructed ureters was 19.3% at 10 years vs 6.4% in preoperatively undilated ureters. For the refluxing Wallace type technique the 10-year ureteroenteric anastomosis stricture rate was 2.4% for preoperatively undilated and 7.6% for preoperatively obstructed ureters. For the nonrefluxing technique the corresponding rates at 10 years were 14.2% and 35.54%, respectively. CONCLUSIONS: Preoperatively obstructed ureters are at significantly higher risk for benign ureteroenteric anastomosis strictures during the postoperative course after ileal neobladder diversion. Most such Le Duc strictures are bilateral and most such Wallace type strictures are unilateral. The risk of ureteroenteric anastomosis stricture after ureteroenterostomy using the nonrefluxing technique is threefold the risk of the refluxing technique. There was no preponderance of left ureteroenteric anastomosis strictures after each technique.

Single Center Experience with Secondary Urinary Diversion after Initial Radical Cystectomy and Primary Urinary Diversion.

PURPOSE: We evaluate the risk of a second urinary diversion in patients after radical cystectomy and urinary diversion. MATERIALS AND METHODS: We retrospectively analyzed the records of 1,614 patients who underwent urinary diversion from January 1986 to March 2009. The primary diversion was neobladder in 71.9% of male patients and 42.3% of female patients, conduit in 17.6% and 38.6%, and ureterocutaneostomy in 9.5% and 12.5%, respectively. The outcome of interest was the need for a second urinary diversion. RESULTS: A total of 51 second/third diversions in 48 patients formed the study population. Mean time from primary to second diversion was 57 months (range 0 to 286). The indication for cystectomy was oncologic in 28 patients and nononcologic in 23. Conversions were continent to continent (14), incontinent to continent (14), continent to incontinent (13) and incontinent to incontinent (10). Twelve patients had tumor recurrence impacting the initial diversion. In 8 patients the indication was abscess necrosis of the diversion or radiogenic damage. Six patients with renal failure required conversion. All patients with conversion from incontinent to continent had a strong desire to avoid a stoma. Four patients died perioperatively and short bowel syndrome developed in 1 patient. CONCLUSIONS: A second urinary diversion was required in 1.8% of patients with bladder cancer with a heterogenous etiology vs 25% when the underlying disease was nononcologic. Only men with apex sparing cystectomy and women whose bladder had not been removed achieved excellent functional outcomes for later orthotopic reconstruction.

The feasibility of ureteral tissue engineering using autologous veins: an orthotopic animal model with long term results.

BACKGROUND: In an earlier study we demonstrated the feasibility to create tissue engineered venous scaffolds in vitro and in vivo. In this study we investigated the use of tissue engineered constructs for ureteral replacement in a long term orthotopic minipig model. In many different projects well functional ureretal tissue was established using tissue engineering in animals with short-time follow up (12 weeks). Therefore urothelial cells were harvested from the bladder, cultured, expanded in vitro, labelled with fluorescence and seeded onto the autologous veins, which were harvested from animals during a second surgery. Three days after cell seeding the right ureter was replaced with the cell-seeded matrices in six animals, while further 6 animals received an unseeded vein for ureteral replacement. The animals were sacrificed 12, 24, and 48 weeks after implantation. Gross examination, intravenous pyelogram (IVP), H&E staining, Trichrome Masson's Staining, and immunohistochemistry with pancytokeratin AE1/AE3, smooth muscle alpha actin, and von Willebrand factor were performed in retrieved specimens. RESULTS: The IVP and gross examination demonstrated that no animals with tissue engineered ureters and all animals of the control group presented with hydronephrosis after 12 weeks. In the 24-week group, one tissue engineered and one unseeded vein revealed hydronephrosis. After 48 weeks all tissue engineered animals and none of the control group showed hydronephrosis on the treated side. Histochemistry and immunohistochemistry revealed a multilayer of urothelial cells attached to the seeded venous grafts. CONCLUSIONS: Venous grafts may be a potential source for ureteral reconstruction. The results of so far published ureteral tissue engineering projects reveal data up to 12 weeks after implantation. Even if the animal numbers of this study are small, there is an increasing rate of hydronephrosis revealing failure of ureteral tissue engineering with autologous matrices in time points longer than 3 months after implantation. Further investigations have to prove adequate clinical outcome and appropriate functional long-term results.

15-year history of spontaneous appendico-vesical fistula (case report).

Appendicovesical (AVF) fistula is rare complication in the modern era. Only a few cases of AVF were described in the literature of the last decade. AVF is meanly associated with a history of appendicitis. The guiding symptoms are coprosuria and pneumaturia, with recurrent infection of the urinary tract. The accurate pre-operative diagnosis is difficult to make. It usually took at least one year from the onset of symptom to confirm diagnosis. It has been reported a few cases of 15 year history of undiagnosed AVF. We represent a case of EVF, spontaneously developed after treated acute appendicular colic presenting an unusual long - 15 years undiagnosed history, without presenting of typical symptoms. The analyses of disease history after cystoscopy lead to correct pre-operative diagnosis. AVF can develop as a complication not only after untreated appendicitis, but also after "successfully" treated with antibiotics appendicular colic may indicate the presence of an AVF and needs to assessing patient's history and applying cystoscopy and modern examination methods in complex diagnosis issues.

Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients.

BACKGROUND: The optimal treatment strategy for muscle-invasive bladder cancer (BCa) remains controversial. OBJECTIVE: Better define the long-term outcomes of radical cystectomy (RC) alone for BCa and determine the impact of pathologic downstaging after transurethral resection in a large and homogeneous single-center series. DESIGN, SETTING, AND PARTICIPANTS: A cohort of 1100 patients undergoing RC with pelvic lymph node dissection (PLND) without neoadjuvant therapy for urothelial carcinoma of the bladder between January 1, 1986, and December 2009 was evaluated. Patients with other than metastases to the pelvic lymph nodes were excluded. Median age was 65 yr. Clinical course, pathologic characteristics, and long-term outcomes were evaluated. Follow-up was obtained until December 2009 with a median of 38 mo and a completeness of 96.5%. INTERVENTION: RC with PLND; urinary diversion with ileal neobladder whenever possible. MEASUREMENTS: Primary end points were disease-specific survival (DSS), recurrence-free survival (RFS), and overall survival (OS) according to the tumor stage of the RC specimen versus the maximum tumor stage. The log-rank test was used to compare subgroups. RESULTS AND LIMITATIONS: The 30-d (90-d) mortality rate was 3.2% (5.2%). The 10-yr OS, DSS, and RFS rates were 44.3%, 66.8%, and 65.5%, respectively. Based on the tumor stage of the RC specimen, the 10-yr DSS rate was pT0/a/is/1 pN0: 90.5%, pT2a/b pN0: 66.8%, pT3a/b pN0: 59.7%, pT4a/b pN0: 36.6%, and pTall pN+: 16.7%. Downstaging by transurethral resection of the prostate was observed in 382 patients. Patients with maximum tumor stage pT2a/b pN0 had distinctly better 10-yr DSS rates than those with pT2a/b pN0 in the RC specimen: pT2a pN0: 92.2% versus 73.8%; pT2b: 75.0% versus 62.0%. A total of 49% female and 80% male patients received an ileal neobladder. CONCLUSIONS: This contemporary and homogeneous single-center series found acceptable OS, DFS, and RFS for patients undergoing RC. Pathologic downstaging had a significant impact on survival.

The ileal neobladder in female patients with bladder cancer: long-term clinical, functional, and oncological outcome.

PURPOSE: To assess long-term clinical and oncological outcome in women undergoing radical cystectomy and ileal neobladder reconstruction for invasive bladder cancer. METHODS: From 1995 to 2010, a total of 121 women with clinically organ-confined urothelial carcinoma underwent radical cystectomy with an orthotopic ileal neobladder. Median follow-up was 56 months. Clinical course, functional, pathological, and oncological outcome of these women were analyzed. RESULTS: Seventy-six patients (62.8%) experienced a complication of some type within 90 days of the procedure. 56 patients (46.3%) experienced minor complications, whereas 20 patients (16.5%) experienced major complications. Pathological subgroups included 70 patients (57.9%) with organ confined, lymph node-negative tumors, 24 (19.8%) with extravesical, lymph node-negative disease and 27 (22.3%) patients with lymph node-positive disease. The 5-year overall survival rate in patients with organ-confined (≤pT2, pN0), locally advanced (≥pT3, pN0), and metastatic disease was 80.2%, 81.9%, and 45.1%, respectively. 4 women (3.3%) experienced a local (pelvic) recurrence. One patient presented with a urethral recurrence (0.8%). Daytime and nighttime urinary continence (0-1 pad) was reported by 82.4 and 76.5%, respectively. Clean intermittent self-catheterization was required by 58.0%. The retrospective study design was the major limitation of the study. CONCLUSIONS: Despite a considerable complication rate, radical cystectomy with orthotopic diversion in female patients with bladder cancer may be considered a standard therapeutic option for selected patients with excellent oncological outcome including a low incidence of local and urethral recurrence.

Partial nephrectomy using porcine small intestinal submucosa.

BACKGROUND: Whenever technically feasible and oncologically justified, nephron-sparing surgery is the current standard of care for localized renal cell carcinomas (RCC). The main complications of partial nephrectomy, especially for large and centrally located tumors, are urinary leakage and parenchymal bleeding. We prospectively evaluated the pros and cons of using porcine small intestinal submucosa (SIS, Surgisis®) to close the renal defect after nephron-sparing surgery. METHODS: We used Surgisis® (Cook medical, Bloomington, IN, USA) to secure and compress the capsular defect after tumor resection in 123 patients submitted to 129 partial nephrectomies between August 2003 and February 2011. RESULTS: The median tumor size was 3.7 cm (range 1.1-13.0 cm). Procedures were performed with cold ischemia in 24 cases (18.2%), with warm ischemia in 46 (35.6%), and without ischemia in 59 cases (44.8%). In the total group of patients, 4 (3.1%) developed urinary fistula, and only 2 (1.6%) required postoperative transfusions due to hemorrhage after the application of the small intestinal submucosa membrane. CONCLUSION: Small intestinal submucosa is an easy-to-use biomaterial for preventing complications such as postoperative bleeding and urinary fistula in nephron-sparing surgery, especially in cases where tumor excision causes significant renal capsular and/or renal pelvic defects.

25 years of experience with 1,000 neobladders: long-term complications.

PURPOSE: We analyzed the long-term complications (greater than 90 days postoperatively) in a large, single center series of patients who underwent cystectomy and substitution with an ileal neobladder. MATERIALS AND METHODS: A total of 1,540 radical cystectomies were performed at our center between January 1986 and September 2008. Of the patients 1,013 received an ileal neobladder. Only the 923 patients with followup longer than 90 days (median 72 months, range 3 to 267) were included in analysis. All long-term complications were identified. The complication rate was calculated using the Kaplan-Meier method. RESULTS: The overall survival rate was 65.5%, 49.8% and 28.3% at 5, 10 and 20 years, respectively. The overall long-term complication rate was 40.8% with 3 neobladder related deaths. Hydronephrosis, incisional hernia, ileus or small bowel obstruction and feverish urinary tract infection were observed in 16.9%, 6.4%, 3.6% and 5.7% of patients, respectively, 20 years postoperatively. Subneovesical obstruction in 3.1% of cases was due to local tumor recurrence in 1.1%, neovesicourethral anastomotic stricture in 1.2% and urethral stricture in 0.9%. Chronic diarrhea was noted in 9 patients. Vitamin B12 was substituted in 2 patients. Episodes of severe metabolic acidosis occurred in 11 patients and 307 of 923 required long-term bicarbonate substitution. Rare complications included cutaneous neobladder fistulas in 2 cases, and intestinal neobladder fistulas, iatrogenic neobladder perforation, spontaneous perforation and necrotizing pyocystis in 1 each. CONCLUSIONS: Even in experienced hands the long-term complication rate of radical cystectomy and neobladder formation are not negligible. Most complications are diversion related. The challenge of optimum care for these elderly patients with comorbidities is best mastered at high volume hospitals by high volume surgeons.

Lessons learned from 1,000 neobladders: the 90-day complication rate.

PURPOSE: We report the 90-day morbidity of the ileal neobladder in a large, contemporary, homogenous series of patients who underwent radical cystectomy at a tertiary academic referral center using a standard approach. MATERIALS AND METHODS: Between January 1986 and September 2008 we performed 1,540 radical cystectomies. A total of 281 patients had an absolute contraindication for orthotopic reconstruction. The remaining 1,259 patients were candidates for a neobladder. Of these patients 1,013 (66%) finally received a neobladder and form the basis of this report. All patients had a thorough followup until December 2008 or until death. All complications within 90 days of surgery were defined, categorized and classified by an established 5 grade and 11 domain modification of the original Clavien system. RESULTS: Of 1,013 patients 587 (58%) experienced at least 1 complication within 90 days of surgery. Infectious complications were most common (24%) followed by genitourinary (17%), gastrointestinal (15%) and wound related complications (9%). The 90-day mortality rate was 2.3%. Of the patients 36% had minor (grade 1 to 2) and 22% had major (grade 3 to 5) complications. On univariate analysis the incidence and severity of the 90-day complications rate correlate highly significantly with age, tumor stage, American Society of Anesthesiologists score and preoperative comorbidity. CONCLUSIONS: Radical cystectomy and ileal neobladder formation represent a major surgery with potential relevant early complications even in the most experienced hands. The rate of severe and lethal complications is acceptably low.

Laparoscopic partial nephrectomy with selective control of the renal parenchyma: initial experience with a novel laparoscopic clamp.

OBJECTIVE: To report a laparoscopic device that facilitates regional ischaemia in laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Mimicking the shape of a clamp successfully applied in open PN, we developed a laparoscopic device that allows selective clamping in LPN. After obtaining transperitoneal access to the renal mass, the laparoscopic clamp was placed around the tumour 1-2 cm proximal to the line of resection. After excising the tumour, haemostasis was mainly achieved by applying a haemostyptic agent. RESULTS: Three patients with elective indications had LPN using this novel laparoscopic clamp. The tumours were in the upper and lower pole of the kidney in one and two patients, respectively. The tumour diameter was 2.4, 2.6 and 3.2 cm, and the selective clamping time 23, 27 and 38 min. Blood loss was minimal in all three cases, with no complications after LPN. The final pathology showed a papillary and clear cell renal carcinoma in two and one patients, respectively. There were no positive margins on histological assessment. CONCLUSION: LPN with clamping of the renal parenchyma using this novel device can be used in selected patients with peripheral tumours. Resection of the tumour in a bloodless field is possible. The main advantage is that ischaemia occurs only in the renal parenchyma next to the tumour, facilitating nephron-sparing surgery without being pressed for time.

Neobladder formation after pelvic irradiation.

OBJECTIVE: To assess the results of the use of the ileal neobladder in patients with previous pelvic irradiation. METHODS: Between January 1986 and July 2008, 1,570 radical cystectomies and 1,002 ileal neobladders were performed at a single institution. From this series, 94 patients (6%) with prior pelvic irradiation were retrospectively identified. In 25 of these irradiated patients, an ileal neobladder was done. All complications within 90 days of surgery were defined and graded using a five-grade modification of the original Clavien system and stratified into 11 categories. Functional outcome data and late complications were reported. RESULTS: Seventy-six percent of the neobladder patients versus 52% of the non-neobladder patients developed complications occurring within 90 days of surgery. However, grade 3-5 complications were less frequent in the neobladder group. Unusual and serious late complications have been observed. Nineteen out of 25 neobladder patients enjoy perfect night and day time continence. Three out of seven female and 1/18 male patients suffer from treatment refractory severe stress incontinence. One male and one female patients are primarily hypercontinent. CONCLUSIONS: Salvage surgery (cystoprostatectomy, anterior exenteration) followed by orthotopic lower urinary tract reconstruction can be a safe, effective procedure that can provide a well functioning lower urinary tract in properly selected patients with defunctionalized bladder, tumor recurrence or de novo bladder cancer after definitive radiation therapy. Prerequisits for the neobladder as procedure of choice are good renal function, perfect preoperative continence, no recurrent gastrointestinal or gynecologic tumor, no fistula formation, and no severe damage of the small bowel.

[11C]Choline PET/CT for targeted salvage lymph node dissection in patients with biochemical recurrence after primary curative therapy for prostate cancer. Preliminary results of a prospective study.

INTRODUCTION: In this prospective study we set out to investigate the diagnostic value of [(11)C]choline-PET/CT in patients with suspected lymph node metastases before salvage lymph node dissection. PATIENTS AND METHODS: 15 consecutive patients with rising PSA underwent [(11)C]choline-PET/CT and consecutive open salvage pelvic/retroperitoneal extended lymph node dissection due to uptake of [(11)C]choline in at least 1 lymph node. Mean age was 62.1 (range 53-73). RESULTS: [(11)C]choline-PET/CT results were compared with the histopathology reports and clinical follow-up (mean 13.7 months, range 6-24). Mean time to progression was 23.6 months (range 4-81). [(11)C]choline uptake was observed in nodes along the external and internal and common iliac arteries and in the paraaortic region. A positive histology was reported in 8/15 patients. Only one patient had a PSA nadir of <0.1 ng/ml after salvage surgery. Another patient had stable disease with a PSA of 0.5 ng/ml. Three patients developed bone metastases during follow-up. CONCLUSIONS: This interim analysis indicates that [(11)C]choline-PET/CT may be a useful technique in detection of lymph node metastases when rising PSA occurs after definite prostate cancer therapy. The presented cohort is limited in size, but there is still strong evidence that the patients benefit from [(11)C]choline-PET/CT and consecutive salvage lymph node dissection is rather small.

Novel technique for in situ cold perfusion in laparoscopic partial nephrectomy.

BACKGROUND: Following clamping of the renal hilus, warm ischemia is an issue in laparoscopic partial nephrectomy. If ischemia longer than 30 min is anticipated, special protective measures are needed. The aim of this study was to develop a solely laparoscopic technique for in situ cold perfusion of kidneys during laparoscopic partial nephrectomy to increase the tolerance of renal parenchyma to ischemic damage in a porcine model. METHODS: Six animals were used in this study. We tried to develop a technique that allowed us to cannulate the renal artery, introduce a catheter to perform an in situ cold perfusion and-the most important feature-secure the catheter throughout the laparoscopic partial nephrectomy. RESULTS: A modified laparoscopic vascular bulldog clamp was ultimately ideal to fulfil expectations. In five pigs, a successful partial nephrectomy in in situ perfusion was performed. The median warm ischemia time, starting from occlusion of the renal artery and vein to the commencement of cold perfusion, was 130 s (range 75-165 s). The subsequent median cold ischemia time in which a partial nephrectomy was simulated was 42 min (range 26-52 min). CONCLUSIONS: The newly developed technique expands the armamentarium of the urologist in laparoscopic partial nephrectomy, if the anticipated time of ischemia exceeds 30 min and renal hypothermia is indicated.

Optimized haemostasis in nephron-sparing surgery using small-intestine submucosa.

BACKGROUND: The indications for nephron-sparing surgery are expanding constantly. One major contributing fact for this development is the improvement of haemostatic techniques following excision of the tumor. Nevertheless, postoperative bleeding complications still occur. To prevent this, we prospectively studied the effect of application of small-intestine submucosa (SIS) over the renal defect. METHODS: We performed 55 nephron-sparing surgeries applying SIS between 08/03 and 10/06 in 53 pts. (mean age: 59 yrs., range 29 - 79 yrs.). After resection of the renal tumor and application of a haemostyptic agent, we used SIS to secure and apply compression on the defect. RESULTS: The final pathology revealed clear-cell and papillary carcinoma, papillary adenoma, oncocytoma, and angiomyolipoma in 39 (70.9%), 6 (10.9), 1 (1.8%), 2 (3.6%) and 7 (12.7%) patients, respectively. The 45 malignant lesions (81.8%) were classified as pT1a and pT1b in 35 (77.8%) and 10 (22.2%) patients, respectively. The median tumor size was 4.5 cm (range: 1.3 - 13 cm). The median operating time was 186 min (range: 90 - 260 min). 18 (32.7%) procedures were performed without ischemia. 23 (41.8%) and 14 (25.5%) cases were operated in in-situ cold and warm ischemia, respectively. The median intraoperative blood loss was 730 cc (range: 100 - 2500 cc). No open operative revision was indicated due to postoperative bleeding complications. Furthermore, there was no necessity to substitute persistent blood loss from the drains postoperatively. No urinoma occurred. CONCLUSION: SIS is a highly effective and easy-to-use instrument for preventing postoperative bleeding and urinary fistula complications in nephron-sparing surgery.

Hydronephrosis as a prognostic marker in bladder cancer in a cystectomy-only series.

OBJECTIVES: Hydronephrosis in patients with bladder cancer is caused by tumour at the ureteral orifice, secondary ureteral tumours, intramural or extravesical tumour infiltration, or compression of the ureter. This study investigated the prognostic impact of hydronephrosis in bladder cancer. METHODS: A series of 788 patients were treated with radical cystectomy with curative intent for transitional cell carcinoma of the bladder without neoadjuvant/adjuvant radiotherapy/chemotherapy between January 1986 and September 2003. All patients had a complete follow-up until death or until the study's end date. Survival rates were calculated using the Kaplan-Meier method. A multivariate analysis with a Cox regression model was performed with respect to potential influencing factors. RESULTS: A total of 108 patients (13.7%) had unilateral and 25 patients (3.2%) had bilateral hydronephrosis. The rate of organ-confined tumours was significantly higher in patients without hydronephrosis (67.9% vs. 37.6%; p<0.001). Forty-three (32.3%) of the 133 hydronephrotic patients had a tumour involving the ureteral orifice. In this group the rate of organ-confined tumours was significantly higher than in the other patients with hydronephrosis (53.5% vs. 30.0%; p=0.009). In the multivariate analysis, preoperative hydronephrosis was determined as an independent prognostic marker for recurrence-free survival besides the pT classification and lymph node status (p=0.0015). The etiology of hydronephrosis did not affect the tumour-specific survival. CONCLUSIONS: Hydronephrosis at the time of diagnosis of bladder cancer is associated with a high probability of advanced tumours. It is an independent prognostic factor for recurrence-free survival.

Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era.

PURPOSE: We studied the effect of radical cystectomy for transitional cell carcinoma of the bladder on survival and failure patterns when the 2 surgical standards cystectomy and neobladder were combined, when possible. MATERIALS AND METHODS: A consecutive series of patients undergoing radical cystectomy with pelvic lymph node dissection for transitional cell carcinoma of the bladder with curative intent was analyzed. Patients with neoadjuvant radiotherapy/chemotherapy were excluded. Pathological characteristics based on the 2002 TNM system, recurrence-free/overall survival and metastatic patterns were determined. RESULTS: A total of 788 patients with a mean age +/- SD of 65 +/- 10 years and a mean followup of 53.5 months who underwent surgery between 1986 and 2003 were analyzed. A neobladder was constructed in 75.4% of patients. Ten-year recurrence-free and overall survival rates were 59.1% and 44.9%, respectively. Positive lymph nodes were present in 143 patients (18%). The rate of recurrence-free survival at 5 years was 82.5% for pT2a pN0, 61.9% for pT2b and pT3a pN0, and 53.1% for pT3b pN0 disease. Local and distant failure rates were 4% and 9.5% for organ confined tumors, 15.9% and 19.2% for nonorgan confined tumors, and 20.4% and 45.1% in patients with positive lymph nodes, respectively. CONCLUSIONS: In patients with organ confined, lymph node negative transitional cell carcinoma excellent survival data can be achieved as long as the tumor is limited to the inner half of the detrusor. These data on a large group of patients support early aggressive surgical management for invasive bladder cancer. The results of this surgery only series may serve as a reference for other treatment modalities for bladder cancer.

Effect of a pT0 cystectomy specimen without neoadjuvant therapy on survival.

BACKGROUND: In some cases of radical cystectomy for bladder cancer, no residual tumor is found in the cystectomy specimen (the pT0 classification). The aim of this study was to evaluate the outcome of such patients in a large cystectomy series. METHODS: All 900 patients with radical cystectomy and pelvic lymphadenectomy for TCC of the bladder in the period January 1986 to September 2003 who received no neoadjuvant therapy were included. Cystectomy specimens from 181 (20.1%) patients were graded as pT0. Complete follow-up was obtained in all cases. Tumor-specific survival (pT0 vs. pT+) was calculated with the Kaplan-Meier method and compared with the log-rank test. RESULTS: The rate of lymph node metastases in the pT0 group was 6.6%. pT0 status was found with Ta/is/1 in 36.8%, T2a in 41.8%, and T2b in 10.9%. The 169 patients with pT0pN0 tumors had 10-year tumor-specific survival rates of 91.0. There was no statistically significant survival benefit for pT0pN0 tumors compared with pT+pN0 tumors for maximal tumor classifications of pTa/pTis/pT1 and pT2b, but patients with a pT0T2apN0 tumor had a statistically significantly better tumor-specific survival than those with a pT2apN0 tumor (P = 0.002). No patient with a pT0pN0 tumor had a local recurrence. The rate of incidental second primary malignancies in a specimen was 15.5%. CONCLUSIONS: A pT0pN0 cystectomy specimen indicates a curative therapy, but there is a substantial risk of tumor recurrence. In the group of tumors with a maximal classification of pT2a, the pT0 tumors constitute a subgroup with a significantly higher likelihood of survival.

Orthotopic ileal neobladder reconstruction in patients with bladder cancer following renal transplantation.

PURPOSE: We analyzed the safety and clinical outcome in a single institution experience with orthotopic ileal neobladder reconstruction following radical cystectomy for transitional cell carcinoma in renal transplant recipients. MATERIALS AND METHODS: From April 1986 to December 2003 radical cystectomy and orthotopic ileal neobladder reconstruction were performed in 760 consecutive patients with bladder cancer, of whom 4 had bladder cancer a median of 10.5 years after renal transplantation. The postoperative clinical course and long-term results in these patients were reviewed. RESULTS: Median followup after surgery was 51.5 months (range 11 to 118). Two patients died at 11 and 15 months of tumor progression and a pulmonary embolism, respectively, whereas 2 were alive at a mean followup of 90 months with no evidence of disease. No neobladder related reoperations were necessary. Serum creatinine as a marker of renal function was stable in 3 patients. In 1 patient chronic graft rejection led to progressive renal failure and hemodialysis. Urinary continence was satisfactory during the day and night with spontaneous voiding in all patients and no significant post-void residual urine. CONCLUSIONS: To our knowledge this is the largest reported series of orthotopic ileal neobladder replacement following radical cystectomy in renal transplant recipients. Our results demonstrate the feasibility of radical cystectomy and orthotopic urinary reconstruction in patients with a renal transplant who have good functional and oncological results despite the high comorbidity in this group.

Pregnancy in women with ureterosigmoidostomy.

OBJECTIVES: To review our experience with four pregnancies during the past 5 years with special attention to the diagnostic and therapeutic aspects of ureterosigmoidostomy. Pregnancy in women with ureterosigmoidostomy is a rare condition that differs in many ways from pregnancies in women with other forms of urinary diversion. METHODS: From 1995 to 2000, we observed four pregnancies in 3 women with ureterosigmoidostomy. Two women had had bladder exstrophy, and one had had interstitial cystitis. During pregnancy, we performed urologic examinations every 4 weeks with renal ultrasonography, calculation of the resistive index, and tests of serum electrolytes, urea, creatinine, and blood gas analysis. In all pregnancies, antibiotic prophylaxis was performed. RESULTS: All women had recurring urinary tract infections before pregnancy. In all cases, reversible dilation of the upper urinary tract was observed during pregnancy. The resistive index never increased to a pathologic range (greater than 0.7). With administration of sodium-potassium-hydrogen citrate, no acidosis was observed. With antibiotic prophylaxis, the women only had one episode each of urinary tract infection during pregnancy. One patient developed preeclampsia that led to a cesarean section at week 36 of gestation. Delivery was achieved by cesarean section in two more cases and vaginally in 1 case. We did not observe any postpartum or neonatal complications related to pregnancy. CONCLUSIONS: Under regular urologic and gynecologic control, there is no contraindication to pregnancy in patients with ureterosigmoidostomy. Antibiotic prophylaxis seems to be recommended.