Cystectomy

Objectives. To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion. Methods. Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-m holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes. Results. With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures. Conclusions. Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate. UROLOGY 58: 924-929, 2001.

Multiple prospective Radiation Therapy Oncology Group (RTOG) protocols have evaluated bladder-preserving combined-modality therapy (CMT) for muscle-invasive bladder cancer (MIBC), reserving cystectomy for salvage treatment. We performed a pooled analysis of long-term outcomes in patients with MIBC enrolled across multiple studies. Four hundred sixty-eight patients with MIBC were enrolled onto six RTOG bladder-preservation studies, including five phase II studies (RTOG 8802, 9506, 9706, 9906, and 0233) and one phase III study (RTOG 8903). Overall survival (OS) was estimated using the Kaplan-Meier method, and disease-specific survival (DSS), muscle-invasive and non-muscle-invasive local failure (LF), and distant metastasis (DM) were estimated by the cumulative incidence method. The median age of patients was 66 years (range, 34 to 93 years), and clinical T stage was T2 in 61%, T3 in 35%, and T4a in 4% of patients. Complete response to CMT was documented in 69% of patients. With a medi...

1 What ' s known on the subject? and What does the study add? Bladder cancer is one of the costliest malignancies to treat throughout the life of a patient. The most cost-effective management for low -risk non-muscle-invasive bladder cancer is not known.

Background: The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre-defined the definition of ''high'' and ''low'' volume surgeons. Aim: To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon's outcomes. Methods: All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon's annual case volume and two outcome measures: in-hospital mortality rate, and hospital stay. The surgeon's outcomes were then analysed with respect to the overall level of activity in their operating centre. Results: A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (20.968, p,0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate. Conclusion: Analysis of HES data confirms an inverse relationship between surgeon's caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.

Cancer Committee of the French Association of Urology (CCAFU) conducted a review of the epidemiology, diagnosis and treatment of intradiverticular bladder tumours (TVID) and proposed therapeutic management. A bibliographic research in French and English using Medline(®) with the keywords "tumor", "bladder" and "diverticulum" was performed. TVID are more frequently of stage T ≥ 3a and with non urothelial histology than classical bladder tumors. At diagnosis, the risk of underestimation of the extent and multifocality of the tumor was described. Their prognosis, that was more pejorative than conventional tumors, should impelled to limit the indications of conservative treatment. The evidence levels of analyzed publications were low, with C level according to Sackett score. the specificities of the TVID have lead the CCAFU to propose specific therapeutic guidelines, based on poor evidence level. Ta-T1 low grade TVID can be treated by transurethral resectio...

For other articles on a related topic see pages 741 and 749. Purpose: We compared 3 predictive models for survival after radical cystectomy, risk group stratification, nomogram and artificial neural networks, in terms of their accuracy, performance and level of complexity. Materials and Methods: Between 1996 and 2002, 1,133 patients were treated with single stage radical cystectomy as monotherapy for invasive bladder cancer. A randomly selected 776 cases (70%) were used as a reference series. The remaining 357 cases (test series) were used for external validation. Survival estimates were analyzed using univariate and then multivariate appraisal. The results of multivariate analysis were used for risk group stratification and construction of a nomogram, whereas all studied variables were entered directly into the artificial neural networks. Results: Overall 5-year disease-free survival was 64.5% with no statistical difference between the reference and test series. Comparisons of the 3 predictive models revealed that artificial neural networks outperformed the other 2 models in terms of the value of the area under the receiver operator characteristic curve, sensitivity and specificity, as well as positive and negative predictive values. Conclusions: In this study artificial neural networks outperformed the risk group stratification model and nomogram construction in predicting patient 5-year survival probability, and in terms of sensitivity and specificity.

Purpose: We evaluated the survival of patients with muscle invasive bladder cancer undergoing radical cystectomy without neoadjuvant chemotherapy to confirm the utility of existing clinical tools to identify low risk patients who could be treated with radical cystectomy alone and a high risk group most likely to benefit from neoadjuvant chemotherapy. Materials and Methods: We identified patients with muscle invasive bladder cancer who underwent radical cystectomy without neoadjuvant chemotherapy at our institution between 2000 and 2010. Patients were considered high risk based on the clinical presence of hydroureteronephrosis, cT 3b -T 4a disease, and/or histological evidence of lymphovascular invasion, micropapillary or neuroendocrine features on transurethral resection. We evaluated survival (disease specific, progression-free and overall) and rate of pathological up staging. An independent cohort of patients from another institution was used to confirm our findings. Results: We identified 98 high risk and 199 low risk patients eligible for analysis. High risk patients exhibited decreased 5-year overall survival (47.0% vs 64.8%) and decreased disease specific (64.3% vs 83.5%) and progression-free (62.0% vs 84.1%) survival probabilities compared to low risk patients (p <0.001). Survival outcomes were confirmed in the validation subset. On final pathology 49.2% of low risk patients had disease up staged.

Bien que le placenta percreta reste une pathologie rare, sa fréquence tend à augmenter avec celle des césariennes. Ce sont donc des situations auxquelles les obstétriciens vont être de plus en plus souvent confrontés or il peut entraîner un risque vital ou au minimum fonctionnel. Nous rapportons le cas d'une patiente qui présentait un placenta percreta avec envahissement vésical et les modalités de sa prise en charge ainsi que la revue de la littérature. Le traitement conservateur, au moins dans un premier temps, est fortement recommandé pour limiter les conséquences. Il se fera au moyen de ligatures vasculaires, d'embolisation et/ou d'un traitement médical par Méthotréxate. La prise en charge peut être prévue grâce aux moyens de détection échographiques qui doivent être disponibles dans les populations à risque.

Pelvic surgeries are among the most common causes of organic sexual dysfunction in men and women. The impact of nerve-sparing surgery on potency has been well documented in radical prostatectomy. However, its impact on potency needs to be evaluated in other pelvic surgeries. Sexual dysfunction is highly prevalent even after multiple technical advances in the field of oncological surgeries. The prevalence varies from 8 to 82%, depending on the type of pelvic surgery. In females, sexual dysfunction has not been evaluated adequately using validated questionnaires. However, in subspecialized circles, treatment for female sexual dysfunction is becoming routine. Currently, physicians have several options for the treatment of erectile dysfunction (ED) in men. Since the introduction of oral PDE-5 inhibitors, oral therapy has become the first-line treatment option for ED, irrespective of etiology. Currently available treatment options for the female sexual dysfunction include estrogens, androgens, phosphodiesterase inhibitors, and dopamine receptor antagonists. Initial reports regarding the role of early rehabilitation are encouraging and may become the part of routine practice in the management of ED after pelvic surgery. In this article, we summarize the sexual dysfunction following pelvic surgeries and their management.

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m Abstract Context: Pathology standards for the diagnosis of bladder cancer (BCa) have recently evolved to better reflect patient diagnosis and clinical outcomes. Objective: To update pathology reporting standards for BCa. Evidence acquisition: We searched the international medical literature and reviewed all articles that addressed BCa gross dissection, pathologic diagnosis, staging, and reporting * Corresponding author.

An ileal conduit is the most common urinary diversion following radical cystectomy for invasive bladder cancer. Unlike internal complications commonly described in urological literature, reports about the incidence of external complications are sparse. A Medline database review (1996-2008) of English-language literature was conducted to: 1) describe and compare external stoma and peristomal complications and complication rates among outpatients with ileal conduit diversion following radical cystectomy, and 2) summarize commonly used prevention and management strategies. Fourteen publications (mostly retrospective, single-center studies) met inclusion criteria. The reported incidence of complications ranged from 15% to 65%. Divided according to pathogenesis, the most commonly reported complications are 1) stoma or abdominal wall-related changes--parastomal hernia, stoma prolapse, stenosis, and retraction; and 2) peristomal skin changes--chemical injury: irritant contact dermatitis, p...

Purpose: Enhanced recovery after surgery protocols aim to improve patient care and decrease complications and hospital stay. We evaluated our enhanced recovery after surgery protocol, focusing on length of stay, early complication and readmission rates after radical cystectomy for bladder cancer. Materials and Methods: From May 2012 to July 2013 a perioperative protocol was applied in 126 consecutive patients who underwent open radical cystectomy and urinary diversion. Nonconsenting patients (2), those with previous diversion (2) and prolonged postoperative intubation (3), and those who underwent additional surgery (9) were excluded from study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and m-opioid antagonists. Outcomes were compared to those in matched controls from our bladder cancer database. Results: A total of 110 patients with a median age of 69 years were included in analysis, of whom 68% underwent continent urinary diversion. Of the patients 82% had a bowel movement by postoperative day 2. Median length of stay was 4 days. The 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion in 19% of patients, urinary tract infection in 13% and dehydration in 10%. The latter 2 complications were the most common etiologies for readmission. The 30-day readmission rate was 21% (23 patients). Patients 75 years old or older had a longer length of stay (5 vs 4 days, p ¼ 0.03) and a higher minor complication rate (72% vs 51%, p ¼ 0.04) than younger patients. Conclusions: Our enhanced recovery after surgery protocol expedites bowel function recovery and shortens hospital stay after RC and urinary diversion without an increase in the hospital readmission rates. Abbreviations and Acronyms ERAS ¼ enhanced recovery after surgery LOS ¼ length of hospital stay POD ¼ postoperative day POI ¼ postoperative ileus RC ¼ radical cystectomy TPN ¼ total parenteral nutrition

Purpose:To developa Korean version of the Functional Assessment of Cancer Therapy(FACT)-Vanderbilt Cystectomy Index (VCI) from the original English version,with subsequent linguistic validationin Korean patients who underwent radical cystectomy with urinary diversion.

KEY WORDS: bladder diseases; cystectomy; urinary reservoirs, continent; urinary diversion Currently, the classical, time-honored ileal conduit as well as the stoma1 continent urinary diversions have given way to the increasingly frequent use of replacement cystoplasty. In 1852 Simon performed the first continent urinary diversion in a form of ureterorectal anastomosis on a paitent with ectopia vesicae' and in 1913 Lemoine reported the first true clinical use of a rectal bladder.2 This and most of the following attempts would be tempered by a high surgical mortality rate. In 1951 Couvelaire reported the first clinical use of bladder substitution, which was followed by only sporadic reports on this method.3 Since Kock et a1 in 1982 reported on their pioneering experience with the use of an ileal segment for the construction of a continent reservoir: we have witnessed an explosion of interest in continent urinary reconstructions via the cutaneous and urethrally anastomosed forms. The number of variants currently average more than 40 worldwide.4-7

Recently, nonabsorbable staples have been safely used in a variety of urologic open and laparoscopic extirpative and reconstructive procedures. We report the surgical steps of our technique of U-shaped orthotopic ileal neobladder created with titanium staples. Technical Considerations. Using stay stitches, a 45 to 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and an afferent limb of 5 or 10 cm. An opening is made at the lowest point of the U-ileal segment on its antimesenteric border. The jaws of the 80 ϫ 3.5-mm nonabsorbable mechanical stapler are accommodated within the bowel loop and fired twice, bringing together and detubularizing approximately 15 cm of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom of the chimney on its medial border. After this, a third nonabsorbable mechanical stapler had its jaws introduced through this opening and through the open end of the bowel segment on the right side and the stapler is fired, completing the U pouch. Subsequently, the open ends of the U segment and the opening made at the base of the afferent limb are closed with absorbable running sutures. Conclusions. Our technique is feasible and may represent an alternative to expand the spectrum of continent urinary reservoirs that could be expeditiously created with nonabsorbable staples. Continued surveillance is mandatory to determine the lithiasis-inducing potential of these titanium staples within the urinary tract. UROLOGY 68: 193-197, 2006.

Context: The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer. Objective: This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure. Evidence acquisition: A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups. Evidence synthesis: Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered. Conclusions: Although age alone does not preclude radical cystectomy for muscleinvasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.

To analyze the complications after robot-assisted radical cystectomy (RARC) by use of a standardized reporting methodology by a single surgeon. We prospectively reviewed a maintained institutional database of 52 patients who underwent RARC to manage bladder cancer and were followed up in 3 months by a single surgeon at Korea University Medical Center from 2007 through 2014. All complications within 90 days of surgery were defined and categorized into 5 grades according to the Clavien-Dindo classification. Logistic regression analysis was used to identify predictors of complications. Fifty percent of patients (26 of 52) experienced a complication of any grade &lt;90 days after surgery, and 11 patients (21.2%) experienced a major complication. Complications were grouped in systems-based categories. Fifty complications occurred in 52 patients and hematologic complication (transfusion) was the most common (13 of 52). Wound dehiscence, anastomotic leakage, urinary tract obstruction, mech...

La cystite interstitielle (CI) est une pathologie de la vessie qui reste largement méconnue du monde médical français. Cette pathologie touche plus les femmes que les hommes. L'étiologie de la CI reste indéterminée. Les différentes études suggèrent que sa physiopathologie est multifactorielle. Le diagnostic de la CI doit être suspecté par le clinicien sur les données de l'interrogatoire. La confirmation de ce diagnostic, qui reste un diagnostic d'élimination repose sur une série d'examens dont le but est d'écarter d'autres pathologies. Aucun test pathognomonique de la CI n'est disponible. La méconnaissance de la physiopathologie rend les traitements empiriques. Un algorithme décisionnel est proposé à la fin de cet article.

The role of surgery in the treatment of patients with metastatic urothelial bladder cancer is controversial. The aim was to review situations where surgical resection of the bladder tumor and/or metastatic urothelial carcinoma has been reported and analyze its results. A bibliographic research in French and English using the keywords BCG, bladder cancer, metastases, cystectomy, metastasectomy, radiotherapy, curative treatment and palliative treatment was performed, 177 articles have been reviewed, and 18 have been selected. Synchronous or metachronous urothelial carcinoma metastases were diagnosed in 4 and 50% of the cases, respectively. The surgical treatment of metastatic urothelial carcinoma of the bladder has been proposed to achieve oncologic resection of all detectable lesions after a first-line chemotherapy or to treat symptoms, which were refractory to other treatment modalities. In achieving complete resection of the primary tumor and metastases after MVAC chemotherapies, t...

Objective: Laparoscopic radical cystectomy is a feasible procedure but there is still controversy if laparoscopic treatment of transitional cell carcinoma (TCC) of the bladder is oncologically safe. We report our experience with laparoscopic radical cystectomy in a consecutive series of 10 male patients with a 3 years follow-up. Methods: Between June 2001 and July 2002, 10 men age 63 to 74 years (mean 68.8) underwent laparoscopic cystoprostatectomy with urinary diversion for muscle-invasive TCC or pT1 G3 TCC plus carcinoma in situ (Cis) after 2 cycles of intravesical bacille Calmette-Guerin therapy and three or more transurethral resections (delayed cystectomy). Results: Histopathology revealed 2 stage pT1N0 TCC G3 plus Cis, 1 stage pT2aN0 TCC G3 plus Cis, 1 stage pT2bN0 TCC G2, 4 stage pT2bN0 TCC G2-3, 1 stage pT2bN0 TCC G3, 1 stage pT3aN0 TCC G3. The mean followup is 30.4 months (range 23-36). No local recurrences, peritoneal carcinosis or trocar-site metastases occurred. Metastases presented in 4 of 10 cases (2 patients with a stage pT1N0 plus Cis and 2 patients with a stage pT2bN0 TCC) respectively after 7, 14, 16 and 28 months. These patients died respectively at 20, 18, 22 and 31 months later. One patient died for unrelated causes. Five patients are alive, free from disease. Conclusions: Laparoscopic radical cystectomy is feasible and accomplished with low morbidity. Up to now publishing data do not support a verified negative oncological effect of the laparoscopy in the treatment of bladder TCC, but our initial results seem worst than those achieved with open surgery. The experience of other Institutions will help to provide objective evaluation of this new and controvers technique because it is not clearly demonstrated that laparoscopic radical cystectomy is an oncologically safe procedure in the management of bladder TCC. Thus in our opinion it should be still considered experimental. #

Ipsilateral multiple synchronous primary renal neoplasms is an uncommon presentation, and only a few cases have been reported in published studies. We report the case of a 57-year-old woman with acute pyelonephritis as the initial presentation, in whom conservative treatment had no effect. Surgical intervention revealed the presence of concomitant renal cell carcinoma, collecting duct carcinoma, and urothelial carcinoma (transitional cell carcinoma) of the kidney. Metastatic renal cell carcinoma to the bladder, liver, and lung subsequently developed. Deceptive inflammatory presentations can occur in aggressive synchronous renal malignancies. Recognition of this rare disease entity could prevent delays in diagnosis and treatment.

detubularized U-shaped ileocystoplasties (Camey II) following radical cystectomy were carried out in our Department of Urology (CMC Foch Suresnes, France). Our first evaluation of this procedure was carried out in 1989 and reviewed initial 57 patients operated on. These data were compared with those of the Camey I operation. The improvement in neobladder capacity as well as nighttime urinary control achieved by the detubularization required in the Carney II operation was obvious. In this article we review the first 110 patients treated by Carney II bladder replacement following cystectomy.

Although calcifications in the prostate are a common manifestation, the relationship between calcifications and prostate cancer is not clearly documented as in breast cancer. In addition, anatomical distribution of calcifications by zones of the prostate and ejaculatory system has not been systematically studied. To study the frequency and patterns of calcifications within the prostate and ejaculatory system, we reviewed the whole mount sections of 298 consecutive prostatectomy or cystoprostatectomy specimens. Calcifications were evaluated in the prostate (central, peripheral and transition zones, and verumontanum), ejaculatory ducts, and seminal vesicles. We graded the degree of calcifications as mild, moderate, or severe. Calcifications in the prostate and ejaculatory system were common, and their frequency in our series is as follows: 88.6% (264/298) of prostates, 58.1% (173/298) of seminal vesicles, and 17.1% (51/298) of ejaculatory ducts. The prostatic calcifications occurred mostly in benign glands and/or stroma of all zones and the verumontanum. Calcifications were more common in the transition zone than other zones. There were 4 cases of prostatic calcifications in the areas of prostatic adenocarcinoma: 3 cases with calcifications in the tumor glands and 1 case with calcifications in tumor stroma but not in the accompanying tumor glands. In conclusion, calcifications are a very common finding in prostatectomy specimens and seem mostly to be associated with benign prostatic hyperplasia. However, calcifications can occur in direct association with prostatic adenocarcinoma, although the incidence of this association is not as high as in breast carcinoma. Also, ejaculatory system calcifications are not an infrequent finding.

To analyze the practice of surgical intensive care unit (SICU) admission of postoperative urologic patients and to define objective criteria to predict active treatment requirements and length of stay in the SICU. The records of 90 consecutive patients admitted to the SICU postoperatively in the 12-month period from January 1996 to December 1996 were retrospectively reviewed. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated from patient parameters acquired within the first 12 hours. The correlation of outcome variables to the length of stay and the requirements for active treatment in the SICU were analyzed and used to develop a risk stratification model. This algorithm was subsequently validated on a population of 46 patients who underwent radical cystectomy the following year. Only the preoperative American Society of Anesthesia class, the event of an intraoperative complication, and the APACHE II score were statistically significant (P &amp;lt;0.05) predictors of length of stay and active treatment. The patients were subsequently categorized into high and low-risk groups, which were found to have mean SICU stays of 39.9 +/- 3.92 hours and 20.2 +/- 0.45 hours, respectively (P = 0. 001), and an active SICU-specific treatment rate of 58.0% and 14.3%, respectively (P = 0.001). These results were confirmed in the validation population. Postoperative risk stratification may be helpful in predicting SICU requirements in the immediate postoperative period and in identifying patients at lower or higher risk of an adverse outcome.

Context: Muscle-invasive bladder cancer (MIBC) is a disease with a pattern of predominantly distant and early recurrences. Neoadjuvant cisplatin-based combination chemotherapy has demonstrated improved outcomes for MIBC. Objective: To review the data supporting perioperative chemotherapy and emerging regimens for MIBC. Evidence acquisition: Medline databases were searched for original articles published before April 1, 2012, with the search terms bladder cancer, urothelial cancer, radical cystectomy, neoadjuvant chemotherapy, and adjuvant chemotherapy. Proceedings from the last 5 yr of major conferences were also searched. Novel and promising drugs that have reached clinical trial evaluation were included. Evidence synthesis: The major findings are addressed in an evidence-based fashion. Prospective trials and important preclinical data were analyzed. Conclusions: Cisplatin-based neoadjuvant combination chemotherapy is an established standard, improving overall survival in MIBC. Pathologic complete response appears to be an intermediate surrogate for survival, but this finding requires further validation. Definitive data to support adjuvant chemotherapy do not exist, and there are no data to support perioperative therapy in cisplatin-ineligible patients. Utilization of neoadjuvant cisplatin is low, attributable in part to patient/physician choice and the advanced age of patients, who often have multiple comorbidities including renal and/or cardiac dysfunction. Trials are using the neoadjuvant paradigm to detect incremental pathologic response to chemobiologic regimens and brief neoadjuvant single-agent therapy to screen for the biologic activity of agents.

Purpose: The aim of this Phase II study was to determine a bladder-sparing treatment in patients with invasive bladder cancer, allowing a better quality of life. Objectives were to test toxicity and disease-free and overall survival of patients given an alternated chemo-radiotherapy definitive treatment. Methods and Materials: Seventy-six patients with bladder cancer Stage TlG3 through T4 NO MO were entered in the same chemotherapy regimen (Cisplatin 20 mg/mq and S-Fluorouracil 200 mg/mq daily for 5 days) alternated with different radiotherapy scheduling, the first 18 patients received two cycles of 20 GyllO fractions/l2 days each; the second group of 58 patients received two cycles of 25 Gy/lO fractions/ 12 days each (the last 21 patients received Methotrexate 40 mg/mq instead of J-Fluorouracil). Results: A clinical complete response was observed in 57 patients (81%), partial response in 7 patients (10% ), and a nonresponse in 6 patients (9% ). At a median follow-up of 45 months, 33 patients (47% ) were alive and free of tumor. The B-year overall survival and progression-free survival was 42% and 40%, respectively. Systemic side effects were mild, while a moderate or severe local toxicity was observed in 14 patients and 13 patients (about 20% ), respectively. Conclusion: Our conservative combination treatment allowed bladder-sparing in a high rate of patients and resulted in a survival comparable to that reported after radical cystectomy.

Lap a r osc opic ra dic al cys t ec t omy wit h or t hot opic ile al ne obla dde r : rep or t of 33 c as es HUAN G Jian , XU Ke2wei , YAO You2sheng , GUO Zheng2hui , XIE Wen2lian , J IAN G Chun , HAN Jin2li and L I Si2yao Keywords : bl a d de r ca nce r l ap a r osc op y ra dical c yst ect o m y ile al ne obl a

Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer I tumori invasivi del tratto urinario sono relativamente rari ed il loro trattamento può causare importanti cambiamenti nelle funzioni sessuali, sociali ed urinarie. È stata effettuata una review sistematica degli studi di radioterapia esterna nei tumori urinari. Questa sintesi della letteratura è basata su dati di meta-analisi, studi prospettici, randomizzati, e retrospettivi. Ci sono pochi studi clinici controllati che hanno utilizzato la radioterapia adiuvante o radicale±chemioterapia nei tumori del rene, degli ureteri e dell’uretra; ci sono diversi studi sul trattamento multimodale del carcinoma invasivo della vescica: chirurgia intravescicale e chemioterapia neoadiuvante alla radioterapia o radio-chemioterapia concomitante con preservazione dell’organo. Le conclusioni raggiunte sul carcinoma renale sono controverse; i dati sul carcinoma degli ureteri e dell’uretra sono pochi e inconclusivi; invece, vi sono ora in letteratura dati sufficienti che dimostrano come l’approccio con preservazione dell’organo, per il carcinoma vescicale invasivo rappresenta una valida alternativa alla cistectomia radicale, considerata per lungo tempo il gold standard.

Purpose: The number of centers performing robotic assisted radical cystectomy has recently increased, spurring greater concerns about oncological outcomes. In this review we summarize the most comprehensive articles published on the oncological outcomes of laparoscopic assisted, robotic assisted and open radical cystectomy. Materials and Methods: A MEDLINE®/PubMed® literature search was conducted in March 2009 to review English language articles published from 1998 onward. Of 217 selected articles on the 3 techniques 19 studies were selected for this review. Results: The laparoscopic series reported recurrence-free survival rates in the range of 83% to 85% at 1 to 2 years and 60% to 77% at 2 to 3 years, while the robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years. Large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years. Overall survival in the laparoscopic cohorts was 90% to 100% at 1 to 2 years and 50% to 87% at 2 to 3 years. Publications reporting robotic cases demonstrated a 90% to 96% overall survival in 1 to 2 years of followup. Conclusions: Despite the surge of centers adopting minimally invasive approaches for radical cystectomy, the long-term effectiveness of these techniques has not yet been proven. This review of recent and landmark articles on open and minimally invasive procedures emphasizes the need for prospective controlled studies and long-term followup data to determine the proper use of laparoscopic and robotic assisted techniques in bladder cancer surgery.