Incidence of urethral tumor involvement in 910 men with bladder cancer

Metachronous urothelial carcinoma in the renal pelvis, bladder, and urethra: A case report

BACKGROUND

Urothelial carcinoma (UC) is a common malignancy of the urinary system that can occur anywhere from the renal pelvis to the proximal urethra. Most UCs are in the bladder and have multifocal growth. Upper urinary tract UC (UTUC), which occurs in the renal pelvis or ureter, accounts for only 5% to 10% of UCs.

CASE SUMMARY

In March 2015, a 70-year-old male who initially presented to a local hospital with a complaint of painless hematuria was diagnosed with UTUC of the right renal pelvis. The doctors administered radical nephroureterectomy and bladder cuff excision. Although the doctors recommended intravesical chemotherapy and regular follow-up, he rejected this advice. In December 2016, the patient presented at our hospital with dysuria. We identified UC in the residual bladder and administered radical cystectomy and left cutaneous ureterostomy. In November 2021, he presented again with urethral bleeding. We detected urethral UC as the cause of urethral orifice bleeding and administered radical urethrectomy. Since then, he has visited regularly for 6-mo follow-ups, and was in stable condition as of December 2022.

CONCLUSION

UTUC is prone to seeding and recurrence. Adjuvant instillation therapy and intense surveillance are crucial for these patients.

Transurethral en bloc submucosal hydrodissection vs conventional resection for resection of non-muscle-invasive bladder cancer (HYBRIDBLUE): a randomised, multicentre trial

OBJECTIVE

To determine whether transurethral en bloc submucosal hydrodissection of bladder tumours (TUEB) improves the quality of the resection compared to conventional transurethral resection of bladder tumour (TURBT) in patients with non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

A randomised, multicentre trial (HYBRIDBLUE) was conducted with a superiority design. Six German academic centres participated between September 2012 and August 2015. Based on literature analysis, a sample size for accurate histopathological assessment concerning muscle invasion was assumed to be feasible in 50% (P₀ = 0.5) of TURBT and 80% of TUEB cases. After pre-screening of a total of 305 patients, participants were allocated to two study arms: Group I: hexaminolevulinate (HAL)-guided TUEB; Group II: conventional HAL-guided TURBT. The primary endpoint was the proportion of specimens that could be reliably evaluated pathologically concerning muscle invasiveness. Secondary endpoints included rates of histopathological completeness of the resection, muscularis propria content, recurrence, and complication rates.

RESULTS

A total of 115 patients (TUEB 56; TURBT 59) were eligible for final analysis. Adequate histopathological assessment, which included muscularis propria content and tumour margins (R0 vs R1), was present in 48/56 (86%) TUEB patients compared to 37/59 (63%; P = 0.006) in the TURBT group. R0 was confirmed in 30/56 TUEB patients (57%) and five of 59 TURBT patients (9%; P < 0.001). No complications of Grade ≥III were observed in both arms. At 3 and 12 months, three and 19 patients recurred in the TUEB group vs seven and 11 patients in the TURBT group, respectively (P = 0.33 and P = 0.08).

CONCLUSIONS

In this randomised study, TUEB was shown to be clinically safe regarding perioperative endpoints. An adequate histopathological assessment concerning muscle invasion was significantly better assessable in the TUEB arm compared to standard TURBT. This finding indicates the clinical potential for reducing the rate of early re-resections. Yet, a larger study with recurrence-free survival as the primary endpoint is needed to assess the oncological efficacy between both techniques.

Management of Urethral Recurrences: Urothelial and Nonurothelial

This article discusses the diagnostic and therapeutic options in the management of urethral cancer recurrence in patients treated with urethral sparing cystectomy as well as those who had urethral preservation following primary urethral carcinoma.

Carcinome urothélial de l’urètre: une nouvelle observation et revue de la littérature

Le carcinome urothélial de l’urètre masculin est une tumeur exceptionnelle. Nous rapportons une nouvelle observation de carcinome urothélial de l’urètre chez un homme de 64 ans qui avait consulté pour une dysurie. L’urétrocystographie rétrograde et mictionnelle (UCRM) réalisée avait mis en évidence des images de rétrécissement de l’urètre bulbopénien traité par urétroplastie. L’examen histologique de la pièce d’urétrectomie a révélé un carcinome urothélial de l’urètre. Le patient refusa tout traitement complémentaire et survécut 14 mois après le diagnostic.

Urethral recurrence of bladder tumor occurring as a perineal mass 2 years after transurethral resection: a case report

Transitional cell carcinoma can develop as a multifocal tumor in the urinary system, especially in the bladder. Here, we report a 69-year-old man who had undergone transurethral resection for bladder tumor and had urethral recurrence that presented as a perineal mass 2 years after treatment. However, he had obtained normal cystoscopy, ultrasonography and computed tomography results at follow-up examinations.

Urinary fluorescence in situ hybridization assay for detecting urothelial carcinoma in Taiwanese patients

OBJECTIVES

To investigate the cytogenetic marker detected by fluorescence in situ hybridization (FISH; UroVysion, Vysis, Inc., Abbott Laboratories, Des Plaines, IL, USA) in the diagnosis of bladder cancer and upper tract urothelial carcinoma (UC) in Taiwanese patients, as FISH has been used in Western countries for detecting UC, but there are limited results in Asian populations.

PATIENTS AND METHODS

We analysed polyploidy of chromosome 3, 7, 17 and aneuploidy of chromosome 21, using uroepithelial cells collected at the first void or by instrumental extraction of urine, for bladder cancer, and shedding cells from the upper tract flushed by normal saline via ureteric catheterization or ureterorenoscopy. The criteria for positive tumour cells included three or more positive staining in two or more chromosomes showing polyploidy or <50% staining of the chromosome 9p21.

RESULTS

In all, 32 patients with bladder UC and 12 with upper tract UC were assessed. The overall sensitivity for bladder cancer by UroVysion was 96.8%. The sensitivity of the cytology test was 36% for UC of the bladder. The sensitivity for UroVysion in upper tract UC was 12/12 but the specificity was three of nine.

CONCLUSIONS

This preliminary report shows that UroVysion was a sensitive screening method for UC of the bladder and upper urinary tract.

Gender-specific differences in bladder cancer: a retrospective analysis

BACKGROUND

A higher incidence of bladder cancer has been reported in men compared with women. Clinical gender differences have been observed but are less well described.

OBJECTIVE

This retrospective analysis further examines clinical differences in the development and manifestation of bladder cancer between men and women.

METHODS

Consecutive male and female patients with bladder cancer treated between 1969 and 1997 at a single center (University Hospital of Innsbruck, Innsbruck, Austria) were included in the study. Patient characteristics regarding age, tumor classification, localization, and recurrence were compared between male and female patients. Statistical analysis was conducted using the t test, the chi(2) test, and the Kaplan-Meier method, with the log-rank test for subgroup analysis.

RESULTS

In the 1,269 patients (876 men, 393 women) who were examined, 1,744 tumors were found. The male-to-female bladder cancer incidence ratio was 2.2:1. Tumors were diagnosed at a significantly younger age in men than in women (mean age: 62 years vs 67 years, respectively; P < 0.001). No difference in the histology of tumors was observed between the sexes. Muscle-invasive tumors more frequently occurred in men than in women (39.8% vs 34.5%; P = NS). In men compared with women, primary tumors were more aggressive (grade 2, 36.6% vs 28.2%; P < 0.001) and tumor recurrences were more invasive (59.0% vs 57.8%; P = NS). Tumors were more often located in the urethra in men than in women (43 [3.4%] vs 9 [1.8%]; P = 0.034), the trigonum (246 [19.8%] vs 75 [14.9%]; P < 0.001), and the bladder dome or vault (128 [10.3%] vs 37 [7.4%]; P = 0.015). Generally, no difference in survival rate was observed between the sexes; only in the subgroup of muscle-invasive tumors (n = 455) did women have a worse overall survival rate than did men (P = 0.022).

CONCLUSIONS

Clinical gender differences in bladder cancer appear to have a higher incidence in men than in women. In this analysis, women were older at the age of detection, but had less-invasive and less-aggressive tumors than did men. However, women with muscle-invasive disease had a worse overall survival rate than did men in the same subset.

Oncological followup after radical cystectomy for bladder cancer-is there any benefit?

PURPOSE

Tumor recurrence after radical cystectomy for bladder cancer can be detected in an asymptomatic patient by regular followup or in a symptomatic patient by symptom guided examination. To our knowledge it is still unknown whether detecting tumor recurrence at an asymptomatic stage offers a better survival rate.

MATERIALS AND METHODS

A total of 1,270 radical cystectomies for bladder cancer were performed at a single institution between January 1, 1986 and December 2006. All patients had regular followup examinations with chest x-ray and abdominal ultrasound every 3 months, computerized tomography of the abdomen every 6 months, and bone scan and excretory urography every 12 months. Additional examinations were required for symptomatic disease. We analyzed the first site and date of tumor recurrence. Survival was compared using the log rank test.

RESULTS

The 20-year recurrence rate was 48.6% in the complete series. Tumor recurrence developed in 444 patients, including 154 asymptomatic and 290 symptomatic patients, with a mean time after radical cystectomy of 20 and 17.5 months, respectively. The most frequent symptoms were pain, ileus, acute urinary retention, hydronephrosis with flank pain, hematuria, neurological symptoms and a palpable mass. Of the 444 patients 182 (41%) had local recurrence and 324 (73%) had distant failure at the time of first recurrence. The overall survival rate 1, 2 and 5 years after first recurrence was 22.5%, 10.1% and 5.5% in asymptomatic patients, and 18.9%, 8.2% and 2.9% in symptomatic patients, respectively (log rank not significant).

CONCLUSIONS

This study fails to demonstrate a survival benefit for detecting tumor recurrence early at an asymptomatic stage by regular followup examinations. These data show that symptom guided followup examinations may provide similar results at lower cost.

National survey on orthotopic neobladder

OBJECTIVE

A national survey was conducted among the urologists in India to find the preference for urinary diversion after radical cystectomy for muscle invasive carcinoma of the urinary bladder, percentage of neobladder reconstruction, segment of the bowel used, complication rate, need for self-intermittent catherisation on follow up and the survival.

MATERIAL AND METHODS

A detailed questionnaire was mailed to all members of the urological society of India (USI) to find out their preference for urinary diversion following radical cystectomy for muscle invasive carcinoma urinary bladder. For the neobladder reconstruction, they were asked for the type of bowel segment used, complication rate, reoperation rate, need for intermittent clean catheterisation on follow up and 5-year survival.

RESULTS

A total of 24 institutions responded to the mailed questionnaire. Of all institutions 12 (50%) did not prefer the orthotopic neobladder (ONB) reconstruction. Among the institutions carrying out neobladder reconstruction, majority perform ileal conduit in more than 50% of the cases. Ileum (66.66%) or ileocaecal (16.66%) segment was the choice of bowel segment for most of the urologists. Only three institutions used sigmoid colon. The complications encountered were wound infection (5-25%), burst abdomen (5%), urinary fistulas (3-25%), faecal fistulas (2-5%), bladder neck stenosis (5-15%) and ureterointestinal anastomosis stenosis (5-25%). The reoperation rate was 5-15% with a perioperative mortality of 0.5-3%. Around 10-100% (average 50%) of the patients require intermittent clean catherisation. Only seven institutions could provide 5-year survival rate data. Of these three institutions reported more than 50% and four institutes less than 50% 5-year survival.

CONCLUSION

Ileal conduit still remains the urinary diversion of choice following radical cystectomy for muscle invasive carcinoma of the bladder among most of the urologists in India. Orthotopic neobladder reconstruction is practiced only in selected centres. Wound infection, urinary leak and obstruction at ureterointestinal anastomosis are the main complications. Clean intermittent cathaterisation is required at an average of 50% of the patients to ensure complete emptying of the neobladder.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

The diagnosis and treatment of urethral recurrence after radical cystectomy

OBJECTIVE

To illustrate the problem of urethral recurrence of transitional cell carcinoma (TCC) after radical cystectomy, and define surveillance and treatment algorithms.

METHODS

There are 6 unique cases of urethral tumor recurrence presented, and current relevant literature is reviewed. Three risk groups are defined based on the likelihood of urethral recurrence. Surveillance and treatment options are delineated.

RESULTS

Although the incidence of recurrent tumor in the urethra is low, the prevalence is increasing because of improvements in bladder cancer survival and the fact that the urethra is retained more often for orthotopic urinary diversion. Patients can be categorized as low, intermediate, and high risk based on the pathologic finding of degree of prostatic involvement by the initial tumor.

CONCLUSION

Based on limited available literature, it appears that surveillance strategies range from observation alone to more invasive monitoring that includes urethral wash cytology and urethroscopy. Treatment options include local resection, intraurethral agents, and complete urethrectomy. A surveillance algorithm based on risk for recurrence and a treatment algorithm based on histopathologic risk factors of the recurrent tumor are proposed. This problem will assume increasing importance in the future.

Tumor Recurrence in the Remnant Urothelium of Females Undergoing Radical Cystectomy for Transitional Cell Carcinoma of the Bladder: Long-Term Results From a Single Center

PURPOSE

We analyzed the risk factors and incidence of secondary TCC of the remnant urothelium in women following radical cystectomy for TCC of the bladder.

MATERIALS AND METHODS

A total of 85 women with a mean age of 64.5 years with clinically localized TCC of the bladder underwent radical cystectomy between 1992 and 2004. Orthotopic bladder substitution was performed in 46 females, while 39 underwent nonorthotopic urinary diversion. Of the entire cohort 22 (26%) patients underwent cystectomy for multifocal or recurrent TCC. Followup examinations were performed at 6-month intervals.

RESULTS

Mean followup in the entire cohort was 49.8 months (median 42). Intraoperative frozen sections obtained from the urethra and distal ureters were negative for TCC and CIS in all patients. Four women (4.7%) had TCC in the remnant urothelium at a mean of 56 months postoperatively. These patients had undergone cystectomy for multifocal or recurrent TCC (4 of 22 or 18%). No secondary TCC was seen in the 63 patients with solitary invasive or nonrecurrent bladder cancer (p <0.05). Urethral recurrence was found in 2 patients (4.3%) 65 and 36 months after orthotopic neobladder surgery, respectively. In the orthotopic group 1 patient (2.1%) had an upper urinary tract tumor 76 months after surgery, while in the nonorthotopic group 1 (2.5%) was found to have an upper urinary tract tumor 48 months postoperatively.

CONCLUSIONS

Recurrent or multifocal TCC may represent a risk factor for secondary TCC of the remnant urothelium after cystectomy. In our series all recurrent tumors were late recurrences (more than 36 months postoperatively). Because the rate of urethral recurrence in the current series corresponds to that reported in men (2% to 6%), urethra sparing cystectomy with orthotopic bladder replacement does not appear to compromise the oncological outcome in women.

Contemporary Management of the Urethra in Patients After Radical Cystectomy for Bladder Cancer

The incidence of urethral TCC after radical cystectomy is approximately 8% overall. The most important risk factor for urethral TCC after radical cystectomy and urinary diversion is prostatic involvement by TCC, particularly stromal invasion. The safety of using the urethra for orthotopic urinary diversion seems to be best when intra-operative frozen section analysis of the urethral margin is performed at the time of radical cystectomy. There is provocative but unconfirmed evidence that orthotopic urinary diversion may be protective against the development of urethral TCC. Although most urethral "recurrences" occur within 5 years, delayed recurrences have been documented, mandating life-long follow-up of the retained urethra. Follow-up should include urinary cytology, either voided or urethral wash cytology as appropriate, with evaluation by endoscopy of any urethral related symptoms or change in voiding symptoms. The management of urethral TCC after cystectomy remains a total urethrectomy including excision of the meatus; however, in carefully selected patients with superficial disease and an orthotopic urinary diversion, urethra sparing may be attempted after a careful discussion with the patient. Survival after urethral TCC has generally been disappointing. The relative value of urethral versus original cystectomy pathologic stage and symptomatic versus nonsymptomatic recurrence in predicting survival remains controversial and awaits further studies that will most likely require the pooling of data from several large series.

Treatment of invasive bladder cancer: lessons from the past and perspective for the future

Radical cystectomy with lymphadenectomy is the gold standard for treatment of invasive bladder cancer. However, the treatment alone does not always provide a satisfactory result for the disease extending outside the bladder. In this review we discuss several clinical issues in the diagnosis and treatment of this invasive disease. Although the quality of diagnostic imaging modalities has improved, they are still not sensitive enough for the staging of the disease, especially for early invasive disease. In addition, lack of serum markers hinders appropriate monitoring of patients with the disease. Regarding the surgical aspect of lymphadenectomy, the area of its dissection, the standard number of nodes retrieved and the method of pathological examination should be established so that the clinical benefits of surgery can be more clearly defined. Neoadjuvant chemotherapy for invasive disease is promising for improvement of survival of patients. A chemotherapy regimen as effective as, but less toxic than, MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) has been reported and several phase III clinical trials have been launched to determine the benefits of adjuvant or neoadjuvant chemotherapy with newly developed agents. However, we still lack a chemotherapy regimen more effective than MVAC, which is the most crucial issue in the treatment of this invasive disease. An alternative option for such disease may be bladder preservation with transurethral resection of tumor followed by chemoradiotherapy. However, patients who are indicated for this treatment may be limited to those with early invasive disease having certain favorable clinical and pathological features.

Urethral recurrence after sigmoid orthotopic neobladder. What should be the ideal treatment approach?

Orthotopic neobladder reconstruction has become a standard procedure in patients undergoing radical cystectomy for invasive bladder cancer. In addition the known sequelae like nocturnal enuresis, need of self-intermittent catherisation and stricture at urethro or ureteroileal anastomosis, one of the most unfortunate event to happen is the recurrence of malignancy that may require the removal of the neobladder lessening the quality of life suddenly. There is a little information about the cases of urethral recurrence of transitional cell carcinoma of the bladder after cystectomy and orthotopic neobladder. We report such a case and management dilemma as the patient is young and does not want to loose body image and a brief review of literature is presented.

Orthotopic bladder reconstruction in women--what we have learned over the last decade

Approximately 10 years ago protocols for urethra-sparing cystectomy and orthotopic urinary diversion to the urethra in female patients with bladder cancer were initiated at several centers. Long-term data regarding the oncological and functional outcome are the subject of this review. Studies regarding the relationship between primary bladder cancer and secondary urethral tumors in women revealed in most studies a lower risk for women than for men in most studies. In a recent meta-analysis the incidence of urethral tumors was 6.8% in 5657 male and 3.6% in 841 female patients with transitional cell cancer of the bladder. Anatomical and functional studies revealed that smooth musculature can be found in the entire length of the female urethra. The rhabdosphincter which is the important structure for postoperative continence in low pressure intestinal reservoirs is in the midportion of the urethra which will not be touched during urethra-sparing surgery. A recent study looked at the oncological and functional results of 102 women with orthotopic urinary diversion after a follow-up ranging from one and half to 100 months (mean 26, median 24 months). There was no perioperative mortality, and an early and late complication rate requiring secondary intervention in 5 (5%) and 12 (12%) patients. With 88 of 102 patients alive and 83 of 102 patients disease free, a disease specific survival of 74% and a disease free survival of 63% was estimated at 5 years. No pelvic recurrence was seen in 81 patients with TCC. Daytime continence was 82%; nocturnal continence was 72%. Twelve patients (12%) were unable to empty their bladders completely and needed some form of catheterization. Increasing experience in recent years confirms the initial preliminary results showing that sparing the urethra at cystectomy will not compromise oncological outcome and can be satisfactorily used for orthotopic reconstruction of the lower urinary tract. Both diurnal and nocturnal continence and clean intermittent catheterization rates after 6 months justify the use of orthotopic neobladders as the procedure of choice in the majority of female patients with bladder neoplasms.

Contemporary cystectomy combined with ileal conduit or bladder substitution

Radical cystectomy remains one of the mainstay treatments for organ-confined invasive bladder cancer. Components of this surgery including the extent of pelvic lymph node dissection, the assessment of ureteric margins and the indications for bladder reconstruction as opposed to the simpler ileal conduit urinary diversion continue to provoke debate. This review provides a broad overview of radical cystectomy and summarises the options for bladder reconstruction. Special emphasis is given to data concerning the role of pelvic lymphadenectomy in the patient staged pre-operatively as N0M0.

The remnant urothelium after reconstructive bladder surgery

The pathology of the remnant urinary tract in an increasing population of cystectomy patients with orthotopic and heterotopic bladder substitution due to primary bladder carcinoma, and its management is discussed. The incidence of urethral tumours in primary or recurrent bladder cancer in long-term studies is approximately 6% for male and 2% for female patients. Risk factors for urethral tumour occurrence are tumours at the bladder neck and recurrent multifocal tumours. CIS of the bladder not involving the bladder neck, and muscle invasive tumours with or without lymph node involvement are not significantly correlated with urethral cancer. Those patients at risk for urethral tumours need additional work-up (multiple urethral biopsies and/or urethral brushings, frozen section of the membranous urethra) before an orthotopic lower urinary tract reconstruction to the urethra should be considered. In a large series of male patients, the majority of patients with urethral tumours had a single conservative treatment session, and did not recur thereafter demonstrating the feasibility of a conservative approach for superficial urethral tumour recurrences in patients with an orthotopic neo-bladder to the urethra. The incidence of upper tract tumours following cystectomy and lower urinary tract reconstruction lies between 2.4-17%. In a group of 258 patients with an orthotopic bladder substitution, we have seen an incidence of 3.5%. Tumour multifocality, carcinoma in situ in the bladder and/or distal ureter, locally advanced bladder tumour stage, and invasion of the intramural ureter were seen as risk factors in some series. A tendency for a higher incidence can be seen in those series with longer follow-up. The median time between cystectomy and diagnosis of upper tract tumours lies between 8 and 69 months in most series. A longer observation period in larger numbers of patients with an orthotopic neo-bladder and longer survival rates in general after cystectomy may reveal an increase in the incidence of upper tract tumours over the next decade.

Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors

BACKGROUND

To the authors' knowledge, few data exist regarding the functional and oncologic outcome of pelvic tumors in women with urethra-sparing cystectomy and orthotopic urinary diversion to the urethra.

PATIENTS AND METHODS

The combined data of 102 women age 28-79 (mean, 59 yrs) years who underwent a urethra-sparing cystectomy and orthotopic urinary diversion for either primary bladder cancer (96 patients), carcinoma of the uterine cervix (2 patients), carcinoma of the vagina (1 patient), primary fallopian tube carcinoma (1 patient), uterine sarcoma (1 patient), or rectal carcinoma (1 patient) were reviewed. The histology of the 96 primary bladder tumors was 81 transitional cell carcinomas (TCC), 8 adenocarcinomas, 5 squamous cell carcinomas, 1 small cell carcinoma, and 1 unclassified. Follow-up ranged from 1.5-100 months (mean, 26 mos; median, 24 mos). In all patients, the bladder neck and up to 1 cm in length of the adjacent urethra were removed with the bladder. An ileal orthotopic neobladder procedure was performed if staging biopsies of the bladder neck and intraoperative frozen section of the urethral margin revealed no tumor.

RESULTS

There was no perioperative mortality, and an early and late complication rate requiring secondary intervention in 5 (5%) and 12 (12%) patients. With 88 of 102 patients alive and 83 of 102 patients disease free, a disease-specific survival of 74% and a disease-free survival of 63% was estimated at 5 years. No pelvic recurrence was seen in 81 patients with TCC. Three pelvic recurrences occurred, two tumors of the inner genitalia and one adenocarcinoma of the bladder, none of them in the area of the urethra or its supplying autonomic nerves. Daytime continence was 82%; nocturnal continence was 72%. Twelve (12%) patients were unable to empty their bladders completely and needed some form of catheterization.

CONCLUSIONS

The functional and oncologic outcome of female patients with an orthotopic urinary diversion to a remnant urethra was found to be comparable to that found in large studies on males. An orthotopic neobladder proved to be an oncologically safe option for women with pelvic tumors and was found to provide quality of life when there was adherence to previously defined selection criteria.

Radical cystectomy and bladder substitution

The incidence of bladder cancer is rising. The main treatment for superficial bladder cancer is local resection and judicious use of intravesical agents. Radical cystectomy can cure organ-confined, invasive disease. The ileal conduit remains the gold standard following cystectomy. Newer methods of bladder substitution and nerve-sparing techniques have resulted in better tolerance of this treatment.

Orthotopic ileocolic neobladder reconstruction following radical cystectomy: history, technique and results of the Johns Hopkins experience, 1986-1998

Reconstruction of the lower urinary tract using intestinal segments has become a standard component of the treatment of patients with bladder cancer. A variety of intestinal segments can be successfully used for this purpose. Between 1986 and 1998, the authors have used a composite ileocolic segment for neobladder reconstruction in patients desiring orthotopic reconstruction of the lower urinary tract. The early and late complication rates are 11% and 30%, respectively. Forty-five percent of men are potent postoperatively. Seventy-six percent of patients are continent both day and night. Three percent of our patients experience nocturnal enuresis, and 15% perform clean intermittent catheterization. Bothersome daytime stress urinary incontinence occurs in 3% of patients evaluated for this report. Although no contemporary studies demonstrate the superiority of a particular bowel segment for lower urinary tract reconstruction, the authors' long-term experience with the ileocolic neobladder suggests that this composite segment provides excellent results for lower urinary tract reconstruction after radical cystectomy.

Transitional cell carcinoma of the urethra in men and women associated with bladder cancer

Multifocal tumor occurrence in the entire urinary tract in time and space is a well-recognized characteristic of transitional cell carcinoma. Synchronous and asynchronous urethral transitional cell carcinoma, in relation to bladder cancer in male and female patients, is the subject of the present mini-review. It is imperative to rule out male and female patients having a high risk for urethral involvement or urethral recurrence. In male patients, prostatic urethral involvement and stromal invasion mainly due to in situ extension of carcinoma seems to be the most important risk factor. In female patients, bladder neck involvement by cancer seems most important. By excluding male and female bladder cancer patients having these characteristics for simultaneous urethrectomy, other patients are good candidates for reconstruction of the urinary tract after cystectomy by an orthotopic neobladder which will offer a good quality of life to bladder cancer patients.

Involvement of the anterior urethra in male patients with transitional cell-carcinoma of the bladder undergoing radical cystectomy with simultaneous urethrectomy

Histological tumor extension into the prostate, urethra and ureters was examined in 52 specimens obtained by cystourethrectomy for transitional cell carcinoma of the bladder with one or more risk factors for urethral involvement. In four (21.1%) of 19 patients with diffuse carcinoma in situ in the bladder extending to the internal urethral orifice and prostatic urethra, the anterior urethra was affected by transitional cell carcinoma, including one specimen with invasion into the corpus spongiosum. However, none of 33 patients without these findings had synchronous anterior urethral transitional cell carcinoma involvement. It is recommended that patients with diffuse carcinoma in situ extending into the prostatic urethra undergo careful preoperative assessment of the anterior urethra before cystectomy. In other cases, the anterior urethra can be preserved and used for orthotopic neobladder replacement.

Update of urethra-sparing approaches in cystectomy in women

The emerging experience in urethra-sparing cystectomy in women undergoing subsequent orthotopic lower-urinary-tract reconstruction with regard to the anatomy of the remnant urethra, patient selection, refinements of the surgical technique, the patients' outcome with respect to the underlying disease, the risk for tumor recurrence, and postoperative urodynamics are the main focus of this report. In the present study, 30 carefully selected female patients underwent orthotopic reconstruction of the lower urinary tract. Surgical variations emerging from the first learning curve, including nerve-sparing anterior exenteration, vaginal reconstruction, omental support of the neobladder floor, and ureterointestinal anastomosis, were applied in 21 patients with lower-urinary-tract reconstruction. Of 24 patients followed for more than 6 months, 21 (87.5%) are continent at daytime, 19 (79%) have nocturnal continence, and only 1 (4%) requires self-catheterization; 3 patients with urinary retention were successfully treated for obstructed ileal valves. After a follow-up period of 2-41 (mean 15.4) months one patient each developed local recurrence (uterine adenosarcoma) after 13 months and distant metastasis transitional-cell cancer of the bladder after 3 months; all other patients are currently free of disease. Urethra-sparing surgery has established itself in selected women with bladder cancer. Refinements in the technique of radical cystectomy and orthotopic creation of a neobladder to the urethra may improve the continence, spontaneous micturition, and surgical oncological outcome of these patients.

Bladder replacement in women: a new experience

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.

The use of neobladders in women undergoing cystectomy for transitional-cell cancer

Recent studies have provided us with new insights into the natural history of female bladder cancer as well as the behavior of the isolated urethra after cystectomy. Based on more than 16 years of experience with orthotopic lower urinary tract reconstruction to the urethra in men, a similar approach was attempted in women with transitional-cell cancer of the bladder. Refinements in the technique of cystectomy and subsequent intestinourethral anastomosis based on anatomical, histological, and clinical studies are described that should improve postoperative results in women undergoing anterior exenteration and creation of an orthotopic neobladder to the urethra. Our findings in a series of 11 patients are presented and compared with data from other institutions. Improved postoperative continence and micturition without compromise of the oncological outcome may be a result of preservation of the entire lateral vaginal walls, nerve-sparing dissection of the bladder neck and proximal urethra, removal of 1 cm of proximal urethra en bloc with the cystectomy specimen, and a J-omentum flap or an additional attachment of the anastomosed intestinal pouch to surrounding pelvic structures. Taken together, our average of 90% daytime and 73% nighttime continence, 90% spontaneous residual-free micturition, and 100% patient satisfaction without compromise of the surgical oncological outcome seems to justify the creation of an orthotopic neobladder in selected women with bladder cancer.