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Context: A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications., Objective: To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD)., Evidence Acquisition: An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis., Evidence Synthesis: Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%., Conclusions: RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results., (Copyright © 2012 European Association of Urology. All rights reserved.)

Background: Although the rationale for active surveillance (AS) in patients with low-risk prostate cancer is well established, eligibility criteria vary significantly across different programs., Objective: To compare the ability of contemporary AS criteria to identify patients with certain pathologic tumor features based on the results of an extended transrectal prostate biopsy., Design, Settings, and Participants: The study cohort included 391 radical prostatectomy patients who had prostate cancer with Gleason scores ≤ 6 on transrectal biopsy with ≥ 10 cores., Intervention: Radical prostatectomy without neoadjuvant treatment., Outcome Measurements and Statistical Analysis: We identified patients who fulfilled the inclusion criteria of five AS protocols including those of Epstein, Memorial Sloan-Kettering Cancer Center, Prostate Cancer Research International: Active Surveillance (PRIAS), University of California, San Francisco, and University of Miami (UM). We evaluated the ability of these criteria to predict three pathologic end points: insignificant disease defined using a classical and updated formulation, and organ-confined Gleason ≤ 6 prostate cancer. Measures of diagnostic accuracy and areas under the receiver operating curve were calculated for each protocol and compared., Results and Limitations: A total of 75% of the patients met the inclusion criteria of at least one protocol; 23% were eligible for AS by all studied criteria. The PRIAS and UM criteria had the best balance between sensitivity and specificity for both definitions of insignificant prostate cancer and a higher discriminative ability for the end points than any criteria including patients with two or more positive cores. The Epstein criteria demonstrated high specificity but low sensitivity for all pathologic end points, and therefore the discriminative ability was not superior to those of other protocols., Conclusions: Significant variations exist in the ability of contemporary AS criteria to predict pathologically insignificant prostate cancer at radical prostatectomy. These differences should be taken into account when making treatment choices in patients with low-risk prostate cancer., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: With the advent of prostate-specific antigen (PSA) screening and the increase in the number of transrectal ultrasound-guided biopsy cores, there has been a dramatic rise in the incidence of low-risk prostate cancer (LRPC). Because > 97% of men with LRPC are likely to die of something other than prostate cancer, it is critical that patients give thought to whether early curative treatment is the only option at diagnosis., Objective: To identify a group of men with LRPC who may not require initial treatment and monitor them on our active surveillance (AS) protocol, to determine the percentage treated and the outcome and to analyze the quality-of-life data., Design, Setting, and Participants: We defined patients eligible for AS as Gleason ≤ 6, PSA ≤ 10, and two or fewer biopsy cores with ≤ 20% tumor in each core., Measurements: Kaplan Meier analysis was used to predict the 5-year treatment free survival. Logistic regression determined the predictors of treatment. Data on sexual function, continence, and outcome were obtained and analyzed., Results and Limitations: The AS cohort consisted of 230 patients with a mean age of 63.4 yr; 86% remained on AS for a mean follow-up of 44 mo. Thirty-two of the 230 patients (14%) were treated for a mean follow-up of 33 mo. Twelve had a total prostatectomy (TP). The pathologic stage of these patients was similar to initially treated TP patients with LRPC. Fourteen underwent radiation therapy, and six underwent androgen-deprivation therapy. Fifty percent of patients had no tumor on the first rebiopsy, and only 5% of these patients were subsequently treated. PSA doubling time and clinical stage were not predictors of treatment. No patient progressed after treatment. Among the AS patients, 30% had incontinence, yet < 15% were bothered by it. As measured by the Sexual Health Inventory for Men, 49% of patients had, at a minimum, moderate (≤ 16) erectile dysfunction., Conclusions: If guidelines for AS are narrowly defined to include only patients with Gleason 6, tumor volume ≤ 20% in one or two biopsy cores, and PSA levels ≤ 10, few patients are likely to require treatment. Progression-free survival of those treated is likely to be equivalent to patients with similar clinical findings treated at diagnosis., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer., Objective: We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure., Design, Setting, and Participants: Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009., Measurements: Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points., Results and Limitations: Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients., Conclusions: RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality., (Copyright (c) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management., Objective: To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy., Design, Setting, and Participants: We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed., Measurements: Disease-free survival (DFS) and disease-specific survival (DSS) were studied., Results and Limitations: The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups-supradiaphragmatic and infradiaphragmatic-there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non-clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non-clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis., Conclusions: Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non-clear-clear cell histology are significant prognostic factors influencing DSS., (Copyright © 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The left upper quadrant of the abdomen may be occupied by a wide range of urologic pathology. When these lesions are large, safely resecting them often presents a significant technical challenge, with the possibility of resultant morbidity and mortality., Objective: We describe a technique derived from our experience with multivisceral transplant and organ procurement, which provides excellent exposure of this anatomic region., Design, Setting, and Participants: From May 1999 to April 2006, 70 patients underwent en bloc mobilization of the spleen and the pancreas and, as necessary, the stomach for masses in the left upper retroperitoneum. Pathology included malignant and benign lesions, including renal cell carcinoma (RCC) with or without inferior vena cava (IVC) involvement, adrenal tumors, retrocrural lymphadenopathy from testicular cancer, and transitional cell carcinoma of the renal pelvis., Surgical Procedure: An extended subcostal transabdominal approach was used to resect large tumors in the left upper abdomen. This approach offers significant advantages over conventional approaches, including a flank, thoracoabdominal, or midline transabdominal incision with reflection of the descending colon., Measurements: Intraoperative variables, including operative time, blood loss, transfusion rate, and extent of mobilization were recorded. Postoperative complications, including prolonged intubation, ileus, and deep venous thrombosis were also noted., Results and Limitations: Mean estimated blood loss during surgery was 973 ml. There were no perioperative deaths. No patients had pancreatitis or acute renal failure. Deep venous thrombosis was not seen. Cardiopulmonary bypass was used in one patient with an atrial thrombus. At a median follow-up of 42 mo, two patients died due to metastasis., Conclusions: Techniques acquired from organ harvesting as well as our experience at multivisceral transplant, such as en bloc mobilization of the spleen, pancreas, and stomach, can be utilized safely and effectively to gain excellent exposure to the left upper retroperitoneum via an extended subcostal incision with no additional morbidity for the patient.

Objectives: The routine placement of a pelvic drain following radical retropubic prostatectomy (RRP) may not be required. We describe our experience in 552 consecutive RRPs to emphasise the safety of this approach and explain our rationale for avoiding a drain when possible., Methods: RRP was performed in 552 consecutive patients with clinically localised adenocarcinoma of the prostate between January 2002 and June 2005. Clinical and pathologic information was documented for each patient. After the prostate was removed and the anastomotic sutures tied, the bladder was gently filled with approximately 50 ml of saline through the urethral catheter. If there was no leak, a drain was not placed., Results: A drain was not placed in 419 (76%) of the 552 patients. We compared the postoperative complication rates in those with (D+) and without (D-) a drain. There were 27 (5%) immediate postoperative complications and no significant difference between the two groups (D+, 6%; D-, 5%; p=0.629): three (1%) patients who did not have a drain had a urinoma, one (1%) who had a drain had a lymphocele, and two (2%) who had a drain had a small pelvic haematoma., Conclusions: If the bladder neck is preserved or meticulously reconstructed, there may be little extravasation and, thus, routine drainage is unnecessary. Our 4-year experience indicates that morbidity is not increased by omitting a drain from the pelvic cavity after RRP in properly selected cases.