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Radical cystectomy completed with an extended pelvic lymph node dissection represents the most adequate curative treatment for muscle-invasive bladder cancer . After surgery, the tumor should be considered as completely removed only if the pathologist finds negative surgical margins. However, although the presence of positive surgical margins (PSM) intuitively appears as a factor conditioning a poor prognosis, the studies published at data could not definitively confirm this relationship. This fact may be mainly attributed to the lack of statistical independence between the presence of PSM and other pathologic factors such as tumor stage and lymph node status, that are themselves well known predictors of poor prognosis. The incidence of PSM has been estimated to be 3-9%. Although the persistence of tumor at both urethral and ureteral margins has been correlated with an increased risk of local recurrence, only perivesical soft tissue PSM have been associated with a significantly reduced risk of cancer-specific survival. Female gender, locally advanced cancer, presence of vascular invasion and rare/mixed histology have been recognized as consistent risk factors for soft tissue PSM. Although, to date, the predictive role of both number and location of PSM remains totally to be investigated, there is general agreement that patients found with soft tissue PSM at the time of radical cystectomy should be proposed for adjuvant strategies, including radiation and chemotherapy. In this direction, many recent studies suggest to include the status of surgical margins in the pathologic report of any radical cystectomy. [ABSTRACT FROM AUTHOR]

Despite the good quality of treatment expected with optimized transurethral resection (TUR) and adjuvant Bacillus Calmette-Guérin (BCG) regimen, many high-risk non-muscle invasive bladder cancer (NMIBC) patients recur and progress. According to the EORTC Tables of risk, cases with a score of 10-17 and those with a score of 7-23 should be considered as being at high risk of recurrence and progression, respectively. AUA and NCCN consider all T1 stage tumors, high grade Ta and CIS at high risk of recurrence and progression. Long-term follow-up shows that T1,G3 patients treated with BCG will suffer from up to 45% and 17% rate of recurrence and progression, respectively. Consequently, EAU, AUA and NCCN Guidelines for bladder cancer recommend radical cystectomy as a first treatment option for those patients who failed after two cycles of adjuvant BCG. However, to date, there is no definitive evidence that in this special subgroup of patients an early radical cystectomy is better than any additional salvage strategy, in terms of oncologic outcome. On the other hand, it is well accepted that radical cystectomy is burdened with consistent reduction of overall post-operative quality of life. The reluctance of patient to accept (and of surgeon to recommend) this major extirpative surgery may explain the reduced disease-free survival rate, well documented when radical cystectomy has been extremely delayed. Defining the criteria for the selection of BCG-failure patients for whom any conservative procedure should be definitively abandoned in favor of a timely radical cystectomy has become of critical importance. Recently, clinical, laboratory and pathologic acquisitions allowed the development of more accurate predictive factors for tumor progression in NMIBC. Among these factors, clinical type of BCG-failure, morphology and tumor growth patterns, pathologic sub-staging and immunohistochemistry will play a paramount role in decision-making with these patients in routine practice. [ABSTRACT FROM AUTHOR]

The term 'Non-muscle invasive bladder cancer' identifies a heterogeneous disease due to different natural history of its various appearances. T1 stage represents a non-predictable population, which might respond to non-operative treatment strategies or to the need of a more aggressive treatment, in order to avoid the progression to invasive, and possibly to metastatic stages. In the first year following transurethral resection of bladder (TURB), tumor recurrence is seen in up to 45% of the population; of this, 15% may progress to muscle invasive or metastatic disease, or both. In order to control the recurrence and progression and identify invasive tumors at the earliest possible stage, it is strongly necessary to define individual patient risk assessment follow-up. To obtain exact staging, besides a proper transurethral resection of bladder, a restaging transurethral resection of bladder should be performed in T1 patients. Data from literature support the immediate postoperative intravesical instillation of different chemotherapeutic agents in low-risk patients. Multifocal papillary lesions might require a more intensive adjuvant regimen, whereas intravesical im-munotherapy using Bacillus Calmette-Guérin is recommended in patients at high risk of progression. Early cystectomy should be considered in patients with recurrent T1 tumors or refractory carcinoma in situ to avoid unfavorable tumor progression. [ABSTRACT FROM AUTHOR]

Non-muscle-invasive bladder cancer is a common urinary malignancy whose management is a challenge: strong evidence supports the use of passive intravesical chemotherapy in the management of this tumor. Despite current guidelines, the treatment is suboptimal as illustrated by the high risk of recurrence and progression. Bacillus Calmette-Guérin (BCG) is the gold standard for the treatment of high-grade non-muscle-invasive bladder cancer, but in case of disease persistence, after 2 consecutive induction courses of BCG, patients must undergo radical cystectomy. We discuss options for second-line adjuvant therapy for non-muscle-invasive bladder cancer in standard treatment non-responder patients. We investigated the use and application of device-assisted therapy for the intravesical treatment of bladder cancer, such as thermochemotherapy (TCT) and electromotive drug administration (EMDA). Many studies demonstrate their synergistic therapeutic effect, greater than the single treatment with chemotherapy, inducing an increased absorption of the chemo-therapeutic agent (Mitomycin C) to the urothelium. TCT and EMDA are safe and effective in terms of outcomes. For the future it will be important to encourage the use of the existing technology within the appropriate clinical indications. [ABSTRACT FROM AUTHOR]

PURPOSE. Seminal-sparing cystectomy is reported in literature only with reference to oncological conditions. However, it can be applied also in non-neoplastic conditions in young patients with good renal function. In the present report we will describe our experience in this field, with special reference to erectile function, urinary continence, fertility and feasibility. MATERIALS AND METHODS. Between 2000 and 2009 we have treated five patients with seminal- sparing cystectomy for benign conditions, namely sclerosing cystitis, tuberculosis and a benign paraganglioma. All patients underwent a complete diagnostic evaluation including CT of upper abdomen and pelvis, and bone scintigraphy. Digital rectal examination was normal, PSA less than 2.5, with a free to total ratio above 25%. Cystectomy was performed, leaving in situ vas deferent, seminal vesicles, neuro vascular bundles and prostatic capsule. Finally, an ortho topic bladder was performed. The ileal segment was anastomized to the prosta tic capsule. RESULTS. All patients had uneventful recoveries and were continent within 2 weeks from the operation. Erectile function was maintained in all cases; in one patients fertility was preserved. CONCLUSIONS. In our experience, seminal-sparing cystectomy showed satisfactory clinical and functional preliminary results in selected patients. Young males, for whom maintenance of bladder function and sexual activity have a great impact on their quality of life, can be offered this alternative surgical procedure. [ABSTRACT FROM AUTHOR]

INTRODUCTION. Conservative management is not applicable to all T1G3 tumors. The appropriate treatment should minimize mortality while assuring reduced morbidity and good quality of life. Several attempts have been done to identify categories of T1G3 patients at higher risk. The role of biologic markers is unclear and the prognostic risk factors are mainly clinical. The proper time to abandon the conservative approach in favor of cystectomy is still object of debate. OBJECTIVES. The aim of the present study is to assess the clinical tumor features showing a detrimental effect on survival, identify the clinical risk factors impacting survival in patients undergoing conservative management of T1G3 bladder tumor, and to analyze the prognostic role of recurrence. METHODS. The present analysis is extended to 236 patients with T1G3 bladder tumors treated by TUR plus intravesical therapy between 1976 and 2005. Patients with previous T1G3, Tis, more than 3 tumors or greater than 3cm were excluded. Urinary cytology was obtained within 30 days after TUR. Since 2000 re-TUR has been performed. A sequential combination of mitomycin-C (30mg/30ml) and epirubicin (50mg/50ml) was adopted in 106 patients (44.9%). BCG or other agents were given intravesically in 85 (36.0%) and 38 (16.1%) patients, respectively. Seven (3%) patients refused intravescical therapy. In the case of Ta-TI recurrence, TUR and one year of adjuvant intravesical therapy were repeated. Patients went off study if Tis, T1G3 or T-category tumor over Ti were detected. Age, previous history, number of tumors, re-TUR, adjuvant therapy, recurrence and progression were considered for survival analysis. RESULTS. Tumors were primary in 177 (75.3%) and single in 144 (61.5%) cases. At a mean follow-up of 52 months (range: 3-246 months), 116 patients (49.2%) relapsed. The recurring tumor was Ti in 47(40.5%) cases and T1G3 in 33 (28.4%). In 11 additional patients (9.5%) a Tis was detected. Twenty-five patients (10.6%) progressed and 15 patients (6.4%) underwent cystectomy. Median overall survival was 167 months. The 5-year progression-free survival rate was 87.8%. Thirty-two patients (13.6%) died, 22 (9.3%) for bladder cancer. A higher mortality was detected in recurrent (p= 0.002) and multiple (p=0.009) tumors undergoing conservative management. Survival was decreased by NM! recurrence (p<0.0001) and by progression (p=0.009). No statistical significant difference in survival was evident in relation to the grade and stage of the recurrent tumor. CONCLUSIONS. Previous positive history and multiplicity are relevant risk factors for survival in patients affected by T1G3 NMI TCCB conservatively treated. Survival is decreased if conservative management is not given up at the time of NMI recurrence, independently from its grade and stage. [ABSTRACT FROM AUTHOR]

A shortage of BCG is foreseen till the end of 2013. Which will be the management of intermediate and high-risk NMI-BC if BCG will not be available? In patients harboring high-risk NMI tumors, particularly T1G3 and Tis, the first therapeutic choice is radical cystectomy. Device-assisted therapies, although showing promising results, should be considered only for selected patients. In intermediate risk patients, intravesical chemotherapy remains a legitimate option even if BCG is available. Thus, in a period of BCG shortage, intravesical chemotherapy should be offered, preferably preceded by early instillation, according to the EAU guidelines. [ABSTRACT FROM AUTHOR]

Despite the good quality of treatment expected with optimized transurethral resection (TUR) and adjuvant Bacillus Calmette-Guérin (BCG) regimen, many high-risk non-muscle invasive bladder cancer (NMIBC) patients recur and progress. According to the EORTC Tables of risk, cases with a score of 10-17 and those with a score of 7-23 should be considered as being at high risk of recurrence and progression, respectively. AUA and NCCN consider all T1 stage tumors, high grade Ta and CIS at high risk of recurrence and progression. Long-term follow-up shows that T1,G3 patients treated with BCG will suffer from up to 45% and 17% rate of recurrence and progression, respectively. Consequently, EAU, AUA and NCCN Guidelines for bladder cancer recommend radical cystectomy as a first treatment option for those patients who failed after two cycles of adjuvant BCG. However, to date, there is no definitive evidence that in this special subgroup of patients an early radical cystectomy is better than any additional salvage strategy, in terms of oncologic outcome. On the other hand, it is well accepted that radical cystectomy is burdened with consistent reduction of overall post-operative quality of life. The reluctance of patient to accept (and of surgeon to recommend) this major extirpative surgery may explain the reduced disease-free survival rate, well documented when radical cystectomy has been extremely delayed. Defining the criteria for the selection of BCG-failure patients for whom any conservative procedure should be definitively abandoned in favor of a timely radical cystectomy has become of critical importance. Recently, clinical, laboratory and pathologic acquisitions allowed the development of more accurate predictive factors for tumor progression in NMIBC. Among these factors, clinical type of BCG-failure, morphology and tumor growth patterns, pathologic sub-staging and immunohistochemistry will play a paramount role in decision-making with these patients in routine practice.

Nowadays, radical cystectomy represents the first choice of therapy for muscle invasive bladder cancer. The first choice after radical cystectomy, both in male and in female patients, is no more urinary diversion, but bladder replacement surgery through orthotopic reconstruction. The ileal conduit is considered a safe procedure and the gold standard to which newer forms of urinary diversion should be compared, although few long-term results are known. Currently, neobladder is the most important urinary diversion in the world, followed by Bricker's ileal conduit. We evaluated the long-term results of the most important forms of urinary diversions, analyzing some data available in the Literature. Then, we focused our attention on long-term outcomes of our "Y Neobladder": functional outcome and long-term complications. At last, we critically examined the widely accepted notion that patients undergoing "Y Neobladder" experience superior quality of life outcomes than patients receiving an ileal conduit.

Advantages and disadvantages of different types of urinary diversion and their choices are of utmost importance for the functional outcome and patient satisfaction. There is a variety of choices for incontinent urinary diversion (ureterocutaneostomy, ileal conduit, colonic conduit) and continent urinary diversion (continent urinary diversion, continent cutaneous urinary diversion, and urethral bladder substitution). The choices may be limited by patient criteria and/or medical criteria. Important patient criteria are preference, age and comorbidity, BMI, motivation, underlying disease, and indication for cystectomy. PERIOPERATIVE NURSING DESCRIPTION AT BRICKER INTERVENTION/ILEAL CONDUIT Teaching the patient with a newly formed stoma, but who also has low vision to manage his/her stoma independently, can be a difficult task. Practical tips on pre- and post-operative nursing care of the patient with a newly formed stoma are provided for the nurse. In some cases, unfortunately, complications may occur following stoma-forming surgery; these are discussed and nursing advice provided. One of the most important ways in which the nurse can support the patient is to teach the patient his/her stoma care, ensuring independence before discharge and showing empathy. There is still no conclusive evidence that any type of urinary diversion offers superior HRQOL (Health-related Quality of life) outcomes. In fact, though postcystectomy patients commonly experience urinary and sexual problems, HRQOL remains good irrespective of the method of urinary diversion. Future research should utilize the validated bladder cancer specific HRQOL instruments and perhaps explore the impact of pre-operative counseling on post-operative HRQOL.

Background: Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity., Introduction: Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence., Materials and Methods: We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones., Surgical Technique: preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted., Results: No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported., Conclusions: In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

Introduction: Neuroendocrine bladder cancer is extremely rare, with an estimated incidence of 0.35-0.70% of all bladder tumors. The small-cell carcinoma represents the most frequent histologic variant described. Small-cell carcinoma is an epithelial tumor associated with a more aggressive behavior and poorer prognosis than transitional cell bladder carcinoma. The overall survival rate at 5 years does not exceed 8%. At the time of presentation 59% of patients have clinical stage >T2 and 56% show metastatic disease. In 50% of the patients, fatal progression occurs within 6 months. Local recurrence after radical surgery occurred in 50-70% of cases., Patients and Methods: We report three cases of pure neuroendocrine small-cell bladder cancer. Hematuria was the most common presenting symptom. Local advanced disease was present in all the cases with stage >T2, metastatic disease in 1 case, lymph node involvement and ureteral bilateral obstruction in 2. Two patients were treated by radical cystectomy, bilateral pelvic limph node resections and urinary derivation. Platinum-based adjuvant chemotherapy was proposed but only two patients received the treatment. One patient with liver metastasis was managed only by extensive TUR and support regimen., Results: In 2 patients residual or relapsed cancer reappered within 2 months after surgery. All of the three patients died of metastatic disease at 5, 7, and 13 months. Median overall survival was 7 months. The most common site of relapse and spread of disease was the peritoneum and intestinal tract, and the reason of death was uncontrolled acute hemorrhage from gastro-intestinal district., Conclusions: In the absence of a prospective study, and because of the rarity of the disease, the best treatment for small-cell bladder cancer remains uncertain. Neoadjuvant chemotherapy with platinum regimen plus aggressive surgical approach will be the treatment of choice. The association of chemotherapy and radiotherapy should also be considered.

Age is a risk factor for the occurrence of bladder cancer and bladder cancer is a disease of the elderly. The choice of treatment relays on the staging into non-invasive and muscle-invasive bladder cancer. Non-invasive bladder cancer is usually treated with transurethral resection of the bladder (TURB) followed by intravesical therapy with BCG or chemotherapeutic agents. The gold standard in the treatment of muscle-invasive bladder cancer is radical cystectomy. The elderly and, in particular, the octogenarian have a worse tolerance for aggressive therapies, due to the higher incidence of side effects and complications. This problem could significantly occur for intravesical BCG therapy and for radical cystectomy. When the urologist faces the treatment of an octogenarian affected by bladder cancer, he should answer many questions: 1. In case of a non-invasive bladder cancer, is it possible to use the same drugs that we use for younger patients (BCG vs chemotherapeutic agents)? Should the timing and the kind of follow-up be the same? 2. Should the octogenarian affected by muscle-invasive bladder cancer undergo radical cystectomy or a less invasive treatment? What kind of diversion should be preferred? Is it possible to propose an orthotopic neobladder to an octogenarian patient? The choice of the treatment should be made on the basis of a careful evaluation of the patient, considering not only the patient's age but also comorbidities and life expectancy.

Today, the most widely employed “solution” after radical cystectomy is bladder substitution through the creation of an orthotopic neobladder. Many kind of orthotopic neobladders have been proposed and employed and, during the last 20 years, we have observed a continuous improvement of such techniques. Nevertheless, notwithstanding these technical improvements, patients with orthotopic neobladder can still report many various complications. Thus, a specific “functional” follow-up is mandatory; “functional” follow-up should be associated and integrated to oncological follow-up that these patients usually undergo. Functional follow-up should be lifelong.

Introduction: Neobladder vaginal fistula is a known complication after cystectomy and orthotopic neobladder in women. The exact incidence is still unknown, even if in some of the largest series is reported in about 5% of female patients. We present our personal experience with a case of neobladder vaginal fistula., Methods: A fifty-year old woman affected by T2G3 bladder cancer underwent radical cystectomy and orthotopic neobladder in December 2007. Definitive pathological examination revealed pT3aN0G3 urothelial cancer with squamous aspects. Two cycles of neoadjuvant chemotherapy were administered before cystectomy. Three weeks after cystectomy, a retrograde cystography revealed a fistula between vagina and neobladder. At first, the patient was treated conservatively, keeping the urethral catheter for two months. Cystographies, repeated every month, recorded a reduction in size of the fistula but not the complete closure. A surgical correction was planned. Preoperative cystoscopy showed the neobladder opening of the fistula on the posterior wall. Then a transvaginal approach with fistula excision and a two layer cross suture were performed., Results: At the cystography performed 1 month after surgical repair no fistula was detected, and the patient was completely dry. At 3 months follow-up the patient was completely dry., Conclusion: The development of a neobladder-vaginal fistula is a significant, even if infrequent, complication after cystectomy. In our case, we performed a transvaginal approach without tissue interposition, with good results. Such procedure is easy and effective and, in our opinion, can be tempted as first line surgical treatment.

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.

Purpose: The aim of this paper is to report the normal and pathological multidetector computed tomography (MDCT) findings in the morphofunctional evaluation of the orthotopic ileal reservoir in patients treated with radical cystectomy for transitional cell carcinoma., Materials and Methods: During a clinical and imaging follow-up of 43 months, 30 patients (27 men and three women) with prior cystectomy and urinary reconstruction with an orthotopic ileal neobladder [six Studer and 24 Paduan Ileal Bladder (VIP)] underwent multislice CT scan with multiplanar reconstruction (MPR), volume rendering and virtual endoscopic evaluation of the contrast-filled neobladder. The following CT data were considered: neobladder position within the pelvis, neobladder capacity, sphericity index, vesico-urethral angle, vesico-ureteral reflux, pseudo-diverticular herniation, visualisation of ileal folds and parietal thickness. The CT scan results were correlated with those of the urodynamic assessment (uroflowmetry and entero-cystometry)., Results: Right-sided dislocation was observed in 12/30 neobladders (six VIP and six Studer); mean capacity was around 254 ml; six VIP were spherical whereas the others were oval. The vesico-urethral angle was less than 90 degrees in five patients (normal range: 90 degrees-170 degrees). One patient had grade-3 unilateral, passive, vesico-ureteral reflux and nine patients had active or passive bilateral reflux. One patient had pseudo-diverticular herniation. The ileal folds in the afferent limb of the neobladder could be visualised in all six patients with Studer neobladders. Mean parietal thickness was 3.59 mm (SD 1.34 mm). Increased endoluminal pressure, evaluated by uroflowmetry, was associated with lateralisation of the new reservoir during straining in nine patients, with decreased neobladder capacity in six patients, vesico-ureteral reflux in five patients and pseudo-diverticular herniation in one case. Decreased urinary flow was correlated with vesico-urethral angle less than 90 degrees in four patients and with low sphericity index in five patients. No significant correlation was found between parietal thickness, presence of ileal folds and urodynamic data. Absorbed dose due to the two additional scans of our CT protocol was 10 mSv for 4-row CT and 15 mSv for 16-row CT., Conclusions: MDCT of the contrast-filled neobladder is useful for the morphological and, in part, functional evaluation of the neobladder during postoperative follow-up and helps detect surgical complications. Radiation protection concerns do not, however, support the routine use of the method, even if the MDCT data are in part correlated to the urodynamic data and may in many cases provide a morphological explanation to the presence of functional alterations.

The ileal conduit has been widely used for urinary diversion. It is a safe procedure with acceptable results, but it has become clear that the conduit can give rise to serious complications, notably renal deterioration in the long run. Stenosis of the ileal conduit, usually developing insidiously many years after the diversion, may be the cause of upper urinary tract damage. In most cases, a variety of possible factors is considered, including microvascular ischemia, urine-borne toxic material, infectious and allergic stimuli and an immunologic defect. Crohn's disease may affect an ileal loop urinary conduit. It presents as a diffuse loop stenosis. Recurrent transitional carcinoma arising within an ileal conduit following cystectomy for malignant disease is rare, but late malignancy in bowel segments exposed to urine without fecal stream is well known. In literature, distinction between conduit complications of patients with underlying benign disease and those with malignancy has not always been clear. Stoma and skin complications are frequently observed and the patients who practiced inadequate stoma care routines are more likely to show peristomal skin complications. Patients bearing an abdominal urostomy should be followed up stringently in stoma centers.

Primary radiation therapy may be recommended for patients with invasive bladder cancer, gynecological or prostatic cancer. When complications occur or in case of malignant recurrence, urinary diversion may be the best chance to restore an acceptable quality of life. The complication rate after this surgery is doubled. We report our experience in 32 patients submitted to urinary diversion after radiotherapy from 1985 to 2000: 2 enteric fistulas; 2 urinary fistulas; 5 stenosis of uretero-intestinal anastomosis were our complications. Radical cystectomy (24 cases) or anterior pelvic exenteration (8 females) preceded urinary diversion. Preoperative high-dose radiotherapy contributes to increased postoperative morbidity rates, particularly entero-enteric fistulas, uro-intestinal fistulas and stenosis of the uretero-intestinal anastomosis. In our experience, in most of the major urinary or enteric complications non surgical management was inefficient and surgical management was necessary.

Penile metastases from bladder cancer are unusual. A case of a man, 50 years old, with undifferentiated bladder carcinoma submitted to radical cystoprostatectomy and ileal conduit is presented. Twelve months after the primary diagnosis the patient presented metastases of the penis.

Metastases to the penis from transitional cell carcinoma of the bladder are rare. In the literature about 300 cases of secondary penile malignancies were described; 35% out of these cases were from primary neoplasms of the bladder. The Authors describe a case of priapism secondary to penile metastases from a transitional cell carcinoma of the bladder.

Background: The aim of the study is to evaluate the nutritional stats in candidates to radical cystectomy in order to minimize post-operative complications., Methods: The evaluation is carried out on the basis of anthropometric, bio-humoral and immunologic indexes in a retrospective analysis of patients who underwent major urologic surgery during the last two years. Twenty cases of invasive bladder cancer (mean age 71 years) who underwent radical cystectomy have been studied: in 13 cases urinary diversion by Camey II technique, in 7 cases by Bricker technique has been performed. In 5 cases of orthotopic neo-bladder, endovenous parenteral protein sparing nutrition was carried out for 4 days, in the remaining 15 cases glucidic and saline solutions have been administered., Results: In all the 20 evaluated patients post-operative complications have not been observed., Conclusions: On the basis of the data obtained, the conclusion is drawn that patients with bladder cancer are generally not so malnourished to need an artificial feeding regimen. Considering the urinary tract substitution effects on renal function and metabolism, particularly for the role of glucose on proximal and distal tubule the usefulness of administering only glucidic solutions and maintaining a good diuresis is underlined.

From January 1992 to September 1997, 29 male patients between the age of 39 and 71 affected by localized bladder cancer underwent radical cystectomy and received detubularized orthotopic ileal neobladder. In most cases we performed the ileal neobladder utilizing the Studer technique, preferring the Wallace 1 method for the uretero-ileal anastomosis, that seems to reduce the risk of stenosis. In some patients we experimented different techniques. One of these was the utilization of staplers but, at present, we are no longer using this procedure due to its high costs without any real advantage in operative time. Another technique is the performance of continuous suture in catgut 000 on the ileal aperture edges for the anastomosis with the urethra, because we believe that this method makes the ileal wall stronger. Usually we apply 6 stitches in vicryl 000 for the urethro-ileal anastomosis. In 14-28 days, after a cystography to exclude the presence of urinary fistula, the catheter was removed. 6 months later an evaluation was made utilizing an auto-evaluation questionnaire, biochemical, radiological and urodynamic examinations. The diurnal continence (96%), the nocturnal continence (71%), the renal function preservation (normal in 86% of patients), the radiological, biochemical and urodynamic (low pressure and high capacity of the neobladder) results were comparable with those published in literature. The discrete percentage of urinary refluxes observed (39%) puts in doubt the real efficacy of the undetubularized ileal tract as an antireflux mechanism, however it does not seem to determine an important reduction of renal function, as confirmed in the check up five years later. In our experience, this operation reduces the risk of stenosis of the uretero-ileal anastomosis.

Background: To evaluate as the natural history of superficial bladder tumors is modified by intravesical chemotherapy and if the behavior of treated tumors allows to forecast subsequent tumoral evolution., Methods: 125 patients with superficial bladder tumor Ta and T1 were submitted to transurethral resection (TURB) and additional chemotherapy for one year. Mean follow-up was of 92.2 +/- 39.8 months and all patients were observed for four years at least., Results: Efficacy of treatment was according to the literature: the median of recurrence was estimated about the 10th year (increase of free interval); the percentage of patients free from recurrence after 14 years of follow-up was 35 +/- 19.9, instead that of specific survival was 87.1 +/- 11.8 (inefficacy in a long period); the percentage of tumor related deaths was of 10.4 (inefficacy to avoid the progression). Regarding the risk factors present on the beginning, there was a significance for the T1 that relapsed in the 56.6% versus the 30.9% of the Ta (p = 0.012) and for the multiple tumors that relapsed in the 64.4% versus the 38.7% of the single one (p = 0.009). Also the time and the T category of the first recurrence were interesting factors for the subsequent evolution of disease. In fact, in the 47 patients at beginning T1 that relapsed, there was a 43.4% of tumor related deaths if the recurrence occurred in the first year of follow-up, versus the 12.5% if the recurrence occurred after the first year (p = 0.017). Furthermore the 61.9% of patients "non Ta" (T1 or Tis) to the first recurrence died for tumor but no one if the first recurrence was Ta (p = 0.000)., Conclusions: Intravesical chemotherapy is still reliable. It is able to increase the free interval of recurrence after TURB. Moreover it can offer a useful criterion to recognize patients with chemoresistant tumors at higher risk of progression.

A case characterized by a rare synchronous occurrence of transitional cell carcinoma of the renal pelvis and renal cell carcinoma in the contralateral kidney is presented. The simultaneous occurrence of renal adenocarcinoma and transitional cell carcinoma of the renal pelvis in the opposite kidney is unusual.

Purpose: to assess the results of bladder preservation in infiltrating bladder cancer. The potential for neoadjuvant chemotherapy followed by extensive TUR and radiotherapy was investigated in 40 patients with T2-T4a G2-G3 bladder carcinoma., Materials and Methods: from 1983 to 1995, 40 patients were submitted to bladder-sparing treatment consisting of neoadjuvant chemotherapy, extensive, TUR and radiotherapy. Most patients had T3G3 cancer. Cystectomy was not performed due to patient" choice in 29 cases (72.5%), for severe pulmonary or cardiovascular disease in disease in 9 patients (22.5) and age over 80 in 2 (5%) patients. A deep TUR-biopsy was performed before and after chemotherapy and an extensive TUR was repeated at the end of radiotherapy. In the first 30 patients chemotherapy consisted of 2-4 cycles of 70 mg/m2 cisplatin on fay 1, and 40 mg/m2 methotrexate on days 8 and 15. In the last 10 patients chemotherapy consisted of 3 cycles of CMV (100 mg/m2 cisplatin on day 2, 30 mg/m2 of vinblastine on days 1 and 8). Total dose of radiotherapy was 60-65 Gy. Recurrent superficial tumors were treated transurethrally. Radical cystectomy, when feasible, was considered for persistent or recurrent invasive disease., Results: after chemotherapy, a clinical objective response was obtained in 27 patients (67.5%), 19 (47.5%) of whom showed a complete response. Thirteen (32.5%) patients showed no response and 5 (12.5%) progressed during chemotherapy. After extensive TUR of any residual mass and radiotherapy, a complete response was achieved in 6 patients who initially showed a partial response and in other 2 patients and stable disease after chemotherapy. Altogether, 27 patients (67.5%) presented had local recurrences, 3 patients underwent cystectomy. Fourteen patients (35%) are alive and 13 NED (65 months mean survival). Five patients died of unrelated disease. Twenty-one patients (52.5%) died of distant metastases (mean survival 28 months). Four patients presented distant metastases after vesical infiltrating recurrence and 4 patients had distant metastases in the absence of loco-regional recurrence. Twenty-two patients (55%) maintained an intact bladder. Patients with complete response to chemotherapy showed a low risk for developing recurrent infiltrating tumors and metastases., Conclusions: A complete tumor was maintained at 5 years in over 50% of the patients conservatively treated. Bladder salvage is feasible in selected patients.

The authors describe a case of infiltrating signet-ring cell carcinoma of the bladder, a rare and extremely aggressive form of adenocarcinoma. This neoplasia in only rarely found in a histologically pure form. In the majority of cases the atypical elements which characterise it are mixed with the gland-like and papillary structures of the adenocarcinoma and with foci of transitional or pavimentous carcinoma. The origin is probably metaplastic. These carcinoma are generally invasive, scarcely differentiated and often cause linitis plastica of the bladder. The histological picture is characterized by atypical epithelial elements with abundant, vacuolised cytoplasma. The nuclei are hyperchromic and eccentric, thus representing the typical appearance of signet-ring cells. The histological picture cannot be distinguished from that of a secondary gastrointestinal or prostatic form, therefore the primary diagnosis requires a full clinical and pathological examination of the sectors describes. The prognosis is severe. Elective therapy consists in radical cystectomy with pelvic lymphadenectomy.

At USC around 90% of female patients undergoing cystectomy have become potential candidates for lower urinary tract reconstruction. There are two important criteria when considering the procedure: the continence mechanism must be preserved (by preserving pudendal innervation) and the cancer surgery should not be compromised by the reconstructive procedure. The reconstruction has a similar appearance and function to the original bladder and does away with the need for a cutaneous stoma, providing a normal micturition pattern and improving the patient's quality of life and self-image. Excellent results have so far been obtained with 34 patients, 85% of whom have achieved continence and the ability to void to conclusion.

Urethral bladder substitution is traditionally suggested to good prognosis cystectomized patients. In our series this diversion was chosen for all but the salvage cystectomized men. Between the 1st of February 1991 and the 30th of April 1996, one hundred consecutive men underwent lower urinary tract reconstruction after radical cystoprostatectomy for bladder cancer. An orthotopic ileal neobladder was constructed (in 84 cases according to Kock's technique and in 16 to Studer's technique). Total early complication rate was 29% (29/100), including one perioperative death due to sepsis (mortality rate 1%). 13 patients required surgery (6 retroperitoneal hematomas, 2 wound dehiscences, 1 urinary fistula, 1 lymphocele, 1 rectal-neobladder fistula, 1 rectal-cutaneous fistula, 1 necrosis of the terminal ureter). The late complication rate was 19% (19/100); in 8 cases reparative surgery was required (1 mechanical ileus, 2 bladder neck stenoses, 3 stenoses of the ureteral anastomosis, 2 laparoceles). Four patients were lost at the follow-up; out of the 96 remaining patients only 85 were evaluable for continence: continence during the day was achieved in a period between there to six months in 78 patients (91.7%); night continence was achieved with planned awakenings in 60 patients (70.5%). Eight patients recovered potency, another 7 had successful intercourses after PGE1 intracavernous injection. Renal function based on creatinine value was mildly impaired in 5/78 evaluable patients (6.4%) (peak creatinine 2.8 mg%). In 29 patients tumour progression was observed (29%): 9 pelvic and 20 metastatic. Among the latter 2 urethral recurrences were observed (2%). Twenty-four patients died for metastatic cancer, one for primitive lung cancer, one patient for postoperative septic shock. Adjuvant chemotherapy was administered in 11 patients without complication with an indwelling catheter in the neobladder to avoid drug reabsorption. Four patients showed complete response (2 are alive after a mean of 12 months), 6 were non responders and 1 had a partial response. In our series the ileal neobladder is a feasible method of urinary diversion when urethral cancer involvement is ruled out. Early and late complications are proportionally decreasing with experience and overall continence is satisfactory. The fate of the neobladder depends on both the technique and patient's compliance. Only educated patients can cope successfully with neobladder diversion without major complications. All the patients operated for non salvage cystectomy deserve to be diverted with a continent urethral bladder substitution.

Purpose: evaluation of results and complications of ileal orthotopic neobladders in men and women with transitional cell carcinoma., Materials and Methods: between 12-89 and 12-95 we performed 146 radical cystectomy for bladder neoplasm, in 32 patients we can perform ileal orthotopic neobladder, 29 were male and 3 were female. Oncologic indications to this kind of operation were: clinical stage T2, T3a, T3b, T1G3 multicentric and or recurrence, absence of metastasis absence of nodal metastasis, negativity of urethral biopsy. General contraindications were urethral stenosis and incontinence. Oncological contraindications, in woman, were bladder neck neoplasm or urethral neoplasm. In 4 patients we use Camey II technique, in 19 pts we performed the paduan ileal neobladder, in 9 pts we use Hautmann technique. 7 patients performed neoadjuvant chemotherapy with 4 circles of MVAC, 4 pts underwent adjuvant chemotherapy, and 2 pts salvage chemotherapy. In woman we take care during cystectomy to dissect cardinal ligament very close to cervix uteri, to resect the uterosacral ligament far to the sacrum. We did not dissect under the ureter and we cut the urethra 0.5-1 cm far from the bladder neck., Results: follow up was between 6 and 66 months. 24 patients are now alive and disease free, 2 patients are alive with disease progression, 1 have a pelvic recurrence and 1 have pulmonary recurrence. 4 pts died for disease progression and 2 for non oncological cause, quality of life was considered as regard to continence and sexual activity. 1 pts was completely incontinent and 1 pts has nocturnal incontinence with a daily micturation every 1 hour. We can evaluate only 18 patients for sexual activity and 4 reported normal erection., Complications: in three cases we had to reoperate for early complications due to mechanical bowel obstruction, ileocutaneous fistula and wound dehiscence. In three cases we had the formation of stones, in two patients ureteroileal stenosis, in two cases urethro-ileal stenosis and 1 reflux from the neobladder. Orthotopic ileal neobladder allows a very good quality of life and is the first choice derivation after radical cystectomy.

We present our clinical and metabolic follow-up data of 74 patients submitted to total bladder substitution using an ileal orthotopic neobladder in one group of 64 patients and a continent stomal pouch in another group of 10 patients. In the first group the mean follow-up was 41.5 months. The daytime continence was early achieved in 89% (57/64) and was maintained with time; at 12 month follow-up nocturnal continence was reached in 71% (45/64). Post voiding residual was significant only in 4 patients (2 men and 2 women). No clinical signs of pyelonephritis nor renal scars at IVP was evidenced in all but 7 patients in which a silent uretero-ileal stenosis developed. No severe metabolic acidosis or B 12 deficiency occurred. In the second group (Continent Pouch) the long term 3-Year follow-up shows a complete continence in all patients with an average capacity of 600 cc. No late complications occurred in all patients but one in which self intermittent catheterization was uncomfortable and now he prefer permanent catheter and in another patient with a stone in the Pouch treated with Lithoclast. In conclusion, total bladder substitution after radical cystectomy is now represented by orthotopic neobladder or continent Pouch in men and women. Early and late complication rate is relatively low and continence generally good.

Strictures of entero-urethral anastomosis in orthotopic neobladder and of the catheterizable conduit in continent diversion after cystectomy are seldom encountered; they are usually treated with dilation, TUR or cold incision. 3 cases that came to our observation are presented. The first was treated with TUR after neo-bladder neck stricture in orthotopic neobladder; total incontinence occurred after this procedure. The patient at present is waiting for AS800 artificial sphincter implant. The second patient had similar features. After repeat TUR a prostacoil removable stent was placed through the stricture and removed after 5 months. At 12 months from removal the patient is continent and doesn't present clinical evidence of restriction. The third patient underwent cystectomy with Indiana continent pouch. After 4 months increasing problems in self catheterization occurred due to stricture of the catheterization conduit (appendix). He was treated twice with cold incision with early recurrence of the stricture. A permanent Memotherm stent (indicated for urethral strictures) was placed inside the appendix. After one month self catheterization was started again. At a 2 months follow up there is no evidence of stricture. In our experience, even if anecdotal, we have verified that treatment of this kind of strictures with TUR can cause incontinence or expose to further recurrences. 2 of the cases presented were treated with different kind of stents; the outcome is good even if the follow up is still short. We believe that this kind of treatment can be considered in selected cases.

We subjected to a functional and metabolic evaluation (urodynamic examination + cystography) 10 patients underwent to radical cystectomy with a ileal orthotopic reservoir (VIP) for bladder cancer. At the moment patients have a minimum 3-years follow-up and they are out of disease. The medium capacity of the reservoir is about 447 ml, with a low pressure flow, a medium pressure of ureteral closing of 62.5 cm of H2O. At the cystography neither ureteral reflux nor post miction residuum have been proved. All the patients are continent, with the exception of one patient suffering from episodes of nocturnal enuresis. The metabolic evaluation hasn't proved substantial changes except the presence of hypocitraturia in the only patient in metabolic acidosis. In conclusion the ileal orthotopic reservoir showed a good long-term functionality without considerable complication of metabolism.

A comparative study between modified Camey II and Studer ileal orthotopic neobladder was performed. The Camey II was modified as follows: 1) The ureters were implanted, using wallace technique, in an undetubularized ileal loop, 15-18 cm. long, to prevent vesico-ureteral reflux; 2) The neobladder was made using staplers. In such a way, time is saved (about one hour) and results are quite similar, with a low rate of ureteral stenosis in both groups.

We refer our experience about continent ileal orthotopic bladder in male patient with bladder tumor we report our selections criteria, with particular attention about technical point of view. We show the results, early and late complications.

42 ileo-colonic orthotopic reservoirs (M.A.I.N.Z.) following radical cystectomy were evaluated with urodynamic studies. Long term results in 19 patients with a follow up longer than 36 months were compared to the findings of 23 patients with a shorter follow-up. Urodynamic evaluation showed a reservoir with large capacity and low pressure in both groups. Nocturnal incontinence occasionally occurred. Many factors may account for this problem. Instillation of hyperosmotic solution during cystometry resulted in increased amplitudes and frequency of intracavitary pressure waves: the nocturnal increase in urine osmolality could be in correlation with nocturnal incontinence.

The high risk of progression found in T1G3 bladder cancer influence the treatment and follow-up of this kind of patients. From January 1983 to December 1992, 803 patients with superficial bladder cancer (first presentation) had observed in the Urology Department at the Spedali Civili in Brescia. In this group, 96 patients were classified as T1G3 and our retrospective study is a critical analysis about their treatment: 13 patients underwent cystectomy as primary treatment and 83 had been cured with a transurethral resection. Of this last group, 26 patients are still without of disease (mean follow-up: 4.2 years), 30 had a recurrence which, in stage and grade, was identical or lower to the initial disease and 27 patients had a progression. Alltogether 36 patients underwent cystectomy: 15 are tumor-free and 21 died. The results of this retrospective study, led us to believe that T1G3 bladder cancer therapy is endoscopic at the beginning. Adjuvant topic chemotherapy treatments improve the recurrence rate tangibily; an early-operated cystectomy permits a good rate of recovery.

Between 13.8% and 27% of all superficial bladder cancers are represented by pT1G3 neoplasm. In the Department of Urology of Policlinico S. Marco-Zingonia, between February 1988 and June 1994, we treated 22 patients suffering for pT1G3 bladder tumor. TUR-B has demonstrated to be a good approach for treatment of superficial bladder cancer, with low morbility; on the opposite side, we have to underline the high rate of recurrence and of progression of the urothelium disease. Now a day our best approach for the treatment of pT1G3 bladder tumor is represented by radical cystectomy supplied by chemotherapy.