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Objective: To evaluate health-related quality of life (HR-QoL) outcomes in elderly patients with different type of urinary diversion (UD), ileal conduit (IC) and ileal orthotopic neobladder (IONB), after radical cystectomy (RC) for bladder cancer, by using validated self-reported cancer-specific instruments. Patients and Methods: We retrospectively reviewed 77 patients who received an IC or an IONB after RC. HR-QoL was assessed with specific and validated disease questionnaires, administered at last follow-up. Result: At univariate analysis, at a mean follow-up of 60.91 ± 5.63 months, IONB results were favourable with regard to the following HR-QoL aspects: nausea and vomiting (p = 0.045), pain (p = 0.049), appetite loss (p = 0.03), constipation (p = 0.000), financial impact (p = 0.012) and cognitive functioning (p = 0.000). This last functional aspect was significantly worse in female patients (p = 0.029). Emotional functioning was significantly better in patients without long-term complications (p = 0.016). At multivariate analysis, male gender and IONB were independent predictors of better cognitive functioning, while long-term complications negatively affected emotional functioning. Conclusions: Obtained results suggest that an IONB can also be suitable for elderly patients compared with an IC with few and selected advantages in favour of the former UD. Preoperative patient’s selection, counselling, education and active participation in the decision-making process lead to a more suitable choice of treatment.

Introduction: Paraneoplastic syndromes (PNS) may represent the main clinical problem in cancer patients; however, the knowledge of their clinical aspect remains quite poor among urologists. Objective: To provide urologists with an overview on main clinical aspects of PNS that have been reported to be associated to urological cancers. Methods: Literature search of peer-reviewed papers published by July 2008. Results: All genitourinary tumors can cause a PNS, and renal cell carcinoma is the most frequent urological malignancy involved. Prostate cancer is the second urological tumor associated with PNS which, conversely, are uncommon in bladder cancer and rare in testicular cancer. Tumor neuroendocrine differentiation is involved in most endocrine PNS. Neurologic PNS are very uncommon but may dominate the clinical picture and need a high suspicion index to be recognized. Important advances have been made on radionuclide scan methods in order to detect the primary tumor. The most effective treatment strategy is always represented by the radical therapy of the underlying cancer, but specific therapeutic options are sometimes available. Conclusions: Endocrine PNS are frequently associated with urological cancers, especially renal and prostate carcinoma. PNS have been rarely reported in association with cancers of bladder, urethra and testicle.

Objective: The thick loop is a new device employed for transurethral resection of the prostate (TURP) using the standard resectoscope. The loop is broader and thicker than the standard one, resulting in better hemostasis because of its ability to cut, coagulate and vaporize tissue simultaneously. We evaluated the safety and efficacy of the thick loop device compared with the standard loop. Patients and Methods: 103 patients with symptomatic benign prostatic hyperplasia were randomized to undergo either thick loop (51 patients) or standard loop TURP (52 patients). Patients were considered for surgery with the American Urological Association (AUA) symptom score greater than 7 and a maximum urinary flow rate max) and postvoiding residual urine volume were evaluated. Results: There were no significant differences between thick and standard loop TURP regarding the operative and catheterization time, prostate resection weight and postoperative levels of hemoglobin, hematocrit and electrolytes. Twelve months after TURP, the AUA score was significantly lower and Qmax greater in the thick loop compared to the standard loop groups. Conclusions: Thick loop TURP is as safe as standard loop TURP with respect to blood loss, operative time and complications. Operating in a virtually bloodless field could allow a more radical TURP and provide an explanation for the better functional results (Qmax and AUA score) obtained by the thick loop resection.

Introduction: The authors present the functional long-term follow-up by means of digital fluorographic video-urodynamics (DFVUDM) of two different surgical urinary diversions. Materials and Methods: 64 of 101 patients submitted to radical cystectomy from 1983 to 1999 for infiltrating bladder cancer, were diverted by means of an Alcini’s ileocecourethrostomy (ICUS+T), and the remaining 37 patients by means of an ileal reservoir (IR). All of those orthotopically diverted patients were submitted to an accurate follow-up which included DFVUDM 1, 3, 6, and 9 years after the surgical procedure (mean follow-up 51 ± 42 months). Results: All the evaluated patients showed a neobladder with good function during both the filling and the voiding phases. In 88.8% of the DFVUDM examinations, it was possible to find a residual peristaltic activity of the neobladder walls. Such a residual peristaltic activity caused urinary leakage during the examination in 11.1% of cases, while vesico-ureteral reflux was detected in 12.5%. The patients voided by relaxing the perineal floor and/or by contracting the abdominal muscles: the emptying of the reservoir was often excellent with average residual urine of 28.5 ml. None of the patients needed clean intermittent catheterization. EMG evaluation of the pelvic floor in some of patients showed a peculiar EMG pattern characterized by an insufficient voluntary control of the perineal musculature with a slight increase of EMG activity during bladder filling. Moreover, an insufficient relaxation of the pelvic floor muscles in the beginning of and during the micturition has been seen. This particular EMG pattern was present in 22.22% of all patients included in this study while it was particularly high (81.81%) in patients with leakage. Conclusion: DFVUDM evaluation represents a highly sophisticated tool which allows an accurate long-term morphofunctional evaluation of the urinary diverted patients. In this study, it is shown that the functional results of the two studied surgical procedures, namely Alcini’s ICUS+T and IR, are quite similar, demonstrating that the taeniotomies on the cecal tract may have almost the same functional effects of detubularization. Although DFVUDM revealed imperfect functional performances in some patients, the quality of life of diverted patients in our series seems to be satisfactory.

Objective: It was the aim of this study to evaluate the accuracy of the measurement of tumor size comparing the objective size with that measured by preoperative cystoscopy, by preoperative ultrasound (US) and with the diameter described by the operator before the transurethral resection. Patients and Methods: This study included 100 patients with bladder papillary endoscopic features of single or multiple neoplasms who were candidates for transurethral resection. The sizes of the same neoplasms measured during preoperative cystoscopy, preoperative US and described by the operator before the transurethral resection were evaluated. A statistical analysis of the errors of measurement was performed if compared with an objective measurement done with an ureteral catheter. Results: The statistical analysis of the data shows that there are no substantial differences between the objective and subjective measurement, and therefore, the measurements reported by individual operators are reliable. On the contrary, the diameters given by preoperative cystoscopy and US differ significantly from the objective measurement. Conclusions: This study shows that the most reliable measurement is the subjective measurement made directly by the urologist in the operating room.

The aim of the present paper was to review findings from the most relevant studies and to evaluate the value of current chemotherapy and surgery in advanced unresectable and metastatic bladder cancer. Studies were identified by searching the MEDLINE® and PubMed® databases up to 2011 using both medical subject heading (Mesh) and a free text strategy with the name of the known individual chemotherapeutic drug and the following key words: ‘muscle-invasive bladder cancer’, ‘chemotherapeutics agents’, and ‘surgery in advanced bladder cancer’. At the end of our literature research we selected 141 articles complying with the aim of the review. The results showed that it has been many years since the MVAC (methotrexate, vinblastine, adriamycin, cisplatin) regimen was first developed. The use of cisplatin-based combination chemotherapy is associated with significant toxicity and produces long-term survival in only approximately 15–20% of patients. Gemcitabine + cisplatin represents the gold standard in the treatment of metastatic bladder cancer. In conclusion, the optimal approach in the management of advanced urothelial cancer continues to evolve. Further progress relies on the expansion of research into tumor biology and an understanding of the underlying molecular ‘fingerprints’ that can be used to enhance diagnostic and therapeutic strategies. Cisplatin-based therapy has had the best track record thus far.

Objectives: Non-muscle-invasive bladder cancer is characterized by a high recurrence rate after primary transurethral resection. In case of bacillus Calmette-Guérin-refractory neoplasms, cystectomy is the gold standard. In this study the effects of thermochemotherapy with mitomycin C were evaluated in high-risk bladder cancer nonresponders to previous therapy. Patients and Methods: Between January 2006 and December 2009, 30 patients were enrolled with recurrent stage carcinoma in situ, Ta and T1, grade G1 to G3 non-muscle-invasive bladder cancer refractory to chemotherapy or immunotherapy and so becoming suitable for radical cystectomy. All patients underwent endovesical thermochemotherapy: 16 patients underwent a prophylactic scheme and 14 patients underwent an ablative scheme. Results: All the patients completed the study. The mean follow-up for all the patients enrolled was 14 months. Thirteen of 30 patients (43.30%) were disease free and 17 patients (56.70%) had recurrence. In the prophylactic group, 7 of 16 patients (43.75%) were disease free and 9 patients (46.25%) had tumor recurrence; no progression was observed. In the ablative group, 3 patients (17, 64%) had progression to muscle-invasive disease. Side effects were generally mild. Conclusions: Thermochemotherapy could be considered an additional tool in patients refractory to intravesical therapies before considering early cystectomy.

Background and Aim: Renal cell carcinoma (RCC) is the 13th most common cancer worldwide and accounts for 4% of all adult malignancies. Herein the state of the art and recent advances in cross-sectional radiological imaging applied to RCC are reviewed, including ultrasonography, computed tomography, magnetic resonance imaging, and positron emission tomography. Methods: Literature search of peer-reviewed papers published by October 2010. Results: In front of more conventional and widespread imaging tools, such as ultrasonography and computed tomography, an array of newer and attractive radiological modalities are under investigation and show promise to improve our ability to noninvasively detect renal tumors and its recurrences, accurately assess the extent of the disease, and reliably evaluate treatment response, particularly in the era of antiangiogenetic therapy. Conclusions: Recent major advances in radiological imaging techniques have considerably improved our ability to diagnose, stage and follow-up RCC. Further studies are needed to evaluate the potential of most recent and still investigational imaging tools.

Advances in imaging have an increasingly significant role in the diagnosis, staging and restaging of patients with bladder cancer. This paper reviews the current use of imaging in bladder neoplasms, comparing the different radiologic investigations, and discusses the potential applications of novel imaging techniques in the management of patients with bladder cancer.

Objective: The aim of this work was to verify the tolerability and the preliminary clinical results of intensive intravesical instillations of a mitomycin C (MMC) regimen. Patients and Methods: From September 2007 to November 2009, 40 consecutive evaluable patients with pathologically confirmed intermediate-risk non-muscle-invasive bladder cancer (NMIBC) were enrolled after complete transurethral resection of all visible tumors. The mean age of the patients was 64.5 years. 40 mg MMC diluted in 50 ml of saline was instilled in the bladder three times a week for 2 weeks. The median follow-up was 9 months. Results: All patients fulfilled the scheduled treatment. The local adverse events seen were negligible, while no significant deviation from normal values was observed in blood counts for each patient. Twenty-three of 40 patients (57.5%) showed negative at the cystoscopic control which was performed every 3 months with normal spontaneous and washing cytological exams. Conclusion: MMC is a well-known chemotherapeutic agent for the intravesical therapy of NMIBC. With a view to improving its results, we changed the frequency and intensity of the instillations. No significant local or systemic toxicity was reported. Intensive intravesical instilllations of MMC might become a tool in the management of NMIBC.

The use of chemotherapeutic agents in the treatment of superficial bladder cancer is well known. In particular, mitomycin C (MMC) is globally accepted also in the early treatment after an endoscopic resection. Complications related to MMC are usually scarce as a systemic absorption is quite absent, while its use is effective for the bladder recurrence reduction. In our experience we report a female patient with a bladder perforation after an early instillation of a single dose of MMC. In this case, systemic toxicity occurred requiring subintensive care for a complete repair.

Introduction: The aim of this study was to retrospectively compare the clinical outcomes achieved in 2 groups of patients with cT3 prostatic carcinoma undergoing neoadjuvant hormonotherapy and neoadjuvant hormonotherapy plus adjuvant hormonotherapy with external beam radiotherapy. Patients and Methods: One hundred patients with cT3N0M0 prostatic carcinoma underwent radiotherapy to pelvic lymph nodes (45 Gy, 1.8 Gy/fraction) with a booster dose (65–70 Gy) to the prostatic cavity. Forty-four patients received neoadjuvant hormonotherapy (goserelin, starting 2 months before radiotherapy and continuing until the end of irradiation); 56 patients received neoadjuvant hormonotherapy plus adjuvant goserelin until disease progression, if present. Results: Patients undergoing adjuvant hormonotherapy as compared to those who received exclusive neoadjuvant therapy showed a higher reduction in PSA level below 1.0 ng/ml (p = 0.0211), a lower incidence of biochemical failures (p = 0.0170), a lower incidence of hematogenous metastases (p = 0.0320) and a trend suggestive of a better disease-free survival (p = 0.0660). At univariate analysis (logrank), Gleason score did not show a significant correlation with any of the end points analyzed. To the contrary, patients with tumor 70 Gy showed a trend with biochemical failure-free survival (p = 0.0554). At multivariate analysis, a correlation between Gleason score and incidence of metastases (p = 0.0232), and between tumor diameter and local control (p = 0.0178) and biochemical failure-free survival (p = 0.0290) was recorded. Conclusions: In patients with cT3N0M0 prostate carcinoma, prolonged hormonotherapy was shown to be significantly correlated with biochemical failure-free survival and distant metastasis-free survival. Furthermore, tumor size had a significant impact on biochemical failure-free survival as well as on local control.

Objective: To compare secretory immunity in cecal and ileal orthotopic neobladders, and to detect its permanence over time. Patients and Methods: IgA was studied in the urine of 33 patients with ileocecourethrostomy (ICUS) and 13 patients with ileal reservoir (IR). The mean follow-up was 55 months. Results were compared in terms of the type of operation, a healthy control group, and the time since surgery. Results: Urinary IgA levels were significantly higher in ICUS and IR patients than in normal controls. No significant differences in IgA concentrations were detected in patients with different reservoirs and with regard to time. Conclusion: Both the reservoirs maintain the function of producing IgA. In particular no differences were detected over time and urine could be a permanent antigenic stimulus. IgA could be considered an adjunctive factor for upper urinary tract protection. For this reason we prefer to use a simple, indirect antireflux mechanism, thus avoiding direct manipulation of the uretero-intestinal anastomosis.