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Orthotopic reconstruction offers the most natural voiding pattern after radical cystecomty, allowing voluntary micturition through the intact native urethra. Several pathologic reviews have demonstrated that with careful selection of appropriate patients, a portion of the female urethra can be preserved for orthotopic reconstruction. Performing minimal dissection anteriorly, and avoiding injury of the pudendal innervations to the rhabdosphincter is crucial in maintaining the midurethral continence mechanism in female patients with neobladders., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Transurethral removal of bladder cancer is performed for diagnostic and therapeutic reasons. Tissue is returned for histologic determination of tumor grade and stage. For tumors that do not invade the detrusor muscle, resection can be curative although there is a high rate of new tumor occurrence. Surgical removal not only eradicates visible existing lesions but also retrieves material for histologic evaluation. This examination allows a determination of tumor grade as well as stage. Because of the importance of good histologic information in determining prognosis and, possibly, the need for further therapy, the method of surgical removal is important.

Given the excellent local control rates achieved with partial penectomy, it is important to consider laser treatment or radiation therapy of squamous cell carcinoma of the penis cautiously. Emotional issues surrounding preservation of a functional penis should not be allowed to compromise adequate therapy. On the other hand, some penile cancers undoubtedly can be managed adequately by techniques other than partial penectomy. The fundamental question is, then, how great a compromise laser treatment or radiation therapy introduces. In patients who present with bulky, long-neglected penile cancers, the point is moot: Partial or even total penectomy is indicated. However, other treatments are feasible in many patients, and an attempt at functional organ preservation should not be restricted simply to the rare small tumor. Lesions up to 2 cm in size can be controlled adequately without amputation. Because tumor grade correlates highly with depth of invasion, the presence of nodal metastasis, and survival, most poorly differentiated squamous cell tumors of the penis probably should be treated by amputation. As mentioned above, it may be several months after laser treatment or radiation therapy before local treatment failure is recognized. Although this is a concern, it probably does not ultimately result in therapeutic compromise in most patients. With most urologic cancers, local recurrence equates with the inability to cure the patient and, ultimately, death. With locally recurrent carcinoma of the penis, however, the situation can be salvaged by converting to partial penectomy. Thus, the patient compromises his chances for cure only if tumor dissemination occurs during the few months between the end of treatment and recognition of failure.

This article assesses the likely role of PSA in the future management of patients with carcinoma of the prostate, taking into consideration new methods for measurement and assessment. In addition, novel tumor markers are discussed that may complement, or even perhaps replace, PSA.

Lasers generate a unique form of energy with specific tissue effects different from those of either unipolar or bipolar electrocautery. A noncontact coagulation necrosis of superficial transitional-cell carcinoma of the bladder can be achieved. There are insufficient data to support the contention that the recurrence rate of transitional-cell carcinoma is decreased by laser therapy. However, there is abundant evidence that laser treatment of superficial bladder cancer is effective in eradicating grossly visible tumors. Bleeding does not occur during laser application, a clear advantage over electrocautery resection. Additionally, the treatment can sometimes be performed without anesthesia, and the energy can be transmitted via flexible fibers, facilitating the use of flexible cystoscopes. Bladder perforation is unlikely, obturator nerve stimulation does not occur, and postoperative Foley catheter drainage of the bladder is unnecessary. Tumors within bladder diverticula can be treated endoscopically with lasers, and stenosis of the ureteral orifice is rare. There is experimental evidence that laser treatment does not increase the absorption of intravesical chemotherapy, possibly allowing earlier adjuvant use of intravesical treatment postoperatively. On the other hand, there are limitations of laser treatment. Lasers are less familiar to both surgeons and operating room personnel. Appropriate eye protection during treatment is mandatory. Tumor staging is suboptimal, because tissue from the base of the lesion is not routinely available for histologic examination. Accordingly, appropriate patient selection is a paramount consideration. Finally, bowel injury without bladder perforation is a unique, though rare, complication of laser surgery. Simultaneous laparoscopy may be of benefit in some patients but is not indicated routinely. Although laser treatment has not revolutionized the management of superficial bladder cancer, it has an established and enduring role. Future changes in surgical instruments seem likely to increase the usefulness of lasers in managing patients with transitional-cell carcinoma of the bladder.

We report one of the largest series of patients treated by radical prostatectomy followed for a minimum of 10 years. The tumor-free survival rate at 10 years seems superior to that achieved with alternative methods of treatment. Pathologic stage, DNA histograms, and tumor grade all correlate with prognosis but none is sufficiently powerful as an independent factor to allow selection of patients for surgery. Although a survival benefit has not been demonstrated, adjuvant treatment such as postoperative irradiation or early hormonal therapy may be indicated in patients with established poor prognostic factors.

Available epidemiologic data do not allow targeting of specific populations for prostate cancer screening or early detection programs. Although certain strong factors have been identified (age, race, location), none sufficiently defines high-risk groups in whom recommendations should differ from those of other age-matched patients. Certainly, a strong familial tendency has been identified, but the relative contribution of genetic and environmental factors in these patients remains unclear. Some hypotheses on the pathogenesis of prostate cancer are possible based on the available data. Genetic factors appear to be permissive, as are hormonal influences, which are partially regulated by genetics. Environmental factors appear to be promotional in genetically susceptible men. Dietary fat may also be an important promotional factor in genetically susceptible men. Dietary factors appear to exert some influence by modulating sex hormone concentration. Several factors demand more investigation and understanding of the epidemiology of prostate cancer. The relative frequency of the disease and the increasing death rate from prostate cancer are of concern. The similarities in the incidence of latent prostate cancer among various groups with strong differences in the rate of clinically apparent disease raise significant issues regarding potential lifestyle or environmental promotional factors. Further understanding of the pathogenesis of prostate cancer may allow a refinement and definition of programs for prevention and early detection of the disease.

Transrectal ultrasonography has defined a new category of stage A disease, namely nonpalpable lesions diagnosed by needle biopsy. How this type relates to classic stage A disease is unclear. Stage A1 carcinoma becomes clinically significant only in a distinct minority of patients, and even in this group, progression does not necessarily mean significant morbidity or death from prostate cancer. An aggressive approach is not justified. In contrast, stage A2 cancer is usually virulent, and aggressive therapy with curative intent is justified in patients of appropriate age and health. Both radical prostatectomy and external irradiation appear to provide long-term survival rates superior to those obtained with observation alone, but nearly 20% of these patients will die of cancer despite therapy. Unfortunately, forecasting the outcome in an individual case is still not possible, and efforts to identify prognostic features must continue. In the meantime, emotional arguments in favor of the treatment of all discovered cancers must be suppressed by an informed and objective understanding of the natural history of nonpalpable prostate cancer and the potential impact of treatment.

Relatively recent changes and improvements in equipment have vastly increased image resolution for transrectal ultrasonography of the prostate. The expanded use of transrectal ultrasonography has greatly furthered knowledge of prostate zonal anatomy and permitted clinical evaluation of internal prostate architecture. The technique is operator dependent, as the quality of the results is related directly to that person's knowledge and experience. The significant majority of prostate cancers originate from the peripheral zone. Palpable stage B nodules characteristically have a hypoechoic appearance. There is disagreement about the tumor characteristics that cause hypoechogenicity, but large tumors may obscure the normal prostate anatomy and appear isoechoic because of the lack of contrast with surrounding prostate tissue. The transition zone of the prostate is the origin of benign prostatic hyperplasia and almost 20 per cent of prostate cancers. These tumors probably correspond to most stage A lesions. Transrectal ultrasonography is less accurate in identifying transition zone tumors because of the mixed echogenicity of the transition zone, interference from prostatic calculi or calcified corpora amylacea, and poorer image resolution in this area. Studies evaluating the use of transrectal ultrasonography for early detection of prostate cancer generally have shown a twofold increase in the detection rate compared with digital rectal examination. However, the decreased morbidity and expense of transrectal prostate biopsy using an automatic gun device have increased the frequency of biopsy in ultrasound-examined patients compared with those historically evaluated by digital rectal examination. The increased detection rate may in part be a function of the increased use of biopsies, independent of other factors. Transrectal ultrasonography rarely detects cancer in patient with normal digital rectal examination and a normal serum prostate-specific antigen level. Transrectal ultrasonography may be capable of identifying early capsular penetration or seminal vesicle invasion in some patients with known prostate cancer. However, its superiority to digital rectal examination for this purpose has not been demonstrated unequivocally. Ultrasonography does allow directed biopsies of the seminal vesicles or other suspect areas, and this may be helpful in staging the disease. The use of transrectal ultrasonography in prostate cancer has evolved rapidly, and changes in technology antiquate reports within a few years.(ABSTRACT TRUNCATED AT 400 WORDS)

Flexible fibers allow transmission of laser energy through endoscopes for treatment of urethral, bladder, and ureteral lesions. Nd:YAG laser destruction is probably the current treatment of choice for intraurethral condylomata acuminata, but results with urethral strictures are less encouraging. Although therapeutic advantages for laser treatment of superficial bladder tumors have not been established, the treatment appears to offer practical advantages over electrocautery resection. Laser treatment of invasive bladder cancer should not be considered an alternative to cystectomy, but may be useful in patients who are not candidates for radical surgery.

The authors review the role of preoperative radiation therapy in the management of patients undergoing cystectomy and the early results of a prospective randomized clinical trial comparing preoperative radiation and radical cystectomy to radical cystectomy alone. It is concluded that the coupling of preoperative radiation therapy with cystectomy has added little to our treatment of bladder cancer.

Although renal cysts occur in children less frequently than adults, they are not as rare as once believed. Eight children with simple renal cysts are reviewed. The diagnostic and radiographic studies in each patient showed characteristic findings. A nonoperative diagnosis of simple renal cyst in a child usually can be made with confidence and surgical confirmation is not necessary.