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Objective: To identify lymph node density thresholds and their prognostic role in patients who underwent radical cystectomy and pelvic lymph node dissection, and to validate findings in an external series., Methods: Between May 2001 and September 2009, data from 750 radical cystectomies carried out at "Regina Elena" National Cancer Institute (Rome, Italy) were collected in a prospectively-maintained database. Once patients who had undergone neoadjuvant treatments and those who had undergone salvage radical cystectomy were excluded from the 210 pN+ patients, 156 patients with urothelial carcinoma were selected for analysis. Optimal cut-off points for age, lymph node count and lymph node density were identified by considering these variables as continuous. External validation of findings was carried out by using data of 154 pN+ patients selected from two prospective series., Results: The optimal identified cut-off points were 11% and 30% for lymph node density, nine and 30 nodes for lymph node count, and 73 years for age. Median cancer-specific survival of patients were significantly different in patients with lymph node density <12%, between 12% and 30%, and >30% (71 months, 24 months and 11 months, respectively; P < 0.001). Cancer-specific survival was independently predicted by lymph node density cut-off points (12-30% vs <12%: hazard ratio 1.51, P = 0.047; >30% vs <12%: hazard ratio 2.89, P < 0.001). In the external series, the prognostic effect of lymph node density according to tertiary distribution of risk based on these lymph node density cut-off points was confirmed at Cox multivariable analysis (12-30% vs <12%: hazard ratio 1.5, P = 0.048; >30% vs <12%: hazard ratio 2.5, P = 0.004)., Conclusions: Lymph node density is the strongest predictor of cancer-specific survival. Identified lymph node density thresholds have shown to be independent predictors of cancer-specific survival in the external validation series., (© 2012 The Japanese Urological Association.)

Background: Narrow band imaging (NBI) is an optical enhancement technology that filters white light into two bandwidths of illumination centered on 415nm (blue) and 540nm (green). NBI cystoscopy can increase bladder cancer (BCa) visualization and detection at the time of transurethral resection (TUR). NBI may therefore reduce subsequent relapse following TUR., Objective: Assess the impact of NBI modality on 1-yr non-muscle-invasive BCa (NMIBC) recurrence risk., Design, Setting, and Participants: Consecutive patients with overt or suspected BCa were included in a prospective study powered to test a 10% difference in 1-yr recurrence risk in favor of cases submitted to NBI TUR. Excluding patients with muscle-invasive BCa, negative pathologic examination, or without follow-up, the study population was composed of 148 subjects randomized from August 2009 to September 2010 to NBI TUR (76 cases) or white light (WL) TUR (72 cases)., Intervention: TUR was performed in NBI or standard WL modality., Measurements: The 1-yr recurrence risks in NBI or WL TUR groups were compared using odds ratio (OR) point and interval estimates derived from logistic regression modeling., Results and Limitations: The 1-yr recurrence-risk was 25 of 76 patients (32.9%) in the NBI and 37 of 72 patients (51.4%) in the WL group (OR=0.62; p=0.0141). Simple and multiple logistic regression analyses provided similar OR points and interval estimates., Conclusions: TUR performed in the NBI modality reduces the recurrence risk of NMIBC by at least 10% at 1 yr., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

The present technique maintains the integrity of voluminous lesions during extraction. Pathological analysis is consequently improved and a proper evaluation of the surgical margins is also possible. Papillary lesions of up to 4.5 cm are amenable to en bloc resection and extraction, while solid lesions comply less well with the urethra and sometimes are very difficult to extract. Nevertheless, the main limitation of the technique remains that lesions originating from the bladder neck are not amenable to en bloc resection,while particular attention should be paid during resection of lesions involving the ureteric orifice to avoid ureteric stripping.

Laparoscopic Radical Cystectomy (LRC) has been proposed since 1999 as a less invasive alternative to Open Radical Cystectomy (ORC). Pioneers of the technique claim that LRC led to faster recovery, shorter hospital stay and more rapid return to daily activities respect to ORC while offering the same functional and oncological results. About 900 cases are published in peer reviewed papers. The greatest series is formed by a cohort of 85 patients. The preferred urinary diversion is the ileal conduit (46%) although in recent series the ileal neobladder is increasingly adopted. Urinary diversion is usually performed extracorporeally through an abdomen incision of about 5-10 used also for the extraction of the specimen. The mean or median follow up of LRC series does not exceed 31 months and the longest follow up reported up to now is 58 months in the series examined. Overall survival rate varies from 72% to 95%. While feasibility of LRC has been demonstrated, cancer control has far from been assured, mainly in consequence of limited follow-up of the series and an unexpected low disease free survival rate. Moreover the advocated advantages related to LRC seem to be related to patients' selection rather than to less invasiveness. Actually when characteristics of the patient and of the disease are similar, outcomes of LRC and ORC, in terms of hospitalization and recovery, are comparable. LRC is currently an experimental procedure which can not be considered at the present time a concrete alternative to ORC.

Purpose: To assess the feasibility of transurethral resection (TUR) of bladder lesions performed entirely by means of a narrowband imaging (NBI) modality., Patients and Methods: Data from an ongoing prospective randomized trial (NCT01004211) were extracted. Quality outcomes of standard TUR and NBI TUR were compared. Complications were graded according to the Clavien-Dindo system., Results: To date, 33 and 29 subjects were randomized to standard and NBI TUR. No significant differences regarding age, sex, American Society of Anesthesiologists score, rate of multiple lesions, or lesions larger than 3 cm in the two groups were found, whereas rate of TUR for recurrent bladder cancer was greater in the NBI group. All procedures ended with complete clearance of the suspected or overt bladder tumor in the modality assigned. No death or major surgical or medical complications were registered. Overall grade I to II complications rate in the NBI and standard groups was, respectively, 8/29 (27%) and 11/33 (33%) (P = 0.831). Median surgery time was, respectively, 20 and 30 minutes in the NBI and standard group (P = 0.381). Median time to catheter removal was, respectively, 2 and 3 days in the NBI and standard groups (P = 0.288). Median time to discharge was 2 and 3 days (P = 0.173). No patient was readmitted after discharge. Muscle tissue was absent in the specimen of one patient who underwent standard TUR., Conclusion: NBI TUR appears to be feasible. The results of the ongoing randomized trial will show whether NBI TUR is able to reduce significantly the 1-year recurrence rate of bladder tumors.

Purpose: We report the oncological and functional results of potency sparing cystectomy with intrafascial prostatectomy for high risk, superficial bladder cancer., Materials and Methods: A total of 37 patients underwent potency sparing cystectomy and orthotopic urinary substitution from 2001 to 2005. Inclusion criteria were age younger than 70 years, Charlson comorbidity index less than 2, high risk superficial bladder cancer, prostate specific antigen less than 4 ng/ml, free-to-total PSA ratio greater than 20% and normal digital rectal examination., Results: Median patient age was 58 years (range 52 to 66). Median followup was 35 months (range 24 to 71). One patient died of disease progression and 1 died of an unrelated cause. Of the 37 patients 35 (95%) were free of tumor. Daily continence was achieved in 36 patients (97.2%) and nighttime continence was achieved in 35 (95%). Two patients (5%) needed clean intermittent catheterization. A total of 35 patients (95%) stated that they maintained erectile function, including 28 (76%) without oral drugs. A significant decrease in the median International Index of Erectile Function score from baseline was noted 2 years after surgery (25 vs 21). A total of 32 patients (86%) had an International Index of Erectile Function score of greater than 17 at 2 years after cystectomy. Median scores on the International Continence Society male short form questionnaires did not show any significant difference before and after surgery. Prostate specific antigen was lower than 0.2 ng/ml in all cases., Conclusions: The main criticism about so-called sexuality sparing cystectomy has been the presence of consistent prostatic remnants. Performing intrafascial prostatectomy together with supra-ampullar cystectomy seems to warrant good functional results with while better preserving oncological safety.

Laparoscopic radical cystectomy (LRC) is a challenging technique, but it has been proposed as an alternative to open radical cystectomy (ORC), which is currently the gold standard treatment for muscle-invasive or high-risk superficial bladder cancer. So far, approximately 200 cases treated with LRC have been reported in the peer-reviewed literature, but follow-up has generally been short (all <48 months). A shorter hospital stay and a quicker recovery of the patient seem to be the main advantages of LRC over ORC. Functional outcomes, cancer control obtained, and safety of the technique need to be confirmed by studies with larger cohorts of patients and longer follow-up than those previously reported, but an initial analysis suggests that LRC is not equivalent to ORC. Given that the majority of patients selected for LRC had lower American Society of Anesthesiologists scores and lower pathological stages than those in ORC studies, the proportion of patients with orthotopic neobladders (47%) and the proportion of disease-free patients (80%) seem to be suboptimal and, actually, those might represent the major disadvantages of LRC.

Laparoscopic radical cystectomy is an emerging technique. It has been proposed as an alternative to open radical cystectomy, which is the gold standard treatment of muscle-invasive or high-risk superficial bladder cancer. The experience in laparoscopic radical cystectomy reported in peer-reviewed journals account for approximately 100 cases, with a median longest follow-up of 11.5 months. Safety of the technique and cancer control need to be confirmed by a larger cohort of patients; however, after an initial analysis, it seems to be equivalent to open radical cystectomy. Equivalent does not mean better. Long-term results will determine if supposed benefits of laparoscopy overweigh the true increment of cost and time.

Female incontinence and pelvic organ prolapse have been defined as contraindications to orthotopic bladder substitution. A 75-old-year woman with slight stress incontinence, Stage III cystocele, and vaginal vault prolapse after subtotal hysterectomy underwent radical cystectomy for Stage T2 bladder cancer. After radical cystectomy, pelvic floor integrity was restored by colposacropexy with a rectangular polypropylene mesh and an ileal reservoir to urethra was constructed. After 1 year of follow-up, she had complete daytime continence and only needed to wear a pad during the night. Her postvoid residual urine volume was constantly less than 100 mL.

Abstract: Objective:: Chronic urinary retention is a frequent complication after orthotopic bladder replacement. Herein a new technical modification to avoid voiding dysfunction is described. Methods:: Between January 1995 and January 2004, 62 women had orthotopic bladder replacement after radical cystectomy. From November 1998 on, 35 patients were operated using a new technical modification, consisting in the fixation of a large and thick flap of peritoneal and extraperitoneal tissue deriving from the posterior wall of the vagina to the edges of endopelvic fascia to create a resistant hammock under the reservoir. Results:: 25 women have a follow-up longer than 12 months, range 12–56, and are considered in this study. Only one, out of 25 patients, still has occasionally stress incontinence but she did not need to use pads. Two patients are incontinent at night. None of 25 patients has a residual urine volume greater than 100ml or needed intermittent catheterization. Median bladder capacity is 350ml, range 280–430ml. Median creatinine level is 1.1mg/dl, range 0.7–1.2mg/dl. Conclusion:: The creation of a posterior support to the neobladder, by harvesting a thick flap, has, in our series, completely avoided the occurrence of chronic urinary retention, which is the most common long-term complication of bladder replacement in the female. Our series is sufficiently large to exclude serendipity and to be compared with other series in the literature. [Copyright &y& Elsevier]