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Objective: To assess safety and efficacy, namely pathological assessment of the specimen and recurrence rate, of en bloc transurethral resection (EBTUR) of bladder tumor., Materials and Methods: We performed a systematic review of the available literature on PubMed. Seventeen articles, mainly prospective case series, were found. EBTUR is performed with a great variety of equipments, whereas the resection technique is similar., Results: Overall, 895 patients have been submitted to EBTUR, accounting for 1191 lesions. Forty complications (4%) were computed. Only 10 (1%) were grade III, mostly bladder perforation or bleeding. Fifty-nine conversions (6.5%) to conventional transurethral resection (TUR) have been reported because of difficult locations of tumors or failure to extract the specimen. Several series, accounting for 763 patients, report about incidence of detrusor muscle in the specimen. Overall, 731 (96%) cases with detrusor muscle were computed. Tumor stage remained uncertain only in 12 (1.5%) cases. Follow-up data were available for 544 patients. Mean follow-up ranged from 9.3 to 40 months. Recurrence rate varied from 6% to 55%. Most of the recurrence occurred outside primary tumor site. Mean weighted follow-up across all series was 20 months, whereas overall recurrence rate was 23%., Conclusions: Irrespective of the technique adopted, EBTUR is a safe procedure. The presence of detrusor muscle in the specimen is high if compared with historical series of conventional TUR. Indeed, recurrence rate is comparable. The objective advantage of a proper histological assessment suggests to perform EBTUR instead of conventional TUR, when feasible.

Narrow band imaging (NBI) is an optical enhancement technology for endoscopy. NBI works filtering the standard white light in two bandwidths of illumination of 415 nm, blue, and 540 nm, green. As a result, capillaries on mucosal surface appear brown and veins in connective subepithelial layer cyan, enhancing the contrast among epithelial, subepithelial tissue and its vascularisation. Given that it is a filter, it is safe, does not need any kind of instillation and the vision modality can be switched from NBI to white light and vice versa without any limitations of time. NBI-assisted cystoscopy increases the detection rate of urothelial lesions and enhances visibility of tumour margins with respect to standard white light modality, although it does not need a particular learning curve. NBI exploration of the bladder should be avoided during active bleeding because the light absorption would be excessive impeding an optimal vision. Moreover, it should always be employed in combination with standard white light modality to avoid an excess of false-positive findings, particularly during or immediately after topic treatments. It can be used in office to anticipate bladder recurrences and in the operating theatre to perform a complete tumour resection. As a matter of fact, it is able to reduce the recurrence rate and ameliorate bladder cancer management by identifying high-grade cancerous tissue, especially Cis, undetected by the standard white light modality.

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.)

Narrow-band imaging is a young optical enhancement technology for endoscopy. It is a filter to the standard white light which increases the contrast between underlying vasculature and epithelial strata of the mucosa, improving the detection of bladder cancer with particular regard to high grade, flat lesions. Narrow band imaging is absolutely safe, may be used any time during a procedure, either during office cystosopy or transurethral resection, and implies a minimal burden for the healthcare provider given the absence of a learning curve and the limited cost of the camera and light source. The ameliorated detection translates into an improved management of the disease and a lower recurrence risk in prospective randomized studies, suggesting the inclusion of the technology in daily clinical practice.

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.

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.

Objective: To determine if narrow-band imaging (NBI) can be used to detect high-grade cancerous lesions missed with the white light at the time of a second transurethral resection (TUR) of high-grade non-muscle-invasive bladder cancer (NMIBC)., Patients and Methods: Consecutive patients with newly diagnosed high-grade NMIBC were enrolled in a prospective observational study. Patients with incomplete resection or absence of muscle tissue in the specimen were excluded. About 1 month after the first TUR, NBI cold-cup biopsies were taken from areas suspicious for urothelial cancer at the end of an extensive white-light second TUR protocol including: (i) resection of the scar of the primary tumour; (ii) resection of any overt or suspected urothelial lesions; and (iii) six random cold-cup biopsies of healthy mucosa., Results: In 2008, 47 consecutive patients were recruited after giving written consent (median age 62 years, range 49-83, 39 men and eight women). Nine patients (19%) had macroscopic or microscopic high-grade NMI urothelial cancer, whereas one was reassessed as having muscle-invasive disease at the white-light second TUR plus the six random biopsies. NBI biopsies were taken in 40 of the 47 patients and detected six more patients with high-grade cancerous tissue (13%). In all 16 of the 47 patients (34%) were found to have residual/recurrent cancer using our extensive protocol of second TUR followed by NBI biopsies., Conclusions: Adding NBI biopsies at the end of an extensive second TUR protocol in patients with newly diagnosed high-grade NMIBC can lead to the identification of patients with otherwise missed high-grade residual/recurrent urothelial carcinoma.

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.