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With the pendulum swinging in low risk prostate cancer (PCa) to ideas of overtreatment and overdiagnosis more urologists are looking at Active Surveillance (AS) as a valid option for their low risk PCa patients. AS will undoubtedly hold a place as a management option in men with low risk PCa, however, it is critical to understand its limitations in its current form as highlighted in this article. We conducted a review of multiple computerized databases (Ovid, Medline, Pubmed, CINAHL, Cohrane Library database) with the keywords active surveillance, prostate neoplasm, and low risk PCa. Manual searches were also carried out. Assumptions of AS are discussed and their implications on selecting the appropriate AS candidate. As with any active treatment option offered to patients with PCa, those who are offered AS must be appropriately selected and counseled as to its risks and benefits.

Intravesical immunotherapy using attenuated bacillus Calmette-Guérin (BCG) strains and intravesical chemotherapy are the modalities most commonly used to treat intermediate- or high-risk patients with non-muscle invasive bladder cancer. BCG has been shown to decrease recurrence rates by up to 67% compared with tumor resection alone, but intensive BCG maintenance regimens are poorly tolerated in a large proportion of patients. Intravesical chemotherapy also decreases the risk of recurrence for these patients, but has diminished efficacy compared with BCG. If BCG dose reduction can be achieved with combined intravesical immunotherapy and chemotherapy, this regimen may improve compliance and thus optimize treatment for these patients by limiting side effects from BCG monotherapy, while at the same time improving oncologic efficacy via the separate anti-tumor mechanisms of these agents. The authors discuss the most recent data regarding combining these agents in an alternating or sequential regimen.

Chemoprevention for prostate cancer (PCa) continues to generate interest from both physicians and the patient population. The goal of chemoprevention is to stop the malignant transformation of prostate cells into cancer. Multiple studies on different substances ranging from supplements to medical therapy have been undertaken. Thus far, only the studies on 5 alpha-reductase inhibitors (the Prostate Cancer Prevention Trial [PCPT] and Reduction by Dutasteride of Prostate Cancer Events [REDUCE] trial) have demonstrated a reduction in the risk of PCa, while results from the Selenium and Vitamin E Cancer Prevention Trial (SELECT) concluded no decreased risk for PCa with selenium or vitamin E.

Germline mutations of FH, the gene that encodes for the tricarboxylic acid TCA (TCA) cycle enzyme fumarate hydratase, are associated with an inherited form of cancer referred to as Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC). Individuals with HLRCC are predisposed to the development of highly malignant and lethal renal cell carcinoma (RCC). The mechanisms of tumorigenesis proposed have largely focused on the biochemical consequences of loss of FH enzymatic activity. While loss of the tumor suppressor gene von Hippel Lindau (VHL) is thought to be an initiating event for the majority of RCCs, a role for FH in sporadic renal cancer has not been explored. Here we report that FH mRNA and protein expression are reduced in clear cell renal cancer, the most common histologic variant of kidney cancer. Moreover, we demonstrate that reduced FH leads to the accumulation of hypoxia inducible factor- 2α (HIF-2α), a transcription factor known to promote renal carcinogenesis. Finally, we demonstrate that overexpression of FH in renal cancer cells inhibits cellular migration and invasion. These data provide novel insights into the tumor suppressor functions of FH in sporadic kidney cancer.

Management of mid-root fractures presents a formidable challenge for clinicians because of the difficulty of achieving a stable reunion of fracture fragments. This article presents two varied treatment options for mid-root fractures. A 15-year-old female reported an impact injury to the maxillary anterior teeth 2 days after its occurrence. Clinically, the maxillary left central incisor was palatally-extruded with a negative vitality response and radiographic evidence of an oblique fracture at the middle third of the root. An endodontic implant was employed which utilized an open technique and has been on follow-up for ten months. A 32-year-old male reported an injury, which resulted in a mobile maxillary right central incisor, three months after its occurrence. Through clinical and radiographic means, a discolored, extruded, and non-vital maxillary right central incisor with an oblique root fracture at the alveolar-crest level was observed. Exploratory surgery was performed; an apical barrier was created with a mineral trioxide aggregate and obturated with gutta percha. The fragments were stabilized with a fiber post and patient has been on follow-up for five months. Short-term follow-up for both of the cases showed promising results both clinically and radiographically.

Purpose: The relationship between prostate-specific antigen (PSA) level and prostate cancer risk remains subject to fundamental disagreements. We hypothesized that the risk of prostate cancer on biopsy for a given PSA level is affected by identifiable characteristics of the cohort under study., Experimental Design: We used data from five European and three U.S. cohorts of men undergoing biopsy for prostate cancer; six were population-based studies and two were clinical cohorts. The association between PSA and prostate cancer was calculated separately for each cohort using locally weighted scatterplot smoothing., Results: The final data set included 25,772 biopsies and 8,503 cancers. There were gross disparities between cohorts with respect to both the prostate cancer risk at a given PSA level and the shape of the risk curve. These disparities were associated with identifiable differences between cohorts: for a given PSA level, a greater number of biopsy cores increased the risk of cancer (odds ratio for >6- versus 6-core biopsy, 1.35; 95% confidence interval, 1.18-1.54; P < 0.0005); recent screening led to a smaller increase in risk per unit change in PSA (P = 0.001 for interaction term) and U.S. cohorts had higher risk than the European cohorts (2.14; 95% confidence interval, 1.99-2.30; P < 0.0005)., Conclusions: Our results suggest that the relationship between PSA and risk of a positive prostate biopsy varies, both in terms of the probability of prostate cancer at a given PSA value and the shape of the risk curve. This poses challenges to the use of PSA-driven algorithms to determine whether biopsy is indicated.

Mutations in the von Hippel-Lindau (VHL) gene give rise to renal cell carcinoma. Reactive oxygen species, generated by Nox oxidases, are involved in tumorigenesis. We have previously demonstrated that in VHL-deficient cells, p22(phox)-dependent Nox1 and Nox4 oxidases maintain hypoxia inducible factor-2alpha (HIF-2alpha) protein expression through an Akt-dependent translational pathway. Phosphorylation of tuberin, by Akt, results in its inactivation. Here we show that diphenyleneiodonium chloride, an inhibitor of Nox oxidases, and small-interfering RNA-mediated down-regulation of p22(phox) inhibit Akt-dependent phosphorylation of tuberin and stabilizes tuberin protein levels in VHL-deficient renal carcinoma cells. p22(phox)-mediated inactivation of tuberin is associated with an increase in ribosomal protein S6 kinase 1 and eukaryotic initiation factor 4E-binding protein-1 (4E-BP1) phosphorylation as well as HIF-2alpha stabilization. Importantly, we find that marked up-regulation of p22(phox) in human renal cell carcinoma correlates with increased tuberin phosphorylation, decreased tuberin protein levels, and increased phosphorylation of 4E-BP1. Our data provide the first evidence that p22(phox)-based Nox oxidases maintain HIF-2alpha protein expression through inactivation of tuberin and downstream activation of ribosomal protein S6 kinase 1/4E-BP1 pathway.

Since its approval by the US FDA in 1986, prostate-specific antigen (PSA) has been employed to monitor men with a diagnosis of prostate cancer. In 1994, PSA was approved for use in prostate cancer screening and has been employed worldwide. However, due to the limited specificity of PSA for the disease, novel biomarkers are needed for detecting prostate cancer and for determining which cancers need to be treated. This review will discuss the development of new biomarkers for prostate cancer detection and disease prognostication, focusing on recent progress and particular topical issues related to the development and validation of these new markers.

The basis of treatment for advanced germ cell tumors is chemotherapy and surgical resection of residual disease. Surgery has maintained its role in staging and therapeutic management. Despite these advances, much of the outcomes depend on proper patient selection. Complete removal of all post-chemotherapy residual masses remains the standard of care in the treatment of advanced nonseminomatous germ cell tumors both within and outside of the retroperitoneum.

Purpose of Review: We examine the role of 5-alpha reductase inhibitors in prevention and diagnosis of prostate cancer, highlight the basic science supporting this role, and analyze the phase III clinical trials addressing the association between 5-alpha reductase inhibitor use and prostate cancer., Recent Findings: To date, the Prostate Cancer Prevention trial (PCPT) is the only reported phase III randomized clinical trial to evaluate the role of 5-alpha reductase inhibitors in the prevention and treatment of prostate cancer. The original PCPT data revealed that finasteride reduced the risk of prostate cancer by approximately 25% in comparison with placebo. However, patients who received finasteride had a greater incidence of high-grade tumors, which prohibited acceptance of finasteride as a chemopreventive agent by most urologists. Recent updates of the PCPT findings confirmed that finasteride reduces the risk of clinically significant prostate cancer, including high-grade tumors, primarily due to its effects on improving the performance characteristics of prostate-specific antigen and prostate biopsy. There was no increase in high-grade prostate cancer. Rather, there was improved detection of high-grade prostate cancer due to decreased prostate volume., Summary: Finasteride is a valuable chemopreventive tool because it reduces the risk of prostate cancer, including high-grade cancer, and enhances our ability to detect high-grade disease.

Purpose: Prostate biopsy is often recommended based on increases in prostate specific antigen and/or abnormal digital rectal examination. We investigated the stability of a single positive test during the next 3 consecutive years., Materials and Methods: A total of 2,578 participants in a San Antonio screening cohort with 2 or more consecutive annual prostate specific antigen and digital rectal examination tests were identified. Occurrences of an increased prostate specific antigen (2.5 ng/ml or greater) followed by 1 or more nonincreased prostate specific antigen results were compared with similar fluctuations of digital rectal examination from abnormal to normal., Results: In 2,272 men who did not have a biopsy during the study, in 23.3% of 744 incidences of an increased prostate specific antigen with 1 year of followup, the next prostate specific antigen was not increased. In 19.5% of 462 incidences of an increased prostate specific antigen with 2 years of followup, the next 2 consecutive prostate specific antigen levels were not increased. Finally, in 17.5% of 285 incidences of an increased prostate specific antigen with 3 years of followup, the next 3 consecutive prostate specific antigens were not increased. Rates were similar but lower in 221 men with 1 or more negative biopsies during the study and in 85 men in whom prostate cancer eventually developed during the study. In contrast, approximately 70% of abnormal digital rectal examinations were normal the following year even in patients with prostate cancer, and in the majority of incidences remained normal the next 2 to 3 consecutive years., Conclusions: Occurrences of reversed prostate specific antigen cut point or abnormal digital rectal examination based decisions to biopsy 1 or more years after the initial test are not uncommon, suggesting repetition of these tests.

Von Hippel-Lindau (VHL) disease is an autosomal dominant inherited tumor syndrome in which a genetic defect in the VHL gene is located on chromosome 3p25. The urologic surgeon is an integral part of the management team for patients who have VHL disease, because patients frequently have multiple urologic tumors. This article presents a cumulative review of the literature regarding the diagnosis and management of urologic tumors in patients who have VHL disease, along with the latest data regarding the genetics and molecular mechanisms of VHL disease.

Purpose: We characterized the long-term stability of total prostate specific antigen in serum samples after storage at -80C from 2001 until 2007., Materials and Methods: From the San Antonio Biomarkers of Risk biorepository we chose serum samples from white men 55.2 to 80.5 years old (median age 63.3) in which prostate specific antigen was measured in 2001. These men were not diagnosed with prostate cancer by 2007. A blocked randomization scheme was used to randomly select 47 serum samples with prostate specific antigen values spread over the reference ranges 0.0 to 0.4 (10), 0.5 to 0.9 (10), 1.0 to 1.9 (10), 2.0 to 3.9 (11) and 4.0 to 10.0 ng/ml (6) for repeat measurement by the same assay in 2007. Spearman's correlation coefficient was used to calculate the correlation and the paired t test was used to test the null hypothesis of no average difference between prostate specific antigen measured in 2001 and 2007., Results: Median prostate specific antigen values were 1.20 ng/ml (range 0.20 to 7.20) in 2001 and 1.30 (range 0.20 to 6.70) in 2007. In 2001 and 2007 mean +/- SD prostate specific antigen was 1.76 +/- 1.59 and 1.84 +/- 1.64 ng/ml, and the coefficient of variation was 0.91 and 0.89, respectively. The correlation between prostate specific antigen values in 2001 and 2007 was high (0.995). Prostate specific antigen values in 2007 were consistently and statistically significantly higher than in 2001 (mean 0.08 ng/ml, p = 0.005). Systematic and random error increased slightly with increasing prostate specific antigen., Conclusions: Agreement between total prostate specific antigen values measured from serum samples in 2001, stored at -80C for 7 years and then remeasured was highly correlative.

Purpose: The limitations of prostate specific antigen as a biomarker for prostate cancer screening, characterized by low sensitivity for acceptable false-positive rates, are well known. New markers that differentiate indolent from aggressive cancers to decrease potential the over treatment of prostate cancer are needed. We reviewed current and potential biomarkers for prostate cancer detection., Materials and Methods: A literature search was performed to identify established and emerging biomarkers for prostate cancer detection. Recent suggested guidelines by the Early Detection Research Network for phases of biomarker studies were interpreted for use in prostate cancer and the existing status of marker studies were reviewed with respect to these phases of study., Results: Advances in high throughput bench research, including high dimensional genomic, proteomic and autoantibody signatures, have the potential to improve the operating characteristics of prostate specific antigen but they are undergoing reproducibility and multicenter validation studies. None of the prostate specific antigen derivatives or isoforms, such as prostate specific antigen density, velocity or percent complexed prostate specific antigen, improve operating characteristics enough to likely replace prostate specific antigen. Prostate stem cell antigen, alpha-methyl coenzyme-A racemase, PCA3, early prostate cancer antigen, human kallikrein 2 and hepsin are promising markers that are currently undergoing validation., Conclusions: The process of discovering novel biomarkers to replace or augment the existing best marker, prostate specific antigen, requires standardized phases of evaluation and validation. Several biomarkers are currently on the cusp of initial validation studies.

Purpose: Age specific prostate specific antigen ranges have been advocated to increase the predictive value of prostate specific antigen based on increases that occur with aging. We suggest that prostate specific antigen is not a dichotomous biomarker and age specific reference ranges delays the diagnosis of high grade prostate cancer in older and black American men., Materials and Methods: Using the Prostate Cancer Prevention Trial risk calculator we evaluated the impact of age on the risk of high grade prostate cancer in white and black men. We created a hypothetical population of men by standardizing risk variables, including negative family history, normal digital rectal examination and no history of negative biopsy. Results were compared in the 2 populations using 5-year age increments from ages 55 to 75 years and increasing prostate specific antigen., Results: Increasing age was associated with a higher risk of high grade prostate cancer in white and black men. The risk of high grade prostate cancer in a black man was twice that in a white man with the same prostate specific antigen at all prostate specific antigen values., Conclusions: Age specific and race specific prostate specific antigen ranges are flawed. Many patients who would not be considered for biopsy based on these prostate specific antigen ranges are at significant risk for high grade prostate cancer. The risk of high grade prostate cancer in black men is twice that in white men. Risk assessment in black men and older men is necessary to diagnose high grade prostate cancer when treatment can be effective.

Objective: We analyzed the association of 54 biomarkers from seven classes including adipokines, immune response metalloproteinases, adhesion molecules, and growth factors with prostate cancer risk adjusting for the Prostate Cancer Prevention Trial (PCPT) risk score., Methods: A total of 123 incident prostate cancer cases and 127 age-matched controls were selected from subjects in the San Antonio Center for Biomarkers of Risk of Prostate Cancer cohort study. Prediagnostic serum concentrations were measured in the sample collected at baseline using LabMAP technology. The odds ratios (OR) of prostate cancer risk associated with serum concentrations of 54 markers were estimated using univariate conditional logistic regression before and after adjustment for the PCPT risk score. Two-way hierarchical unsupervised clustering techniques were used to evaluate whether the 54-marker panel distinguished cases from controls., Results: Vascular endothelial growth factor, resistin, interleukin 1Ra (IL-1Ra), granulocyte colony-stimulating factor, matrix metalloproteinase-3, plasminogen activator inhibitor, and kallikrein-8 were statistically significantly (P < 0.05) underexpressed in prostate cancer cases, and alpha-fetoprotein was statistically significantly overexpressed in prostate cancer cases, but all had area underneath the receiver-operating characteristic curve <60%; none were statistically significant adjusting for multiple comparisons (P < 0.0008) or after adjustment for the PCPT risk score. Statistical clustering of patients by the marker panel did not distinguish a separate group of cases from controls., Conclusions: This age-matched case-control study did not support findings of increased diagnostic potential from a 54-marker panel when compared with the conventional risk factors incorporated in the PCPT risk calculator. Future discovery of new biomarkers should always be tested and compared against conventional risk factors before applying them in clinical practice.

Objectives: Family history has been identified as a risk factor for prostate cancer. We assessed the risk of prostate cancer in men with a positive family history (at least one first-degree or second-degree relative), normal digital rectal examination (DRE) and a serum prostate-specific antigen (PSA) level of 4.0 ng/mL., Methods: A total of 87 volunteers from the San Antonio Center of biomarkers of risk for prostate cancer study enrolled in a prospective study to assess the prevalence of prostate cancer in men with a family history of prostate cancer, normal DRE findings, and a serum PSA level of 4.0 ng/mL or less. All subjects underwent transrectal ultrasound-guided prostate biopsy., Results: Prostate cancer was diagnosed in 22 (25.3%) of the 87 participants. The PSA values were significantly greater statistically in the men with prostate cancer (median 2.1 ng/mL) than in the men without prostate cancer (median 1.2 ng/mL, P = 0.01), and the odds of prostate cancer nearly doubled for a doubling of the PSA level within this interval (odds ratio 1.97, P = 0.02). No statistically significant difference was found in age, race, or number and type of affected relatives in men with and without prostate cancer., Conclusions: The results of our study have demonstrated a high frequency of prostate cancer in men with a positive family history but normal DRE findings and a PSA level of 4.0 ng/mL or less. These prospectively collected data raise an important consideration regarding lowering the PSA cutoff values for offering biopsy in patients with a positive family history and normal DRE findings.

Improved survival following radical cystectomy for bladder cancer as a result of advancements in combination chemotherapy and surgical technique has resulted in a philosophical change in the surgeon's approach to urinary diversion selection. Aims have evolved from the mere diversion of urine to a functional bowel conduit such as an ileal conduit or ureterosigmoidostomy, to providing the optimal diversion for the patient's quality of life. While quality of life is important, one must also consider the stage of cancer and individual patient comorbidities. Which diversion provides the best local cancer control, the lowest potential for complications (short and long term), and the easiest emotional adjustment in lifestyle while still allowing the timely completion of chemotherapy and therapeutic goals? A multidisciplinary approach to diversion selection that includes the patient, the medical oncologist, radiation oncologist, internist, and surgeon is ideal. We describe the three most commonly used types of diversions today, including conduits, continent cutaneous reservoirs, and orthotopic urethral diversions, as well as issues relative to patient selection and functional outcomes in patients undergoing radical cystectomy for the treatment of bladder cancer.

Objective: To prospectively evaluate p53 overexpression as a predictor of survival in patients with a first diagnosis of T1 transitional cell carcinoma (TCC) of the bladder, as several reports implicate p53 as an important prognostic marker for progression and survival, but all previous studies were retrospective, giving conflicting and irreproducible results, rendering inappropriate any attempt at integrating p53 into clinical decision-making., Patients and Methods: Patients with a first diagnosis of T1 TCC of the bladder were enrolled; p53 overexpression was assessed by immunohistochemistry (IHC) using both monoclonal antibody 1801 and DO7. The pathological stage and IHC score were assigned by one pathologist, and the markers were scored categorically., Results: Of the 89 patients who were evaluable, 53 had p53-positive tumours. The median follow-up for the survivors was 52 months. Eighty-two patients had high-grade tumours, using the World Health Organisation/International Society of Urological Pathology 1998 grading system. Fifty-eight patients had unifocal tumours and 34 had associated carcinoma in situ. The 3 year and 5 year overall survival rates were 81% (95% Cl: 73%, 90%) and 68% (95% Cl: 56%, 80%) respectively. The 3 year and 5 year disease specific survival rates were 87% (95% Cl: 79%, 94%) and 79% (95% Cl: 70%, 89%) respectively. There was no difference in disease-specific survival between patients with and without p53 over expression (p=0.56) [corrected], Conclusions: p53 tissue typing by IHC in a prospective cohort of patients with T1 bladder cancer was not clinically useful as a prognostic marker in a contemporary series of T1 tumours.

Bladder cancer is a heterogeneous disease. Non-muscle-invasive bladder cancer embraces a spectrum of tumors with varying degrees of clinical behavior. Transurethral resection remains the surgical mainstay for the treatment of non-muscle-invasive bladder cancer. In an attempt to decrease the recurrence or progression rate, intravesical chemotherapy or immunotherapy is also used. Radical cystectomy with bilateral pelvic lymph node dissection remains the gold standard for treating muscle-invasive bladder cancer. Over the last decade, the orthotopic neobladder has gained widespread popularity as the preferred mode of urinary diversion in both males and females with similar oncologic and functional outcomes. Well-designed trials with effective chemotherapy have shown a beneficial role for neoadjuvant chemotherapy.

Objectives: To evaluate the recently developed Prostate Cancer Prevention Trial (PCPT) prostate cancer risk calculator in the San Antonio Center of Biomarkers of Risk for Prostate Cancer (SABOR) cohort of the Early Detection Research Network, a younger and more ethnically diverse population than that in the PCPT., Methods: From 3488 SABOR participants, we identified 446 who had undergone prostate biopsy and had undergone prostate-specific antigen measurement and digital rectal examination before biopsy. Most biopsies were performed for abnormal digital rectal examination findings, a prostate-specific antigen level of more than 2.5 ng/mL, or elevated risk because of a first-degree relative with prostate cancer. We evaluated the operating characteristics of the PCPT calculator for detecting prostate cancer in this cohort of SABOR participants. Of the 446 men in this cohort, 24% were younger than 55 years of age., Results: Of the 446 men who had undergone biopsy, 148 (33.2%) had prostate cancer. The observed SABOR prostate cancer rates increased with increasing PCPT risk: 15.7%, 39.0%, 48.8%, and 100.0% for a PCPT risk calculator value of less than 25%, 25% to 50%, 50% to 75%, and greater than 75%, respectively. The PCPT risk calculator had an area under the receiver operating characteristic curve of 65.5% (95% confidence interval 60.2% to 70.8%, P < 0.0001), was greater in African-American men (area under curve of 80.0%, 95% confidence interval 67.8% to 92.2%) than in other races (P = 0.02), and was not different in Hispanic men (P > 0.05)., Conclusions: The results of our study have shown that the PCPT risk calculator, available from the Internet and incorporating the current best panel of risk factors, is valid in other, more diverse, populations.

Purpose: Radio frequency ablation is a promising modality for treating small renal tumors. Several studies have been published showing its efficacy. A major drawback in the current management of renal tumors with radio frequency ablation is the lack of an effective modality to accurately monitor the progress of the ablation zone in real-time fashion. Previous studies have demonstrated the feasibility of using optical spectroscopy to assess tissue thermal damage, especially in hepatic lesions. We examined the feasibility of this technology in the setting of renal radio frequency ablation., Materials and Methods: A portable spectroscopic system was used to acquire in vivo fluorescence and diffuse reflectance spectra from porcine renal tissue undergoing radio frequency ablation in real-time fashion with simultaneous temperature recordings. Fluorescence and diffuse reflectance spectral data were then correlated with various degrees of thermal damage and temperature recordings., Results: The most noticeable change in fluorescence characteristics of renal tissue resulting from thermal coagulation was a strong decrease in fluorescence intensity between 400 and 550 nm. When fully coagulated, a significant increase in diffuse reflectance intensity was observed between 500 and 800 nm., Conclusions: Optical spectroscopy, specifically fluorescence and diffuse reflectance spectroscopy, differs significantly in porcine renal tissues with varying degrees of thermal damage from radio frequency ablation in an in vivo setting. Future clinical studies with sufficient sample size are required to validate the potential of these findings. Optical diagnostics may prove to be a rapid, noninvasive, low cost option for monitoring the tumor response to radio frequency based ablative techniques. It may be integrated into future radio frequency ablation probes.

Purpose: Promising results of optical signals have been reported in the literature for the diagnosis of Barrett's esophagus, oral cavity lesions, brain tumor margins, cervical intraepithelial neoplasia, skin cancer and bladder cancer. The potential usefulness of these techniques in renal tissues and neoplasms has not been described to date. This initial study examined the feasibility of using fluorescence and diffuse reflectance spectroscopy to differentiate between malignant and benign renal tissues., Materials and Methods: An ex vivo study was conducted to identify optical characteristics of various renal tissue types. Pathologically confirmed benign and malignant renal samples were obtained from nephrectomy specimens from patients undergoing radical nephrectomy. Fluorescence and diffuse reflectance spectra were measured from benign and malignant renal tissues., Results: All renal tissues, malignant or benign, contain 2 primary emission peaks-a strong one at approximately 285 nm excitation, approximately 340 nm emission (Peak A), and a weak one at approximately 340 nm excitation, approximately 460 nm emission (Peak B). Peak A of normal renal tissue typically locates at the shorter excitation wavelength region than that of malignant tissue. The intensity of Peak B from benign tissues tends to be greater than that from malignant renal tissues. Diffuse reflectance intensities from malignant renal tissues between 600 and 800 nm are markedly greater than those from normal renal tissue. Empirical discrimination algorithms developed based on selected fluorescence and diffuse reflectance spectral characteristics yields accurate differentiation between benign and malignant renal tissues., Conclusions: Highly accurate differentiation between normal human renal tissues and renal cell cancers is feasible using combined fluorescence and diffuse reflectance spectroscopy in an ex vivo setting. If successful in future clinical studies, optical spectroscopy could aid in margin detection and tissue discrimination while performing nephron sparing surgery.

Purpose: We present a contemporary review of patients with renal cell carcinoma (RCC) in whom renal vein/inferior vena caval thrombus was treated with radical nephrectomy and thrombectomy., Materials and Methods: A total of 220 patients underwent radical nephrectomy for RCC at our institution from 1998 to 2002. Of them 49 patients with renal vein/inferior vena caval involvement (T3b/c) were selected for review. We evaluated demographics, presenting symptoms, imaging modalities, clinical staging, pathological features, adjuvant treatment and clinical outcomes. We also evaluated surgical incisions, liver mobilization procedures, blood loss, transfusion requirements and perioperative mortality/morbidity., Results: Gross hematuria was the most common presenting symptom, seen in 22 patients (45%), followed by constitutional symptoms in 8 (16%). Stage T3b/c was clinically diagnosed in 44 patients, while 2 had T2 and 2 had T4 disease. A subcostal incision was made in 30 patients, a chevron incision was made in 18, and a sternotomy and flank incision were made in 1. Liver mobilization was necessary in 13 patients and 2 required a Pringle maneuver. Cardiopulmonary bypass was performed in a single patient. Lymph node involvement was seen in 4 patients (8%) and distant metastases were present in 10 (20%). Median tumor size was 10 cm. Clear cell carcinoma was most common, as seen in 42 patients. Early (30-day) mortality in this series was 8%. At a median followup of 15 months 21 patients (43%) were without evidence of disease, 14 (29%) had disease, 8 (16%) had died of disease and 2 (4%) had died of other causes. None of the patients with lymph node involvement survived beyond 8 months after surgery. Tumor grade and T stage were found to be significant negative predictors of survival on univariate analysis., Conclusion: Most patients with RCC and tumor thrombus are symptomatic at presentation and metastatic disease at presentation is not uncommon. These results support the role of aggressive surgical treatment as the best initial management of these tumors. The majority of tumors can be approached and safely controlled without the need for a thoracoabdominal incision. While surgery provides modest disease-free survival, most patients should be offered immunotherapy, particularly those with advanced stage, grade, nodal involvement or metastases.

Purpose: We determine whether routinely performing catheterless ureteroneocystostomy would minimize hospital stays without compromising postoperative outcomes., Materials and Methods: Between May 1996 and February 2002 patients who underwent ureteroneocystostomy at a single major tertiary care institution were identified. Patients who underwent additional, simultaneous surgical procedures were excluded from the study. Data recorded included patient demographics, reflux grade, use of a bladder catheter, length of hospital stay, medication use, postoperative complications and subsequent rehospitalization., Results: Of the 300 patients included in the study 266 were girls and 34 were boys, with a median age of 4 years (range 3 months to 19 years). Reimplantation was bilateral in 215 cases and unilateral in 85. Reflux was grade I in 1% of cases, grade II in 18%, grade III in 47%, grade IV in 25% and grade V in 9%. Similar distributions were observed among the 76 patients who received bladder catheters and the 224 who did not. The average length of postoperative hospitalization for patients who received catheters compared to those who did not was 2.1 versus 1.4 days (p <0.001), and the rate of prolonged hospitalization are 18% versus 5%, respectively (p <0.01). Postoperative complication rates were 17% versus 8% (p <0.05) for patients who received catheters compared to those who did not. There was no statistically significant difference in the rate of rehospitalization whether urethral catheters were used (1.3% vs 4.9%, respectively, p = 0.07). Furthermore, there was no statistically significant difference in the amount of either ketorolac or oxybutynin used by patients who received catheters compared to those who did not., Conclusions: Surgical repair of vesicoureteral reflux via catheterless ureteroneocystostomy can reduce hospital stay without adversely affecting complication rates, rehospitalization rates and the amount of medications needed postoperatively.

Background and Purpose: Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model., Materials and Methods: Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed., Results: Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals., Conclusions: Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.

Background and Purpose: The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications., Patients and Methods: All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons., Results: The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12)., Conclusions: Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.

Purpose: The low rate of pelvic node metastasis in most contemporary series of patients undergoing radical prostatectomy for carcinoma of the prostate has been attributed to earlier and better patient selection than historical series. Alternatively, it has been suggested that the limited dissection commonly performed misses nodal metastasis in a substantial number of patients. To assess the value of an extended node dissection in detecting nodal metastasis, we performed a randomized prospective study., Materials and Methods: A total of 123 patients undergoing radical prostatectomy were randomized to an extended node dissection on the right versus the left side of the pelvis with the other side being a limited dissection. The extended dissection included removal of all external iliac nodes to a point above the bifurcation of the common iliac artery, the obturator nodes and the presacral nodes. The limited dissection included only the nodes along the external iliac vein and obturator nerve., Results: Mean patient age was 61 years. Clinical stage was T1c in 88 patients (72%), T2a in 26 (21%), T2b in 7 (6%) and T3 in 2 (1%). Mean preoperative prostate specific antigen was 7.4 ng./ml. Pelvic lymph node metastasis was histologically confirmed in 8 patients (6.5%). Positive nodes were found on the side of the extended dissection in 4 patients, on the side of the limited dissection in 3 and on both sides in 1. Complications possibly attributable to the node dissection included lymphocele in 4 patients, lower extremity edema in 5, deep venous thrombosis in 2, ureteral injury in 1 and pelvic abscess in 1. These complications occurred 3 times more often on the side of the extended dissection (p = 0.08)., Conclusions: Extended node dissection in contemporary series of patients undergoing radical prostatectomy identifies few with nodal metastases not found by a more limited dissection. A trend toward an increased risk of complications attributable to the lymphadenectomy occurs with an extended dissection.

Purpose: Radical cystectomy is gold standard treatment for muscle invasive bladder cancer and is an option for many patients with nonmuscle invasive disease at high risk for disease progression. We assessed the early complications of radical cystectomy among patients with nonmuscle invasive compared to those with muscle invasive disease., Materials and Methods: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We evaluated complications that occurred within 30 days of the procedure. Cases were stratified into nonmuscle invasive (PO, Pa, P1 and PIS, N0) or muscle invasive (P2-4, N0-3) tumors based on final specimen pathology. The 2 groups were then compared with respect to age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, estimated blood loss, operative time and length of stay, and major and minor complications., Results: Of the 293 available patients 105 (36.8%) had nonmuscle invasive specimen pathology. Overall major and minor complications occurred in 4.9% and 30.4% of cases, respectively. Independent t test revealed no significant difference between groups in terms of age (p = 0.85), gender (p = 0.77), race (p = 1.0), American Society of Anesthesiologists (p = 0.32), type of urinary diversion (p = 0.33), estimated blood loss (p = 0.31), operative time (p = 0.41), length of stay (p = 0.75), or presence of major (p = 0.78) or minor (p = 0.79) complications., Conclusions: The early morbidity associated with radical cystectomy for nonmuscle invasive disease is similar to but not less than that associated with muscle invasive tumors. These acceptable risks as well as the potential benefits should be discussed with patients with nonmuscle invasive bladder cancer at high risk for disease progression.

We present a rare case of a primary neuroendocrine carcinoma of the urethra after radical cystectomy and orthotopic urinary reconstruction for transitional cell carcinoma of the urinary bladder.

Purpose: A significant number of patients requiring radical cystectomy for bladder cancer have substantial co-morbidity. Nonetheless, these patients often prefer orthotopic neobladder reconstruction to avoid an abdominal stoma. We performed a retrospective study to determine perioperative morbidity in this group of patients., Materials and Methods: We used the American Society of Anesthesiologists physical status classification to assign perioperative risk. Of 250 patients undergoing orthotopic neobladder reconstruction after radical cystectomy during a 5-year period we identified 84 with an American Society of Anesthesiologists score of 3 or greater. Charts were available for review for all patients and none was lost to followup., Results: Median operative time (calculated from anesthesia ready time to completion of surgery and application of a dressing) was 256 minutes. In 14 patients (16.6%) transfusion of a median of 2 units of allogeneic blood was required. A total of 79 patients (94%) were transferred directly from the recovery room to the general urology floor without a need for postoperative cardiac monitoring. Median hospital stay was 7 days. One patient (1.1%) died on postopera-tive day 9 of a presumed pulmonary embolus after having been discharged home on postoperative day 6. Minor complications occurred in 16 patients (19%). Only 1 patient required a return to the operating room for endoscopic removal of a retained stent fragment., Conclusions: In experienced hands radical cystectomy and orthotopic neobladder can be offered to patients with co-morbid conditions. Expeditious performance of the surgical procedure, minimization of blood loss, restricting the surgical incision to an infraumbilical location, and avoidance of intraoperative complications all contribute to decreasing morbidity and mortality. Although orthotopic reconstruction is more complex than performance of an ileal conduit, there is no apparent increase in perioperative morbidity or mortality. Therefore, orthotopic reconstruction can be offered to patients who want to avoid an abdominal stoma even in the face of significant co-morbid conditions.

We report an unusual case of a leiomyosarcoma of the urinary bladder after chemotherapy for retinoblastoma and the results of a review of the published reports of bladder sarcomas. A 22-year-old man presented with hematuria and was found to have a mass in his urinary bladder on computed tomography. Transurethral resection of the mass revealed a leiomyosarcoma. The patient underwent radical cystectomy and an ileal conduit was created. The final pathologic examination confirmed high-grade leiomyosarcoma. Prospective randomized combination trials similar to the Intergroup Rhabdomyosarcoma Study in the pediatric population are necessary to better understand and manage these potentially curable sarcomas.

Purpose: The role of hypercalciuria for the evaluation of unexplained asymptomatic gross and microscopic hematuria in children remains unclear, as evidenced by conflicting reports in the literature. We study the function of hypercalciuria in these patients, and determine whether routine evaluation of urine for hypercalciuria and treatment with thiazide diuretics, based on the results of a urinary calcium-to-creatinine ratio, is necessary. We also wanted to compare the yield of a urinary calcium-to-creatinine ratio in patients with gross and microscopic hematuria subgroups., Materials and Methods: Between 1991 and 1998 we treated 96 patients with microscopic hematuria (group 1) and 46 with gross hematuria (group 2). All patients had isolated unexplained hematuria. Patients with organic and anatomical causes, including urinary tract infection and other urinary symptoms, were excluded from the study. Nephrological urine and serum analyses in patients with hematuria were otherwise normal, as were all imaging studies. Group 1 included 50 males and 46 females, with a mean age of 7.6 years (range 1 to 14), and a spot urinary calcium-to-creatinine ratio was done in 79. Group 2 included 35 males and 11 females, with a mean age of 8.5 years (range 8 months to 14 years), and a spot urinary calcium-to-creatinine ratio was done in 43. A ratio of 0.2 or greater was considered hypercalciuria. The season of presentation was noted to determine any pattern., Results: There were no seasonal variations regarding presentation. Followup of 34 patients in group 1 and 15 group 2, with a mean followup of 10.6 months (range 1 month to 8 years), was available. A total of 28 (82.3%) patients in group 1 and 15 (71.4%) group 2 had complete resolution of hematuria. However, there were 6 patients in both groups who had persistent hematuria but remained totally asymptomatic. Hydrochlorothiazide was used in only 2 patients in group 1 and 1 group 2 due to intractable hematuria on expectant management, a markedly increased urinary calcium-to-creatinine ratio and positive family history of urolithiasis., Conclusions: Although we cannot establish a direct cause and effect relationship, hypercalciuria is detected in a substantial number of cases of unexplained gross and microscopic hematuria. However, based on our study we do not recommend treatment with thiazide diuretics in all patients diagnosed with hypercalciuria, as hematuria resolved in a majority with observation or expectant treatment and minor dietary modification. We reserve treatment with thiazide diuretics only for those patients with intractable hematuria, a markedly increased urine calcium-to-creatinine ratio and family history of urolithiasis

Purpose: We determine the efficacy of a prospective screening analysis of an asymptomatic sibling of patients with reflux., Materials and Methods: A total of 78 siblings of patients with reflux were evaluated and 40 (51%) had reflux. The resolution rate and necessity for surgical intervention were evaluated., Results: A total of 40 patients had vesicoureteral reflux, including grade I in 12, II in 33, III in 19 and IV in 1. No patient had gross renal scar on ultrasound or renal pelvis dysmorphism on voiding cystourethrogram. Treatment consisted of prophylactic antibiotics in all. One patient required surgical correction for breakthrough urinary tract infection. Followup was available in 31 patients, of whom reflux resolved completely with medical management in 26. Reflux was downgraded in 4 patients. Of the patients in whom reflux resolved completely grades I to II vesicoureteral reflux were in 18, and II to IV in 8. Mean time to resolution was 15.6 months., Conclusions: The incidence of sibling reflux is significant. However, grade specific time to resolution appears to be decreased compared to primary reflux diagnosed after urinary tract infection. Furthermore, the incidence of renal damage appears to be decreased compared to "traditional" reflux. Although it is reasonable to recommend screening, we suggest that sibling reflux may follow a more benign course.

Purpose: The health related quality of life assessment is becoming increasingly important among patients with prostate cancer. Meanwhile, treatment of patients with increasing prostate specific antigen (PSA) after radical retropubic prostatectomy remains controversial. We attempt to define the impact of PSA recurrence on the health related quality of life of patients after radical retropubic prostatectomy., Materials and Methods: Of 604 consecutive patients who underwent radical retropubic prostatectomy between March 1991 and September 1998, 510 (84%) were available for followup. Each patient was mailed the RAND 36-Item Health Survey and University of California, Los Angeles, Prostate Cancer Index questionnaire. A total of 348 (70%) questionnaires were returned. Health related quality of life scores were then compared between patients with and without PSA recurrence. A multivariate analysis was also performed to elucidate further the cause of differences between the groups., Results: Overall, 88 (25%) patients had PSA recurrence. In regard to health related quality of life there were small (less than 10%) but statistically significant differences in 2 of 4 physical health domains (RAND 36-Item Health Survey). There was a significant decrease in only 1 category of the mental health domain for patients with PSA recurrence. Only sexual function was statistically lower on the University of California, Los Angeles, Prostate Cancer Index. This result reflects the lower incidence of nerve sparing in these patients, as confirmed by the multivariate analysis. Overall patient satisfaction was similar between those with and without PSA recurrence (76% and 79%, respectively)., Conclusions: Our study demonstrates small health related quality of life differences in patients with biochemical PSA recurrence versus those without. These findings provide a baseline assessment of general and disease specific health related quality of life domains among these patients. Future studies should focus on differences in the measure of cancer anxiety before and after administration of adjuvant therapy in these asymptomatic patients.

Purpose: Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution., Materials and Methods: We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively., Results: Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2., Conclusions: The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

Purpose: Idiopathic hypercalciuria is believed to be the cause of a variety of urinary tract complaints in clinical pediatrics, including urinary frequency, urgency, and/or dysuria, often associated with gross or microscopic hematuria. In children noncalculous manifestations of idiopathic hypercalciuria are reportedly more common than urolithiasis. We determine the use of the calcium-to-creatinine ratio for the evaluation of different subsets of functional voiding disorders., Materials and Methods: We retrospectively evaluated 288 patients with functional voiding disorders during the last 8 years. Patients presenting with isolated urinary tract infection were not included in the study. A thorough history with emphasis on voiding patterns was elicited and a routine urinalysis was performed in all patients. Patients were divided into 5 groups of 22 with total gross hematuria and dysfunctional voiding pattern, 102 with microhematuria and dysfunctional voiding pattern, 66 with isolated childhood daytime frequency, 45 with the isolated dysuria syndrome and 53 with combined childhood frequency-urgency-dysuria syndrome. The season at presentation was noted to determine a seasonal pattern. In 149 patients urine was evaluated for a spot calcium-to-creatinine ratio., Results: Mean age of the 95 (33%) males and 193 (67%) females was 6.1 years (range 2 to 14) and mean duration of symptoms was 10 months (1 week to 10 years). The incidence of idiopathic hypercalciuria was 28% in cases with gross hematuria and dysfunctional voiding, 30% with microscopic hematuria and dysfunctional voiding, 21% with pure childhood daytime frequency, 22% with pure dysuria, and 28% with frequency, urgency and dysuria. The patients were treated predominantly with behavioral therapy, correction of faulty voiding habits, anticholinergics and minor diet modification in some. Mean followup of 6.5 months (range 1 month to 10 years) was available for 153 patients (53%). Resolution of symptoms along with marked improvement in voiding habits was noted in 136 (89%) patients, moderate improvement in 10 (6.5%) and persistent symptoms with minimal improvement in 7 (4.5%). Treatment with thiazides was used in only 6 (2%) patients who had intractable symptoms and a markedly elevated urine calcium-to-creatinine ratio of whom 5 responded favorably., Conclusions: Idiopathic hypercalciuria may have a significant role in cases of functional voiding disorders. It affects the different subsets of voiding disorders with remarkable consistency but the exact mechanism remains unknown. Although a significant number of patients with voiding dysfunction have an elevated calcium-to-creatinine ratio, the majority respond to standard behavioral therapy and pharmacotherapy in the form of anticholinergics, and treatment directed toward hypercalciuria is not required in most cases.

Objectives: To compare postoperative morbidity and mortality in a concurrent and contemporary series of patients who underwent radical cystectomy with ileal conduit versus orthotopic neobladder., Methods: The data of 198 patients were reviewed, 117 with orthotopic reconstruction and 81 with ileal conduit during a 5-year time frame. Thirty-day morbidity, mortality, reoperative rates, and parameters associated with the surgical procedures were obtained from chart review., Results: No perioperative or postoperative deaths occurred in either group. The median operative time for the ileal conduit was 201 minutes (range 140 to 373), and for the orthotopic neobladder, it was 270 minutes (range 230 to 425). The median blood loss was 389 and 474 mL, respectively. The median length of hospitalization was 8 days for the ileal conduit group and 7 days for the orthotopic neobladder group. Diversion-related complications recognized within 30 days that ultimately required a return to the operating room occurred in 3.4% of those with a neobladder and 1.2% of those with an ileal conduit., Conclusions: The orthotopic neobladder is a longer and technically more complex procedure than the ileal conduit procedure. However, no demonstrable difference in morbidity or perioperative complications were found between the two procedures in our review.

Purpose: We reviewed our experience with orthotopic continent urinary reconstruction after radical cystectomy to determine the functional voiding patterns and compare different methods of reservoir construction., Materials and Methods: The study included 100 consecutive patients who underwent cystectomy and orthotopic neobladder. Reservoir construction consisted of a W-shaped ileal reservoir in 40 patients, ileal reservoir with afferent limb in 26, a Padua ileal reservoir in 18, right colon in 14 and sigmoid colon in 2. The functional voiding outcome was determined by a detailed patient interview and chart review., Results: There were no perioperative deaths. All patients regained good daytime urinary control and none required protective pads, although 18% used protective padding at night because of nocturnal leakage. Eight patients (8%) performed self-intermittent catheterization because of poor reservoir emptying. There were no substantial differences in outcomes among the various methods of reservoir construction., Conclusions: Excellent functional voiding outcomes are obtained with radical cystectomy and orthotopic bladder reconstruction. Comparable results can be achieved with use of either large bowel or ileum and with various methods of bowel folding as long as principles of preservation of the periurethral sphincter muscle, and construction of an adequate capacity and low pressure reservoir are maintained.