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Purpose: The desirable outcomes after open radical prostatectomy (RP) for localized prostate cancer (PC) are to: a) achieve disease recurrence free, b) urinary continence (UC), and c) maintain sexual potency (SP). These 3 combined desirable outcomes we called it the “Trifecta”. Our aim is to assess the likelihood of achieving the Trifecta, and to analyze the influencing the Trifecta . Materials and Methods: A total of 1738 men with localized PC underwent RP from 1992-2007 by a single surgeon. The exclusion criteria for this analysis were: preoperative hormonal or radiation therapy, preoperative urinary incontinence or erectile dysfunction, follow-up less than 24 months or insufficient data. Post-operative Trifecta factors were analyzed, including biochemical recurrence (BR).. We defined: BR as PSA ≥ 0.2 ng/mL, urinary continence as wearing no pads, and sexual potency as having erections sufficient for intercourse with or without a phosphodiesterase-5 inhibitor . Results: A total of 831 patients met the inclusion criteria. The mean age of the entire cohort was 59 years old. The median follow-up was 52 months (mean 60, range 24-202). The BR, UC and SP rates were 18.7%, 94.5%, and 71% respectively. Trifecta was achieved in 64% at 2 year follow-up, and 61% at 5 year follow-up. Multivariate analysis revealed age at time of surgery, pathologic Gleason score (PGS), pathologic stage, specimen weight, and nerve sparing (NS) were independent factors. Conclusions: Age at time of surgery, pathologic GS, pathologic stage, specimen weight and NS were independent predictors to achieve the Trifecta following radical prostatectomy. This information may help patients counseling undergoing radical prostatectomy for localized prostate cancer.

Objective • To analyse if there is a trend in recent years towards performing radical cystectomy (RC) before muscle invasion or extravesical spread after failure of bacille Calmette-Guerin (BCG) for high grade Ta/T1 bladder cancer. Although BCG is indicated for prophylaxis after endoscopic tumour resection there is still a risk of progression. Patients and methods • A retrospective analysis of our RC database (1992-2008) was performed to identify patients who underwent RC after receiving BCG. • Relevant clinical and pathological data for the patients with clinical stage Ta, T1 and/or Tis at initial transurethral resection of bladder tumour were analysed. • Pathological stage and survival for patients undergoing RC from 2003 to 2007 (group 2) were compared with those for patients operated between 1992 and 2002 (group 1). Results • A total of 152 patients were included (75 in group 2 and 77 in group 1). Both groups were similar in T-stage before BCG initiation, number of BCG cycles received and time interval to RC. • There was no change in the proportion of patients undergoing RC with ≥ pT2 bladder cancer in recent years (P= 0.5). • Fifty-two percent of group 2 and 43% of group 1 had ≥ pT2 BC. The 5-year survival was similar. Conclusions • Despite concerns about delay in performing RC for patients failing one or more courses of BCG we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG. • A high proportion of patients have muscle-invasive bladder cancer; more than 10% have lymph node metastasis.

Introduction: We analyze patient-physician dialogue prior to radical cystectomy (RC) when choosing the type of urinary diversion (UD). Methods: 132 patients operated by one surgical team between 2003 and 2005 were included. Physician’s recommendation, patient’s decision and UD (neobladder (NB) or ileal conduit (IC)) performed were analyzed. Patients were grouped based on age, considering that age is often a limiting factor for NB. Results: When offered either NB or IC, 85% (49/58) in group I (Conclusions: Counseling patients is important. When an IC was suggested, over 80% accepted this advice. When both were offered, younger patients usually elected a NB. Older patients preferred an IC.

PURPOSE: Renal cell carcinoma (RCC) has a propensity to propagate into the renal vein and inferior vena cava (IVC). Due to inherent differences in the venous anatomy of the right and left kidneys, tumor thrombus involvement of IVC may vary. The aim of this study is to compare clinical presentation and outcome of right vs. left RCC with IVC thrombus. MATERIALS AND METHODS: Patients who underwent radical nephrectomy and IVC thrombectomy between 1997 and 2008 were identified. All relevant data were collected and analyzed. Results: Eight-seven patients were included. Sixty patients (69%) had a right sided tumor. Mean tumor size was 10.2 (± 4) cm and was not significantly different on either side. Fifty-six percent of right sided tumors had level-III (intra-hepatic) or higher tumor thrombus, while 22% of left sided tumors had similar level thrombus extension (p < 0.0001). Nearly 50% of left sided tumors showed level-I thrombus compared to 10% of right side tumors. A comparison of age, estimated blood loss and transfusion rate was not significantly different. The recurrence free (p = 0.9) and disease specific survival (p = 0.4) were not significantly different between the right and left side tumors with IVC thrombus. Conclusion: A level-III IVC tumor thrombus is more frequently seen with a right side tumor. However, clinical and operative characteristics among the left and right sided tumors with IVC thrombus were not different. More significantly, recurrence rate and survival did not differ with the laterality of the tumor.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To report our experience of synchronous panniculectomy with stomal revision in morbidly obese patients after radical cystectomy (RC) and ileal conduit urinary diversion (UD). Abnormal skin folds with an uneven surface, stomal retraction and stomal stenosis result in a poorly fitting appliance which leads to urinary leakage, need for frequent change of appliances and skin excoriation. PATIENTS AND METHODS In all, 302 RCs with UD were done by one surgical team between 2002 and 2008, with ileal conduit diversion in 182 (60%); 18 had a body mass index (BMI) of >35 kg/m2, and among them four had severe stomal stenosis with retraction. We report the technique we used for managing stomal stenosis in these patients. RESULTS The mean (range) BMI of the patients was 42 (38–46) kg/m2; all were women. The mean (sd) operative duration was 2 (0.5)h. The drain was removed once the drainage was

To determine the prognostic significance of lymphovascular invasion (LVI) in patients with urothelial carcinoma of the bladder undergoing radical cystectomy (RC) and bilateral pelvic lymph node dissection.From 1992 to 2008, 526 patients underwent RC and pelvic lymphadenectomy at our institution by a single surgical team. All relevant data were entered into a database and analyzed. LVI was defined as "the presence of tumor cells within an endothelial lined space." The exclusion criteria were non-TCC histology, salvage cystectomy, neoadjuvant chemotherapy, and unknown LVI status.A total of 357 patients met the inclusion criteria. Overall prevalence of LVI was 29%. LVI was significantly associated with higher T stage, lymph node (LN) metastases, and higher grade. Patients with LVI had significantly higher recurrence rate (P0.001) and decreased long-term survival (P0.001). In patients without LN metastases, LVI in the primary led to a significantly decreased recurrence-free (P = 0.003) and disease-specific survival (P = 0.001). In the presence of LN metastases, LVI did not significantly alter the recurrence-free or disease-specific survival. On multivariate analysis, T stage (P0.0001) and LN metastases (P = 0.01) were significant independent prognostic factors influencing disease-specific survival. LVI did not have independent prognostic value. T stage was the only significant prognostic factor in the lymph node negative group.Although, the presence of LVI in node-negative patients is an adverse prognostic factor on univariate analysis of disease-specific survival, it is not an independent prognostic factor on multivariate analysis. Pathological stage is the only independent prognostic factor for survival.

The management of incisional hernia following radical cystectomy (RC) and neobladder diversion poses a special challenge. Mesh erosion into the neobladder is a potential complication of hernia repair in this setting. We describe our experience and steps to avoid this complication. Three patients developed incisional hernias following RC involving the neobladder. The incisional hernias were repaired by the same surgeon. A systematic dissection and repair of the hernias with an onlay dual-layer mesh (made of polyglactin and polypropylene) was carried out. The critical steps were placing the polyglactin side of the mesh deeper and positioning of an omental flap anterior to the neobladder. The omental flap adds a protective layer that prevents adhesions between the neobladder and abdominal wall, and prevents erosion of the mesh into the fragile neobladder wall. All of these patients had received two cycles of neoadjuvant chemotherapy prior to RC. The time duration from RC to the repair of hernia was 7, 42, and 54 months. No intraoperative injury to the neobladder or other complication was noted during hernia repair. The patients were followed after hernia repair for 20, 22, and 42 months with no recurrence, mesh erosion, or other complications. Careful understanding and attention to details of the technique can minimize the risk of complications, especially incisional hernia recurrence, injury to the neobladder, and erosion of mesh into the neobladder wall.

We present a rare case of renal gastrinoma. To the best of our knowledge, only one case of renal gastrinoma has been reported in the literature so far. An African American male was diagnosed with Zollinger Ellison syndrome at the age of 15 years, when he underwent surgery for peritonitis secondary to duodenal ulcer perforation. Further evaluation was deferred and proton pump inhibitors were prescribed. Later evaluation showed a left renal mass. Serum gastrin levels were 4,307 pg/ml. A CAT scan of the abdomen showed 4- x 4-cm heterogeneous solid mass in the interpolar region of the left kidney with central hypodensity. Somatostatin scintigraphy confirmed a receptor-positive mass in the same location. Nephrectomy was done and the tumor was diagnosed on histopathological examination as a gastrinoma. At 6-month follow-up, gastrin levels were 72 pg/ml. After a follow-up of 6 years, the patient has no recurrent symptoms.

Radical prostatectomy (RP) as a monotherapy is most likely to be curative only in patients with truly organ-confined PC. Several clinical and pathologic factors affect recurrence following RP. In an effort to improve the outcome Androgen deprivation therapy (ADT) has been evaluated in conjunction with RP. In this review we summarize the available evidence from prospective randomized studies concerning the use of ADT in both the preoperative and postoperative scenarios.

Inflammatory myofibroblastic tumor (IMT) is an uncommon tumor believed to be benign and can arise in various organs. We report a case of renal IMT in a 74-year old female with right upper quadrant abdominal pain. Computerized tomography showed a 4.5 cm upper pole renal mass, consistent with a renal cell carcinoma. Subsequently a laparoscopic right radical nephrectomy was performed. Pathology revealed an unusual lesion consisting of spindle cells having prominent nucleoli, with plasma cells and lymphocytes throughout the lesion. Staining was positive for anaplastic lymphoma kinase (ALK), vimentin, CK 18, CK-AE 1/3, and CAM 5.2 consistent with an IMT.

Renal artery pseudoaneurysm (RAP) is an uncommon complication following an open partial nephrectomy. We present a case of RAP diagnosed four and a half months following open partial nephrectomy for renal cell carcinoma. RAP was managed by selective angiographic embolization using coils. The etiology and management of this potentially life-threatening condition is discussed. fig. 1. CT scan image of the abdomen post contrast showing a) a left RAP and b) subsequent resolution of the RAP following coil embolization. a b

Gender, smoking history, patient age, and tumor size have been found to impact the likelihood of benign histology at the time of nephron-sparing surgery (NSS). Providing external validation of these variables and evaluating the relationship between body mass index (BMI) and tumor location on the likelihood of benign histology during NSS for T1 tumors were the objectives of this study.Data were analyzed for consecutive patients undergoing NSS for T1 disease. Central tumors either were completely encircled by renal parenchyma, descended below the cortico-medullary junction, or were in direct opposition to the collecting system, renal sinus, or the hilar structures. Categorical variables were evaluated with chi-square test, and continuous variables were analyzed with independent sample t test. Logistic regression identified independent predictors of final pathology.NSS was performed in 316 patients, of whom 79 (24 %) had benign tumors. Patients with benign tumors were more likely to be female, to have a lower BMI, and to have peripheral tumors. On multivariate analysis, female gender (hazard ratio, 3.97; 95 % CI, 2.92-4.53, p0.001), peripheral tumor location (hazard ratio, 2.27; 95 % CI, 1.73-3.21, p = 0.014), and lower BMI (hazard ratio, 1.5; 95 % CI, 1.12-1.94, p = 0.015) were independently associated with benign histopathology at the time of surgical resection.Prospectively identifying which T1 tumors are benign would have tremendous implications for the patient. Ours is the first study that has identified the impact of tumor location and BMI on the risk of benign histology. Additional studies are needed to corroborate these findings and incorporate these data into future nomograms.

Objective Radical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS. Methods and materials We collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience. Results The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years). Conclusions The cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.

• To analyse if there is a trend in recent years towards performing radical cystectomy (RC) before muscle invasion or extravesical spread after failure of bacille Calmette-Guérin (BCG) for high grade Ta/T1 bladder cancer. Although BCG is indicated for prophylaxis after endoscopic tumour resection there is still a risk of progression.• A retrospective analysis of our RC database (1992-2008) was performed to identify patients who underwent RC after receiving BCG. • Relevant clinical and pathological data for the patients with clinical stage Ta, T1 and/or Tis at initial transurethral resection of bladder tumour were analysed. • Pathological stage and survival for patients undergoing RC from 2003 to 2007 (group 2) were compared with those for patients operated between 1992 and 2002 (group 1).• A total of 152 patients were included (75 in group 2 and 77 in group 1). Both groups were similar in T-stage before BCG initiation, number of BCG cycles received and time interval to RC. • There was no change in the proportion of patients undergoing RC with ≥ pT2 bladder cancer in recent years (P= 0.5). • Fifty-two percent of group 2 and 43% of group 1 had ≥ pT2 BC. The 5-year survival was similar.• Despite concerns about delay in performing RC for patients failing one or more courses of BCG we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG. • A high proportion of patients have muscle-invasive bladder cancer; more than 10% have lymph node metastasis.

Active surveillance (AS) is an alternative to total prostatectomy (TP) in managing low-risk prostate cancer (PC). Our aim is to compare urologist reimbursement for managing low-risk PC by AS or TP. The urologist's reimbursement for TP includes the fee for the procedure and follow-up visits. For AS, our protocol involves digital rectal examination (DRE) and PSA testing every 3 months for first 2 years and every 6 months thereafter. Transrectal ultrasound (TRUS)-guided biopsies are performed yearly. Some urologists recommend spacing the biopsies by 1–3 years. Medicare reimbursement values were used. The urologist reimbursements for a follow-up visit, prostate biopsy, open TP and robotic TP are $72, $595, $1905 and $2939, respectively. We also corrected for a 15% chance of having TP after being on AS. The cumulative reimbursements from open TP and following the patient up to 10 years are approximately $2121 (1 year), $2265 (2 years), $2697 (5 years) and $3057 (10 years). For robotic TP, the urologist reimbursements are $3155 (1 year), $3259 (2 years), $3731 (5 years) and $4091 (10 years). For AS, the urologist reimbursements are $883 (1 year), $1766 (2 years), $4269 (5 years) and $7964 (10 years). The urologist reimbursement from AS and TP become nearly equal between 3 and 4 years follow-up, subsequently AS attains higher reimbursement.

Asphysicians,we should strive for clear communicationwith our patients, particularly when the diagnosis is cancer. We choose words with the intention of accurately and precisely conveying information about the diagnosis and treatment alternatives. This is especially true whenwe are faced with a patient with newly diagnosed prostate cancer (PCa) because there are several management options. A patient with lowgrade, clinically confined PCa, for example, may be offered active surveillance, radiation therapy, or total prostatectomy. The language we use to deliver this information must not complicate an already challenging decision. Many patients with PCa will consider radiation or surgery as their initial treatment. These approaches are often referred to as definitive therapy. To physicians, the intention is clear: The intervention is the best or is one of several equivalent treatment options when all approaches have been considered. But when read or heard by patients, we may have caused confusion with the use of the term definitive. Will the patient think that this treatment is the only one that will be required? In this era of open access to medical information [1] and free exchange on unlimited numbers of Web sites [2], our patients are often exposed to unfamiliar medical jargon. In using the term definitive therapy, the intention is not to confuse the patient; rather, it is the opposite. Nonetheless, we have some concerns about the term’s use related to treatment. An adjective is often prefixed to a named intervention toqualify thenatureof a treatment; for example, thewords radical, total, subtotal, and partial convey the extent of a surgical procedure. Similarly, words such as prophylactic, curative, and palliative convey the intent of a named intervention. Most often these prefixes are self-explanatory and very precise. The term definitive, however, hasmore than one definition. To some, definitive therapy conveys the message that the treatment is the best option after all modalities have been considered. To others, this term may suggest that no

Objectives To report our technique of robotic-assisted laparoscopic radical cystectomy with a modified Pfannenstiel incision. Robotic-assisted laparoscopic radical cystectomy has been gaining in popularity. A completely intracorporeal procedure is a technically difficult and time-consuming procedure. Most surgeons perform the diversion using a small incision, typically midline, that is also used for specimen retrieval. Methods Radical cystectomy and pelvic lymph node dissection was performed using a da Vinci robotic platform in a standard fashion. The robot was undocked and an 8-10 cm modified Pfannenstiel incision made. A self-retaining retractor was used to expose the wound. The specimen was extracted, and an ileal neobladder was reconstructed using the incision. Results We have performed this procedure in 14 patients to date. The mean age was 58 years (range 56-61). The mean estimated blood loss was 310 ± 220 mL, and the mean operating time was 6 ± 0.8 hours. No intraoperative visceral injuries were noted. None of the patients had positive surgical margins. The mean number of lymph nodes removed was 12 ± 3. The mean hospital stay was 8.5 days. Conclusions Our initial experience with our technique of robotic-assisted laparoscopic radical cystectomy and neobladder construction using a modified Pfannenstiel incision has been favorable. The incision provides good exposure, facilitating neobladder reconstruction, can be used for specimen retrieval, and heals better with a cosmetic scar.

Small cell carcinoma (SCC) of the urinary bladder is a rare diseaseaccounting for 0.5% to 0.7% of all primary bladder cancers.Transplant recipients are a special subset of patients with increasedrisk for various urologic malignancies, including transitional cellcarcinoma of the bladder. However, to the best of our knowledge,a SCC of the urinary bladder has not been reported in transplantrecipients. We report what we believe are the first 2 reportedcases of transplant recipients with SCC of the bladder. Small cellcarcinoma was diagnosed 5 years after transplantation in bothpatients and they died due to metastatic SCC. Our report emphasizesthe highly aggressive nature of SCC and also the rapid progressionseen in transplant recipients.

To report our experience of synchronous panniculectomy with stomal revision in morbidly obese patients after radical cystectomy (RC) and ileal conduit urinary diversion (UD). Abnormal skin folds with an uneven surface, stomal retraction and stomal stenosis result in a poorly fitting appliance which leads to urinary leakage, need for frequent change of appliances and skin excoriation.In all, 302 RCs with UD were done by one surgical team between 2002 and 2008, with ileal conduit diversion in 182 (60%); 18 had a body mass index (BMI) of35 kg/m(2), and among them four had severe stomal stenosis with retraction. We report the technique we used for managing stomal stenosis in these patients.The mean (range) BMI of the patients was 42 (38-46) kg/m(2); all were women. The mean (sd) operative duration was 2 (0.5)h. The drain was removed once the drainage was25 mL in 24 h. The mean (sd) hospital stay was 3 (1) days; there were no significant complications. After a mean follow-up of 3 years there was no recurrent stomal stenosis or retraction.The unique advantage of this procedure is that it avoids laparotomy in a morbidly obese patient, and it provides excellent cosmesis while correcting the stomal complication.

PURPOSE: Many urologists recommend a six-week time interval between a prostate biopsy and a total prostatectomy (TP) to allow the biopsy induced inflammation to subside. Our aim was to assess whether the time interval between prostate biopsy and TP has an impact on the surgical outcome. MATERIALS AND METHODS: A retrospective analysis was performed on data from patients who underwent a TP by a single surgeon from 1992 to 2008. The patients were divided into two groups according to the time interval between biopsy and TP, Group 1 ≤ 6 weeks and Group 2 > 6 weeks. Relevant perioperative variables and outcome were analyzed. RESULTS: 923 patients were included. There was a significant difference between the two groups in the surgeons' ability to perform a bilateral nerve sparing procedure. Those who had a TP within six weeks of the biopsy were less likely to have a bilateral nerve sparing procedure. No significant difference was noted in the other variables, which included Gleason score, surgical margin status, estimated blood loss, post-operative infection, incontinence, erectile function, and biochemical recurrence. CONCLUSIONS: TP can be safely performed without any increase in complications within 6 weeks of a prostate biopsy. However, a TP within six weeks of a biopsy significantly reduced the surgeon's perception of whether a bilateral nerve sparing procedure was performed.

Objectives To determine how often complete eradication of all visible tumors during transurethral resection of bladder tumor (TURBT) is accomplished in a referral setting. The American Urological Association guidelines recommend complete eradication whenever possible. Methods We retrospectively reviewed the records of patients who underwent a second TURBT within 4 weeks of being referred to us. Relevant data such as residual tumor location, number, stage, and grade were collected and analyzed. Patients with muscle invasive tumor or known incomplete resection were excluded. Results Forty-seven patients met the inclusion criteria. Mean age was 75 years. In the initial TURBT, 35 (75%) had a high grade tumor and 12 (25%) had low grade tumors. Twenty-four (52%) were Ta and 23 (48%) were T1 tumors. Of the 47 patients who satisfied the criteria, 33 (70%) had an initial incomplete resection. Of these, 10 (30%) had macroscopic residual tumor at the resection site. Twenty-three (70%) had at least 1 unresected tumor away from the previous resection site. There were 39 unresected or partially resected tumors. Thirteen (33%) tumors were located in the anterior wall, 12 (31%) in the posterior wall and trigone, 10 (26%) in the lateral wall, 3 (7.5%) in the dome, and 1 (2.5%) in the prostatic urethra. Conclusions Although TURBT is a commonly performed operation, in this selected series, the incidence of unresected and gross residual tumor after initial TURBT is high. This indicates a need to emphasize the guidelines for a complete resection and to emphasize the use of a proper technique in this commonly performed urological procedure.

OBJECTIVE To analyse the outcome after radical cystectomy (RC) in patients with clinical T2 bladder cancer not responding to neoadjuvant chemotherapy (NAC). PATIENTS AND METHODS In a retrospective analysis, study patients received NAC for clinical T2 disease before RC and a control group had RC for clinical T2 disease with no NAC. Patients treated with NAC were further grouped based on the pathological response; failure to respond was defined as ‘no change in T stage or a higher T stage in the RC specimen (≥pT2)’, and the relevant clinical and pathological data were analysed. RESULTS In all, 53 patients satisfied the inclusion criteria for the study group and 200 for the control group. In the study group 18 (34%) responded to NAC (group 1) of whom 11 (61%) were pT0 and seven (39%) pT1, and among the non-responders (group 2) 19 (54%) were pT3/pT4 and 16 (46%) were pT2; 16 (46%) patients in group 2 had lymph node metastasis. The mean follow-up was 26 months. In group 2, local recurrence occurred in six (17%) vs none in group 1. Seven patients (20%) in group 2 developed metastases, vs one (5%) in group 1 (P = 0.01). The 5-year disease-free survival was significantly lower for group 2 (40%) than group 1 (91%, P = 0.007) and the control group (67%, P = 0.04). There were 14 deaths from bladder cancer in group 2, vs one in group I (P = 0.01). The 5-year disease-specific survival was significantly lower for group 2 (52%) than group 1 (83%, P = 0.008) and the control group (70%, P = 0.001). CONCLUSION A lack of response to NAC is associated with a significantly higher local and distant recurrence, and with lower survival.

Background Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management. Objective To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy. Design, setting, and participants We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed. Measurements Disease-free survival (DFS) and disease-specific survival (DSS) were studied. Results and limitations The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I ( p =0.03). However, when analyzed in two groups—supradiaphragmatic and infradiaphragmatic—there was no significant difference in DSS ( P =0.14). On univariate analysis, metastasis at presentation, non–clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade ( p =0.03), metastasis at presentation ( p p =0.03) were independent prognostic factors on multivariate analysis. Conclusions Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non–clear-clear cell histology are significant prognostic factors influencing DSS.

Introduction: Chemotherapy was shown to improve survival in patients undergoing radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). The initiation and completion rates for perioperative chemotherapy are variable. Our aim is to compare the likelihood of initiating and completing neoadjuvant (NAC) and adjuvant chemotherapy (AC) in patients who underwent of RC for MIBC. Materials and Methods: We performed a retrospective analysis of patients who underwent RC between 1992 and 2011. NAC was advised for patients with clinical stage ≥T2, hydronephrosis, extensive lymphovascular invasion (LVI), or prostatic stromal invasion. Patients with ≥pT3 or lymph node metastases were considered for AC. Results: A total of 363 patients were considered for perioperative chemotherapy. Among the 141 patients who were offered NAC, 125 (88.6%) initiated NAC. A total of 222 were considered for AC, and 151 (68.0%) initiated AC (P < 0.001). In the NAC group, 118 (83.5%) completed planned number of cycles of chemotherapy and 7 (5.6%) did not complete the planned chemotherapy. In the AC group, 79 (35.5%) completed at least four cycles and 72 (47.3%) could not complete the planned cycles (P < 0.001). Conclusions: Patients with MIBC are more likely to initiate and complete NAC than AC.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To present our long-term experience comparing uretero-intestinal anastomotic (UIA) stricture rates after radical cystectomy (RC) in patients with and without previous pelvic radiotherapy (pRT), as the risk of stricture is thought to be higher in patients undergoing RC and urinary diversion (UD) with a history of pRT. PATIENTS AND METHODS We retrospectively analysed patients who had RC and UD between 1992 and 2008 by one surgical team. Patients were divided into two groups, those with (group 1) and with no (group 2) previous pRT. Relevant clinical and pathological data were entered into a database. Patients who were symptomatic and required intervention for a UIA stricture were analysed; patients with malignant strictures were excluded. RESULTS In all, 526 patients had RC by one surgical team during the study period; 65 had pRT before RC, 37 for prostate cancer, 23 for bladder cancer and the rest for other pelvic malignancies. All the patients in group 1 had an ileal conduit (IC) diversion. There were 250 IC and 211 neobladder diversions in group 2. There were 130 (12%) UIAs in group 1, vs 922 (88%) in group 2. There was no statistically significant difference between the groups in demographic profile and follow-up. The overall stricture rate for UIA was 1.3%; there were two (1.5%) UIA strictures in group 1 vs 12 (1.3%) in group 2. The mean (median, range) time to onset of the stricture was 10 (6, 2–39) months. There was no statistically significant difference in stricture rate between the groups (P > 0.05). CONCLUSIONS In patients undergoing RC with UD there was no significant difference in UIA stricture rates between those with and without previous pRT.