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Background: The indication for extended pelvic lymph node dissection (ePLND) at the time of radical prostatectomy (RP) is based on nomograms predicting the risk of lymph node invasion (LNI). However, limited data are available on the comparison of these predictive models in high-risk prostate cancer (PC) patients. Therefore, we compared the accuracy of the most used nomograms (MSKCC, Briganti 2012, 2017, and 2019) in the setting of high-risk PC patients submitted to ePLND. Methods: 150 patients with high-risk PC disease treated from 2019 to 2022 were included. Before RP + ePLND, we assessed the MSKCC, Briganti 2012, 2017, and 2019 nomograms for each patient, and we compared the prediction of LNI with the final histopathological analysis of the ePLND using pathologic results as a reference. Results: LNI was found in 39 patients (26%), and 71.3% were cT2. The percentage of patients with estimated LNI risk above the cut-off was significantly higher in pN+ cases than in pN0 for all Briganti nomograms. The percentage of patients at risk of LNI, according to Briganti Nomogram (2012, 2017, and 2019), was significantly higher in pN+ cases than in pN0 (p < 0.04), while MSKCC prediction didn’t vary significantly between pN0 and pN+ groups (p = 0.2). All nomograms showed high sensitivity (Se > 0.90), low specificity (Sp < 0.20), and similar AUC (range: 0.526–0.573) in predicting pN+. Particularly, 74% of cases patients with MSKCC estimated risk > 7% showed pN0 compared to 71% with Briganti 2012 > 5%, 69% with Briganti 2017 > 7%, and 70% with Briganti 2019 > 7%. Conclusions: Despite the high-risk disease, in our patients treated with ePLND emerges a still high number of pN0 cases and a similar low specificity of nomograms in predicting LNI.

The indwelling urinary catheter (UC) is a significant bother for men after radical prostatectomy (RP) and should be removed as soon as possible without jeopardizing the outcome. Our aim was to assess the feasibility and safety of its removal on postoperative day (POD) 2 after robot-assisted laparoscopic RP (RALP). A consecutive series of patients undergoing RALP for localized prostate cancer (PCa) were prospectively enrolled. Inclusion criteria were: no bladder-neck reconstruction, watertight urethrovesical anastomosis at 150 ml filling, ≤ 200 ml of intraoperative bleeding, ≤ 80 ml of fluid from the drain on POD 1, clear urine from the UC on POD 2. Patients were discharged on POD 2. Continence was assessed at catheter removal and 1, 3 and 6 months after surgery. Urethrovesical anastomosis was performed with a standard technique on 3 layers. Sixty-six patients were enrolled. The UC was removed on POD 2 in all the cases and 96.4% of the patients were discharged on POD 2. Re-catheterization was needed 16 times and it was always performed easily. Twenty-four complications were reported by 20 patients, mostly Clavien–Dindo (CD) grade II; 2 CD IIIB complications were observed. No anastomotic strictures were diagnosed. At catheter removal, 29% of the patients were completely continent, 41% at 1 month, 67% at 3 months and 92% at 6 months. In selected patients, removing the UC 48 h after RALP is feasible and safe and has no negative impact on continence if compared with the best international standards.

Objective To analyze the performance of prostate-specific antigen density (PSAD) as a predictor of upstaging and prognostic grade group (PGG) upgrading. Materials and Methods We retrospectively evaluated data on men with prostate cancer (PCa) treated with robot-assisted laparoscopic radical prostatectomy (RALP) at our center in 2014-2015. Preoperative PSAD was calculated. Bioptic and pathologic PGGs were also considered in the analysis. We defined upgrading as any increase in PGG after RALP; upstaging was the pathologic diagnosis of a clinically unsuspected stage ≥3a PCa. Results Data on 379 patients were analyzed. Upgrading was found in 41.4% of the patients; 29% of the patients were upstaged. On multivariable analysis, core involvement and PSAD were found to be predictors of upgrading (odds ratio [OR] 1.017, 95% confidence interval [CI] 1.001-1.034, P = .039; and OR 3.638, 95% CI 1.084-12.207, P = .001, respectively). Furthermore, core involvement and PSAD were predictors of upstaging (OR 1.020, 95% CI 1.020-1.034, P = .003; and OR 5.656, 95% CI 1.285-24.894, P = .022, respectively). PSAD showed areas under the curve of 0.712 (95% CI 0.645-0.780, P = .000) and 0.628 (95% CI 0.566-0.689, P = .000) for the prediction of upgrading and upstaging, respectively. In a subpopulation of 90 patients theoretically eligible for active surveillance, 14% were found upstaged and 17% were upgraded. PSAD showed areas under the curve of 0.894 (95% CI 0.808-0.97, P = .000) and 0.689 (95% CI 0.539-0.840, P = .021) for the prediction of upgrading and upstaging, respectively. Conclusion PSAD is a valuable predictor of upgrading and upstaging in men with PCa who were candidates for surgery and is accurate in selecting patients for AS.

Objective To describe preliminary results of our monopolar transurethral enucleation of prostatic adenoma (mTUEPA). Materials and Methods A consecutive series of male patients treated with mTUEPA, a retrograde enucleation of the prostatic adenoma performed by means of a standard monopolar resectoscope, were prospectively enrolled. Symptoms, uroflowmetry parameters, and post-voiding residual were assessed at baseline and at 1, 6, and 12 months postoperatively. Prostate volume was evaluated at baseline by means of transrectal ultrasound. Antiplatelet and anticoagulant drugs were stopped at least 1 week before the operation. Results Forty-seven patients were enrolled. Mean preoperative prostate volume was 64.9 ± 28.5 g. When assessed at baseline, the mean total International Prostatic Symptoms Score was 15.2 ± 3.9, peak flow rate (Qmax) was 8.4 ± 2.9 mL/s and the post-voiding residual was 103.2 ± 90.6 mL. Four weeks after surgery, patients reported a mean International Prostatic Symptoms Score of 5.3 ± 3. This lower urinary tract symptoms relief was further maintained at 6 and 12 months after surgery. A significant postoperative improvement in uroflowmetry parameters was described, being the 6 and 12 months mean Qmax of 23.4 ± 10.6 mL/s and 18.8 ± 9.2 mL/s, respectively (P

Objectives To compare the efficacy of transperineal versus transrectal six-core prostate biopsy. Transrectal sextant biopsy is the most common method for prostate cancer detection. However, the cancer detection rate with this technique is increasingly considered inadequate. Different prostate biopsy procedures, mainly based on addition of additional transrectal cores to traditional sextant biopsy, have been proposed to increase the cancer diagnosis rate. The efficacy of the transperineal approach has not yet been fully established. Methods In a prospective study, 107 patients with elevated prostate-specific antigen levels (greater than 4.0 ng/mL) underwent prostate biopsy with six transperineal cores, using a “fan” scheme, plus six transrectal cores, according to the sextant technique. The median prostate-specific antigen level was 8.2 ng/mL (range 4.1 to 240). Results The overall cancer detection rate was 40% (43 of 107); prostate cancer was found in 38% (41 of 107) of patients with the transperineal approach and in 32% (34 of 107) of patients with the transrectal approach. Of 43 diagnosed cancers, 41 (95%) were found with the transperineal approach and 34 (79%) with the transrectal approach ( P = 0.012). No patient had low-grade cancer (Gleason score 2 to 4), 25 patients had intermediate-grade cancer (Gleason score 5 to 6), and 18 patients had high-grade cancer (Gleason score 7 to 10). Conclusions This is the first report comparing in vivo two different approaches to prostate biopsy. Transperineal biopsy seems superior to transrectal biopsy to detect prostate cancer. Both the transperineal and the transrectal approach should be familiar to the urologist who needs to obtain an adequate cancer detection rate. Transrectal sextant biopsy cannot be considered the standard technique for prostate cancer detection.

BACKGROUND Neoadjuvant chemotherapy for patients with muscle-invasive bladder carcinoma is given to treat micrometastases and to preserve the bladder. The objective of this study was to evaluate the possibility of bladder preservation in patients with muscle-invasive bladder carcinoma who were treated with neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy. METHODS One hundred four consecutive patients with T2–T4,N0,M0 transitional cell carcinoma of the bladder were treated with 3 cycles of neoadjuvant M-VAC chemotherapy. After clinical restaging, 52 patients underwent transurethral resection of the bladder (TURB) alone, 13 patients underwent partial cystectomy, and 39 patients underwent radical cystectomy. RESULTS The median survival for the entire group was 7.49 years (95% confidence interval, 4.86–10.0 years). Forty-nine patients (49%) were T0 at the time of TURB after receiving M-VAC. Thirty-one of 52 patients (60%) who received chemotherapy and underwent TURB alone were alive at a median follow-up of 56 + months (range, 10–160 + months): Twenty-three patients (44%) in that TURB group maintained an intact bladder. Of 13 responding patients with monofocal lesions who underwent partial cystectomy, only 1 patient required salvage cystectomy, and survival generally was good. The 5-year survival rate for this group was 69%. With a long median follow-up of 88 + months (range, 16–158 months), 4 patients (31%) were alive with a functioning bladder. In the radical cystectomy group, the median follow-up was 45 months (range, 4–172 + months), and 15 of 39 patients (38%) patients remained alive. In 77 patients who had their tumors down-staged to T0 or superficial disease, the median follow-up was 63 months (range, 4–172 + months), and the 5-year rate survival was 69%. This is in contrast to a 5-year survival rate of only 26% in 27 patients who failed to respond and had a status ≥ T2 after receiving chemotherapy (median follow-up, 31 months; range, 7–156 + months). The median survival for 27 elderly patients (age ≥ 70 years; median age, 73 years; range, 70–82 years) was 90 months (7.5 years). For elderly patients who underwent TURB and partial cystectomy, the 5-year survival rate was 67% with a 109-month (9-year) median survival; 47% of patients preserved their bladders intact. The median follow-up of the living elderly patients was 61 months (range, 20–120 + months). CONCLUSIONS Bladder sparing in selected patients on the basis of response to neoadjuvant chemotherapy is a feasible approach that should be confirmed in prospective, randomized trials. Selected elderly patients are candidates for this approach. Cancer 2003;97:1644–52. © 2003 American Cancer Society. DOI 10.1002/cncr.11232

Prostate cancer detection on standard sextant biopsy is considered inadequate. Various biopsy protocols have been introduced to improve cancer diagnosis. We report our experience with transperineal 12-core prostate biopsy.In a prospective study 650 patients underwent prostate specific antigen (PSA) measurement during a 15-month period, of whom 141 with PSA greater than 4 ng./ml. also underwent transperineal 12-core prostate biopsy using the fan technique. Median PSA was 8 ng./ml. (range 4.1 to 5,000).Prostate cancer was detected in 72 of the 141 patients (51%), including 44 of the 97 (45%) with PSA between 4.1 and 10 ng./ml. This incidence is higher than previously reported in the literature using other biopsy techniques. Disease was low grade Gleason 2 to 4 in 4 cases (5%), intermediate grade Gleason 5 to 6 in 26 (35%) and high grade Gleason 7 to 10 in the remaining 42 (60%).A high cancer detection rate is achieved by 12-core transperineal prostate biopsy. Most tumors represent clinically significant cancer. Further randomized trials are required to confirm these data.

Objective To evaluate the occurrence of increased prostate-specific antigen (PSA) serum concentration in patients with prostatitis and low incidence of benign prostatic hyperplasia and prostatic cancer, PSA was measured in a selected population. Methods PSA levels were evaluated in 72 patients with prostatitis under 50 years of age. Results An increased PSA (> 4 ng/ml) was found in 5/7 (71%) patients with acute prostatitis, and in 2/13 (15%) and 2/32 (6%) patients with chronic bacterial and abacterial prostatitis, respectively. No patient with prostatodynia had an increased PSA. In patients with bacterial prostatitis PSA level decreased to normal value after effective antibiotic therapy in most cases. Conclusion Prostatitis must be considered when using PSA as tumor marker.

Purpose: We performed a retrospective long-term study to evaluate the results of immunotherapy in the treatment of high grade superficial bladder tumors.Materials and Methods: Between 1981 and 1993, 593 patients with superficial transitional cell carcinoma of the bladder underwent transurethral resection. Of 64 patients with stage T1 grade 3 disease 50 received intravesical bacillus Calmette-Guerin after transurethral resection of all visible tumor.Results: At a median followup of 42 months (range 12 to 112) 36 patients (72 percent) are disease-free and have not required further treatment. Superficial recurrence was noted in 8 patients (16 percent). Disease progressed in 6 patients (12 percent), including 5 with locally invasive and 1 with metastatic disease. Cystectomy was performed for progression in 4 patients and for recurrent stage T1 grade 3 disease in 1. There was 1 disease related death (2 percent). The overall survival rate is 94 percent.Conclusions: Intravesical bacillus Calmette-Guerin ...

To report our 8-year experience with buccal mucosa onlay urethroplasty with the dorsal approach in the treatment of bulbar urethral strictures. The buccal mucosal graft is widely used as an effective option for urethral reconstruction.Since June 1994, we have treated 65 patients with bulbar urethral strictures with buccal mucosa urethroplasty. A free graft of buccal mucosa was used as a ventral onlay in 9 patients and as a dorsal onlay in the remaining 56 patients. The bulbar urethra was isolated from the corpora. Endoscopic urethrotomy was performed dorsally. The graft was obtained from the lower lip and sutured to the urethra and corpora cavernosa. A transurethral grooved catheter and suprapubic drainage was maintained for 7 and 14 days, respectively.The median follow-up was 41 months (range 6 to 94). The overall recurrence rate was 3% (2 of 65). One recurrence occurred in a ventral onlay patient and one in a dorsal onlay patient. Minor complications occurred in 9 patients (14%).Buccal mucosa dorsal onlay urethroplasty is an excellent option for the treatment of bulbar urethral strictures.

Intraoperative Frozen Section (IFS) with further tissue resection in case of positive margins has been proposed to decrease positive surgical margins rate during radical prostatectomy. There are a few reports on the benefits of this potential reduction of positive margins (PSM).The aim of this study is to assess the oncological advantages of PSM rate reduction with the use of IFS and additional tissue excision in case of PSM. DESIGN, SETTING AND PARTECIPANTS: 270 patients undergoing laparoscopic radical prostatectomy were included in a prospective study, to evaluate the results of further tissue excision in case of PSM at IFS. Median age was 65 yrs. Median PSA was 7.0 ng/ml.The prostate was extracted during the operation. IFS was performed in all patients on the prostate surface, at the base, the apex and along the postero-lateral aspect of the gland. In case of PSM additional tissue was excised from the site of the prostatic bed corresponding to the surgical margin.Endpoint was biochemical recurrence-free survival.PSM were found in 67 patients (24.8%). With additional tissue resection, PSM rate dropped from 24.8% to 12.6%. Decreased PSM after further resection didn't improve biochemical-free survival. Patients with initial PSM at IFS rendered negative with further resection, had similar results if compared to patients with margins still positive, and worse results if compared to patients with negative margins (NSM). Biochemical recurrence rate was 2.95% at 58 months in 203 patients with NSM, 15.1% at 54 months in 33 patients with PSM at IFS that were rendered negative after further resection, and 11.7% at 67 months in 34 patients with still PSM after additional resection. These results were confirmed also according to: stage, nerve-sparing procedure, Gleason score.Our data don't support IFS during radical prostatectomy to improve biochemical-free survival.

Purpose: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. Materials and Methods: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. Results: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. Conclusions: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Transperineal prostate biopsy is receiving renewed scientific interest. Although neglected for several decades in favor of transrectal ultrasound biopsy, the transperineal procedure continues to have a minor, but defined and specific role in prostate cancer diagnosis. It is an effective procedure for detection and has a low incidence of infective complications. This chapter illustrates the technique and surgical approach for transperineal biopsy. Comparison of the two procedures is offered.

Radical cystectomy is the treatment of choice for nonmetastatic, muscle-infiltrating bladder cancer. Several researchers have proposed the use of a bladder-sparing approach in carefully selected patients. Strict selection criteria and close follow-up are needed for bladder-preservation protocols. Although repeated transurethral resection of bladder tumors or partial cystectomy might be offered to high-risk patients, combined protocols with transurethral resection of bladder tumors and chemotherapy, with or without additional radiotherapy, seem to provide the best results, with 5-year survival rates of about 50%. Even if the chance of preserving the bladder is appealing, and despite evidence of some promising results, these protocols should still be considered investigative because, as yet, there are no randomized trials available that compare cystectomy with bladder-sparing surgery.

To establish the additional value of 3D magnetic resonance spectroscopy (3D-MRS) imaging to endorectal MR imaging in the diagnosis of prostrate cancer in the peripheral zone. MR imaging and MRS imaging were performed in 79 patients with suspicion of prostate cancer on the basis of digital rectal exploration, transrectal ultrasound and PSA level. All the examinations were performed with 1.5 T MR scan using an endorectal coil (transverse and coronal FSE T2-weighted sequences, axial SE T1-weighted and PRESS 3D CSI). MR examinations have been evaluated by two Radiologists blind of the clinical data in a “per patients” analysis. MR imaging and MRS imaging findings were compared with the result of histological data from radical prostatectomy in 53 patients and biopsy in 17 patients. Nine patients (11.4%) were excluded because of serious artefacts in the MR spectrum. The reported values of sensitivity, specificity, PPV and NPV for MR imaging alone were respectively 84%, 50%, 76% and 63% (LR+ 1.7; LR− 0.3). Instead the reported values of sensitivity, specificity, PPV and NPV for the combination of MR imaging to MRS imaging were respectively 89%, 79%, 89% and 79% (LR+ 4.28; LR− 0.14). We found an incremental benefit of MRS imaging to MR imaging for tumour diagnosis although these results did not show statistically significant differences. The MRS imaging improves the accuracy of the endorectal MR imaging in the diagnosis of prostate cancer.

Accurate tumor grading is critical for adequate prostate cancer treatment. Nonetheless, the Gleason score of standard sextant biopsy correctly predicts the Gleason score of the radical prostatectomy specimen in about 50% of cases. We investigated if extended needle biopsy could improve biopsy Gleason score accuracy.Laparoscopic transperitoneal radical prostatectomy was performed in 135 patients. Prostate cancer was diagnosed in 89 cases by standard sextant transrectal (6 to 8 cores) biopsy and in 46 by extended needle (12 core transperineal under transrectal guidance) biopsy. Preoperative evaluation included digital rectal examination, prostatic specific antigen measurement, transrectal ultrasonography and endorectal coil magnetic resonance imaging in all patients. All biopsy and prostatectomy specimens were reviewed by a single pathologist.Clinical characteristics were similar in the 2 groups. The concordance between prostate biopsy and radical prostatectomy Gleason score was 32 of 46 cases (70%) and 44 of 89 (49%) for 12 core and standard transrectal biopsy, respectively (z test p = 0.0127). Biopsy under grading was found in 11 of 46 cases (24%) and 35 of 89 (39%) (z test p = 0.0366), and biopsy over grading was found in 3 of 46 (6%) and 10 of 89 (11%) (z test p = 0.1894) with 12 core and standard transrectal biopsy, respectively. Primary Gleason pattern was predicted exactly by biopsy in 40 of 46 cases (87%) and 56 of 89 (63%) with 12 core and standard sextant biopsy, respectively (z test p = 0.0018).Extended needle biopsy significantly increases the accuracy of biopsy Gleason score for assessing final prostate cancer grade.

The prostate cancer detection rate in patients with elevated prostate specific antigen (PSA) increases with extended needle biopsy protocols. Transperineal biopsy under transrectal ultrasound guidance is rarely reported, although notable cancer diagnoses are obtained with this technique. We describe the results of 6 and 12 core transperineal biopsy.A total of 214 patients with PSA greater than 4.0 ng/ml were prospectively randomized to undergo 6 or 12 core transperineal biopsy. Each group of 107 patients was comparable in terms of clinical characteristics. The procedure was performed on an outpatient basis using local anesthesia. Specimens were obtained with a fan technique with 2 puncture sites slightly above the rectum (1 per lobe) under transrectal ultrasound guidance. Cores were taken from all peripheral areas, including the far lateral aspect of the prostate.The overall cancer detection rate was 38% and 51% for 6 and 12 core biopsy, respectively. In patients with PSA between 4.1 and 10 ng/ml the cancer detection rate was 30% and 49% for 6 and 12 core biopsy, respectively.The 12 core transperineal prostate biopsy is superior to 6 core biopsy. The technique provides optimal prostate cancer diagnosis. About half of the patients with PSA greater than 4.0 ng/ml and a slightly lower percent with PSA between 4.1 and 10 ng/ml have prostate cancer.

Neoadjuvant chemotherapy for patients with muscle-invasive bladder carcinoma is given to treat micrometastases and to preserve the bladder. The objective of this study was to evaluate the possibility of bladder preservation in patients with muscle-invasive bladder carcinoma who were treated with neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy.One hundred four consecutive patients with T2-T4,N0,M0 transitional cell carcinoma of the bladder were treated with 3 cycles of neoadjuvant M-VAC chemotherapy. After clinical restaging, 52 patients underwent transurethral resection of the bladder (TURB) alone, 13 patients underwent partial cystectomy, and 39 patients underwent radical cystectomy.The median survival for the entire group was 7.49 years (95% confidence interval, 4.86-10.0 years). Forty-nine patients (49%) were T0 at the time of TURB after receiving M-VAC. Thirty-one of 52 patients (60%) who received chemotherapy and underwent TURB alone were alive at a median follow-up of 56 + months (range, 10-160 + months): Twenty-three patients (44%) in that TURB group maintained an intact bladder. Of 13 responding patients with monofocal lesions who underwent partial cystectomy, only 1 patient required salvage cystectomy, and survival generally was good. The 5-year survival rate for this group was 69%. With a long median follow-up of 88 + months (range, 16-158 months), 4 patients (31%) were alive with a functioning bladder. In the radical cystectomy group, the median follow-up was 45 months (range, 4-172 + months), and 15 of 39 patients (38%) patients remained alive. In 77 patients who had their tumors down-staged to T0 or superficial disease, the median follow-up was 63 months (range, 4-172 + months), and the 5-year rate survival was 69%. This is in contrast to a 5-year survival rate of only 26% in 27 patients who failed to respond and had a status/= T2 after receiving chemotherapy (median follow-up, 31 months; range, 7-156 + months). The median survival for 27 elderly patients (age/= 70 years; median age, 73 years; range, 70-82 years) was 90 months (7.5 years). For elderly patients who underwent TURB and partial cystectomy, the 5-year survival rate was 67% with a 109-month (9-year) median survival; 47% of patients preserved their bladders intact. The median follow-up of the living elderly patients was 61 months (range, 20-120 + months).Bladder sparing in selected patients on the basis of response to neoadjuvant chemotherapy is a feasible approach that should be confirmed in prospective, randomized trials. Selected elderly patients are candidates for this approach.

Purpose of review Urethral surgery is rapidly changing because of developments in techniques. The aim of this paper is to provide an update and a review of the most significant surgical options and their outcomes in the treatment of urethral strictures. Recent findings Indications and results of anastomotic repair, pedicled flap, free graft and complex urethral reconstruction are reported. New trends such as dorsal urethroplasty and the use of buccal mucosa are reviewed. Summary Most urethral strictures can be managed successfully by urethral surgery. A wide spectrum of effective procedures is available. To obtain optimal results, adequate knowledge and experience of the most common techniques are required.

Objectives: Immunotherapy with bacille Calmette–Guerin (BCG) has been proposed in the past decade as first-line treatment for high-grade superficial bladder cancer (G 3 T 1 ). We report our 18-year experience in the treatment of patients with G 3 T 1 bladder cancer. Methods: From January 1989 to July 1997, 670 patients underwent transurethral resection for superficial bladder cancer. Eighty-one patients (12%) had G 3 T 1 tumors. All of these patients were treated with an innovative schedule of Pasteur strain BCG followed by maintenance BCG therapy. Treatment consisted of four cycles of 6 instillations per cycle of BCG. The first cycle was administered weekly × 6, the second was given every 2 weeks × 6, the third cycle was given monthly × 6, and the fourth was given every 3 months × 6 instillations. Results: Sixty-nine patients (84%) completed at least the first two cycles. At a median follow-up of 76 months (range 30 to 197), the overall recurrence rate was 33% (27 of 81). The median time to recurrence was 20 months (range 5 to 128). Of these patients, 12 (15%) had progression at a median follow-up of 16 months (range 8 to 58). Cystectomy was required in seven patients (8%). Death from disease occurred in five (6%) of 81 patients. One patient died of adenocarcinoma at the ureterosigmoidostomy site. Sixty patients (74%) were alive at a median follow-up of 79+ months (range 15 to 182). Of these, 56 (69%) were alive with a functioning bladder. Conclusions: Conservative treatment with BCG is a reasonable approach for patients with primary G 3 T 1 transitional cell carcinoma of the bladder. The long-term results of BCG therapy are good. Cystectomy may not be justified as the therapy of choice in first- line treatment of high-grade superficial carcinoma of the bladder.

We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures.Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra.At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group.Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.

The wallstent has been proved to be effective for the treatment of bulbar urethral strictures. Only a few failures are reported in the literature. We present a case of a patient with a recurrent stricture after wallstent implantation. The recurrence has been managed successfully with gradual dilation and with the insertion of an inner stent inside the first one, with a twenty-nine-month follow-up.