Search

Purpose: To perform a comparative study of 500 consecutive (125)I seeds implants for intracapsular prostate carcinoma with two techniques differing in terms of both strand implantation and planning., Material and Methods: From 2002 to 2007 we performed 250 implants with fixed stranded seeds (RapidStrand™) and a preplanning system and from 2007 to 2010, 250 with real-time and ProLink™ system. Mean age was 68 and 66, respectively, median PSA (prostate-specific antigen) 7.3 and 7.2, stage T1-T2a in 98% and 94%, and Gleason ≤ 6 in 96% and 86%. Low risk cases were 81% and 71%. The prescribed dose was 145 Gy to the prostate volume, or 108 Gy plus EBRT 46 Gy in some intermediate risk cases. Hormonal treatment was given to 42% and 28%., Results: Median follow-up was 48 and 47 months, respectively, 14 patients in the first group and 7 patients in the second developed biochemical failure (BF). Actuarial biochemical relapse-free survival (bRFS) at 5 years increased from 90.2% to 97.2% (low risk from 91.3% to 97.2%, intermediate risk from 84.2% to 97.1%). Biochemical failure was independent of hormone treatment. Rectal complications were G1-2 in 1.2% and 5.2%, respectively. A urinary catheter was necessary in 6.9% and 9.6%, and urethral resection in 1.9% and 4.4%. Genitourinary toxicity was G1-2 in 4.6% and 12%, G3-4 in 1.9% and 4.8%. An assessment of mean D90 in a sample of patients showed that the dosimetry in postoperative planning based on CT improved from a mean D90 of 143 Gy to 157 Gy., Conclusions: The outcome of patients with low risk prostate carcinoma treated with (125)I seed is very good with low complications rate. The real-time approach in our hands achieved a more precise seed implantation, better dosimetry, and a statistically non-significant better biochemical control. We have made this our standard technique.

Objective: Penile cancer has a predominantly lymphatic dissemination. Lymph nodes metastatic involvement conditions disease prognosis and inguinal lymph node dissection has both prognostic and therapeutic value. High and intermediate risk patients with non-palpable lymph nodes will benefit of a precise diagnosis by means of selective sentinel node biopsy with minimal surgical aggressiveness., Methods: Retrospective review of our experience on dynamic sentinel node biopsy in penile cancer from November 1999 to July 2014., Results: We performed this procedure in 33 patients, technically successful in 29 (88%). The patients who did not undergo lymph node dissection due to positive sentinel node biopsy have been followed a mean of 60.4 months (Median 59, range 5-145). 20 patients underwent simultaneous sentinel node biopsy and surgical treatment of the primary lesion and in 13 it was performed posteriorly. In these cases the time lapse was 5.5 months (median 5, range 2-12). In 6 (18.9%) of the 29 patients successfully biopsied, metastasis was founded in any of the lymph nodes identified as sentinel. Two patients were false negative (6,25%). Sensitivity (S), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of successfully performed sentinel node biopsies were 66, 100, 100 and 93%, respectively., Conclusion: Sentinel node biopsy enables a correct lymph node staging avoiding the morbidity of inguinal lymph node dissection. The rate of technical failure and false negative results is low and it may be considered the diagnostic technique of choice in high and intermediate risk penile cancer with non-palpable lymph nodes.

Objectives: To know the necessary information to reproduce the results found in the literature on active surveillance (AS) in prostate cancer (PCa) in our own center so that the information would be objective and correctly given to the patients. We have aimed to study the percentage of candidates for AS chosen in our setting, and the data on infrastaging, subgrading and prediction of insignificant PCa, debugging the predictive value of clinical variables to improve our selection criteria and finally to analyze the results of our patients enrolled in AS., Materials and Methods: A retro- and prospective review of our data bases was performed. A one-year period was analyzed to know AS candidates. Analysis of our radical prostatectomy specimens for infrastaging, subgrading and prediction of insignificant PCa (Epstein's criteria) was made as well as a uni/multivariate analysis of clinical variables in patients with insignificant PCa in the specimen. A prospective validation was performed with overall survival and survival free of active treatment (SFAT) as endpoints in patients enrolled in AS., Results: Between October-2010/October-2011, 44.7% of our PCa were candidates for AS, but only 11.2% choose it. The percentages found for infrastaging, subgrading and prediction of insignificant PCa were 14%, 31.4% and 55.7%, respectively. However, only just 6 patients (6.97%) had≥pT3a+Gleason≥7+volume>0.5cc PCa. The multivariate analysis showed that PSA density and number of affected cores were independent predictors of insignificant PCa. With a mean follow-up of 36±39months, 63 out of 232 patients enrolled in AS went on to active treatment (27.1%), with only 13 due to anxiety without pathologic progression. Median time of SFAT was 72.7 months (CI 95% 30.9-114.4). SFAT at 24 months was 76.4% (69.7-83.1%) and at 48 months 58.1% (48.8-67.4%). Only 10 patients died (4.3%), 9 due to causes different of PCa. Estimated overall survival at 5 years was 92.8% (CI 95% 86.7-98.9%)., Conclusions: It should be mandatory to have the exact knowledge of the local data of each Center in order to objectively inform patients about prostate biopsy efficiency, and if percentages of infrastaging, subgrading and prediction of insignificant PCa are in accordance with the literature. At 3 years, we reproduced the results of the longest series of AS, so we have ascertained that our AS protocol can be implemented with increasingly more patients., (Copyright © 2014 AEU. Published by Elsevier Espana. All rights reserved.)

Objectives: To reduce unnecessary biopsies (Bx) in an opportunistic screening programme of prostate cancer., Material and Methods: We perform a prospective evaluation of PCA3 as a second line biomarker in an opportunistic screening for prostate cancer (PCa). From September-2010 until September-2012, 2,366 men, aged 40-74 years and with >10 years life expectancy, were initially screened with PSA/digital rectal examination (DRE). Men with previous Bx or with recent urine infections were excluded. Men with abnormal DRE and/or PSA >3 ng/ml were submitted for PCA3. All men with PCA3 ≥ 35 underwent an initial biopsy (IBx) -12cores-. Men with PCA3 < 35 were randomized 1:1 to either IBx or observation. Re-biopsy(16-18 cores) criteria were PSA increase >.5 ng/ml at 4-6 months or PSAv > .75 ng/ml/year., Results: With median follow-up (FU) of 10.1 months, PCA3 was performed in 321/2366 men (13.57%), 289 at first visit and 32 during FU. All 110 PCA3+ men (34.3%) were biopsied and PCa was identified in 43 men in IBx (39.1%). In the randomized arm, 110 were observed and 101 underwent biopsy, finding 12 PCa (11.9%), showing a statistically significant reduction of PCa detection rate in this cohort (P<.001). Global PCa detection rates were 40.9% and 9.5% for the PCA3+ and PCA3- branches, respectively (P<.001). Area under the curve for PSA and PCA3 were .601 and .74, respectively. This is an ongoing prospective study limited by its short follow-up period and still limited enrolment., Conclusions: PCA3 as a second line biomarker within an opportunistic dual screening protocol, can potentially avoid 65.7% and 50.1% biopsies at first round and at median FU of 10.1 months, respectively, just missing around 3.2% of high grade PCa., (Copyright © 2013 AEU. Published by Elsevier Espana. All rights reserved.)

Objectives: DD3(PCA3) (PCA3) gene expression is prostate cancer-specific. Routine use of this biomarker has resulted in a 35-67% reduction in the number of required biopsies. The aim of this study is to evaluate our outcomes in its routine use and to establish in which group of patients this is the most efficient, depending on the number of previous PCA3 biopsies., Material and Methods: A total of 474 consecutive patients who had previously undergone a biopsy (group A, n=337) or not (group B, n=134) for whom a PCA3 was requested were analyzed. We subdivided group A into A(1) (a previous biopsy, n=182) and A(2) (<1 previous biopsy, n=155). The recommendation of whether to perform a biopsy or not was made independently by each of the 11 clinicians and guided by prostatic specific antigen (PSA) levels and digital rectal examination., Results: Median age was 65 years (range 38 to 84). PCA3 score had an informative ratio of 99.6%, with a median of 29 (range 1-3245). The percentage of biopsy sparing was 49% of the cases. ROC analysis demonstrated an AUC for PSA and PCA3 of 0.532 (P=.417) and 0.672 (P<.0001), respectively. Sensitivities of PSA≥ 4 and PCA3≥ 35 were 87% vs. 85%, with specificities of 12% vs. 33%, PPV 34% vs. 39% and NPV 63% vs. 81%, respectively. The PCA3 score showed direct correlation with the percentage of positive biopsies (P<.0001)., Conclusions: Routine use of PCA3, due to its high NPV, results in a significant reduction in the number of biopsies. PCA3 appears to be more efficient in biopsy-naive patients. Among patients already biopsied, the results are superior in those biopsied only once., (Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.)

Introduction: We review the experience with prostate carcinoma patients treated with permanent implants of 125-I seeds and the outcome eight years after the beginning of this technique., Material and Methods: From 2002 to 2007 we have performed 250 implants with LDR brachytherapy with RapidStrand(®) and preplanning system. Mean age was 68 (49-78). Mean PSA was 7.32 (2.31 - 14.6). T1-T2a was the stage in 98%, and Gleason ≤ 6 in 96%. Low risk cases were 81% and intermediate risk 19% (ten of them received 46 Gy EBRT). Hormonal treatment was used in 42%., Results: With a mean follow-up of 48 months, 14 patients (5.7%) showed biochemical failure (BF). Eleven patients (4.5%) with theoretical BF were observed and PSA decreased without treatment. Actuarial PSA relapse-free survival at 5 years was 91%, (92% low risk, 86% intermediate cases), and 92% vs 81% with PSA <10 vs >10 (p<0.05). Rectum complications were G2 in 0.6%. A urinary catheter was necessary in 6.5%. Sexual function was conserved in 60%. Mean V100 was 89% and D90 143 Gy., Conclusion: The outcome of patients with low risk prostate carcinoma treated with I-125 seed is very good with very low complications rate. Cases with PSA bounces should be controlled before starting a salvage treatment., (Copyright © 2010 AEU. Published by Elsevier Espana. All rights reserved.)

Introduction: We analyse our experience in the conservative surgical management of penile cancer and/or penile skin pathologies at our institution., Material and Methods: We have retrospectively reviewed all the skin grafting procedures performed in penile surgery in the last eight years. We show the indications and results of these surgical procedures and the detailed surgical technique originally described by Bracka., Results: Ten patients had several types of partial penile removal surgery followed by free-skin graft resurfacing, creating a neoglans. There were no relevant or major complications; two patients suffered partial necrosis of the skin graft. There was no local recurrence. 6 Patients returned to normal sexual activity after complete healing., Conclusions: There is a significant number of patients with penile cancer and/or other penile skin pathologies who can undergo definitive and non-mutilating surgery with excellent oncologic, cosmetic and functional results with skin grafting., (Copyright © 2010 AEU. Published by Elsevier Espana. All rights reserved.)

Purpose: To determine our results in high risk (HR) prostate cancer (PCa) patients treated with radical prostatectomy (RP) and to establish preoperative prognosis factors., Material and Methods: Retrospective study of 925 RP. Mean follow-up for the HR group was 89.8+/-53.6 months. Following NCCN criteria, we operated 210 (22.7%) HR and 715 (77.3%) low/intermediate risk patients. End point was metastatic progression. Kaplan-Meier method for survival comparison among groups and Cox regression model for multivariate analysis of preoperative prognostic factors were used., Results: Revised period; 1986-2007. Fifty-four patients (25.7%) were free of disease and 8 patients (3.8%) died for other causes free of disease. Disease progressed in 148 patients (70.5%); death due to tumour progression occurred in 42 cases (20%) and due to other causes in 25 patients (11.9%). Seventy-nine patients in HR group (38%) vs 549 low/intermediate risk group (78.5%) did not deserve further treatments (p<0.001). The uni and multivariate analysis for metastatic progression showed both Gleason score at biopsy (RR=1.922; 95% CI 1.106-3.341, p=0.020) and clinical stage (RR=2.290; 95% CI 1.269-4.133, p=0.006) showed independent prognostic value for metastatic progression, but not PSA., Conclusions: A HR patient can be cured in a third of the cases and will need multimodal treatments in more than half of the times. We prompt surgery in a young healthy patient with a resectable tumour, mainly if just one bad prognostic factor is present and defiantly if this is just PSA elevation.

Background: Many phase 2 bladder-sparing programmes using transurethral resection of the bladder (TURB) plus chemotherapy or radio-chemotherapy have been undertaken, but some controversies remain., Objective: To determine the efficacy of complete TURB plus three cycles of cisplatin-based chemotherapy in selected patients with muscle-invasive bladder cancer (MIBC)., Design, Setting, and Participants: A phase 2 nonrandomized trial was designed that included patients with MIBC who underwent complete TURB with positive biopsies of the tumour bed. Patients with negative biopsies of the tumour bed, with macroscopically residual tumour, with hydronephrosis, or with distant metastasis were excluded from this trial. Patients included in this trial were offered three cycles of systemic chemotherapy or radical cystectomy (RC). Clinical response (cR) was denoted by either no tumour or the presence of Ta1-Tis bladder tumour at 3-mo evaluation; clinical non-response (cNR) was denoted by cases of muscle-invasive tumour or distant metastasis. Of 146 patients who entered this trial, 75 choose the bladder-sparing programme and 71 chose RC., Measurements: At 5 yr and 10 yr, the cancer-specific survival (CSS) rate was 64.5% and 59.8%, respectively, with no significant difference compared to the RC arm (p=0.544). The progression-free survival with bladder preserved was 52.6% and 34.5%, respectively. In multivariate analysis, cR was the only predictive factor for survival (p=0.001) and bladder preservation (p=0.000)., Results and Limitations: This was not a randomized trial, and patients were included over 16 yr. However, no modifications were made to the therapy schedule except from chemotherapy schemes considered standard at the time., Conclusions: Patients with microscopic residual cancer after complete TURB seem to be good candidates for the bladder-sparing programme using three cycles of systemic chemotherapy, with CSS comparable to RC.

Objective: To retrospectively evaluate the toxicity of low-dose-rate brachytherapy and to relate it to the dose-volume to organs at risk., Material and Methods: We study 160 patients with early prostate cancer, treated with (125)-I implants. Most of them were T1c (63.1%), T2a (35.6%) and Gleason < or =6 (96.2%). Median PSA was 7.2 ng/ml (2.3-13.5); 85.6% were lowrisk cases and 14.4% high-risk cases. Mean follow-up was 24 months (7-48)., Results: Acute urinary toxicity related to urological quality of life (UQL=CVU) was tolerable in 75% and unsatisfactory in 25%. Urinary retention was present in 6.9%. IPSS, V100 and D90 were related to the urinary toxicity grade. Rectal toxicity (RTOG) G2 was 0.6%. Sexual potency showed no changes with regard to the basal in 69%. Actuarial biochemical control was 89.8% at four years., Conclusions: Brachytherapy with (125)-I seeds yields acceptable toxicity and excellent biochemical control.

Purpose: We evaluate the safety and efficacy of conservative elective treatment of upper urinary tract tumors, and determine predictive factors for recurrence and progression to optimize indications of this type of treatment., Materials and Methods: Since 1984 we have performed a prospective study of conservative treatment of single, low grade and stage, less than 3 cm. upper tract tumors. The study includes 54 patients with a normal contralateral kidney who had been followed for more than 36 months. Open conservative surgery was performed in 31 cases and endourological surgery in 23. Minimum followup was 36 months, maximum 210 and mean 84.8. Univariate and multivariate analyses of recurrence and progression were performed in relation to age, sex, association with a bladder tumor, bladder tumor stage and grade, sequence of bladder tumor in relation to upper urinary tract tumor, number of previous bladder tumor recurrences, association with bladder carcinoma in situ, upper urinary tract tumor grade, stage, location, size and therapy, and upper urinary tract cytology., Results: Of the 54 patients 19 (35%) had recurrence, which was bilateral recurrence in 4, and progression occurred in 9 (16%). At the end of analysis 44 (62.9%) patients were disease-free and alive at a mean time of 92.88 months, 13 (24%) died disease-free at a mean of 72.7 months and 7 (12.9%) died of disease at a mean of 97.85 months. Cause specific mortality occurred in 7 (12.9% cases). Among the 54 initially conservatively treated units 42 (77.7%) kidneys were ultimately preserved. On univariate and multivariate analysis tumor location in the renal pelvis and association with a previous multi-recurrent bladder tumor were variables significantly related to recurrence and progression, as well as bilateral recurrence., Conclusions: Conservative treatment is an optional approach for select upper urinary tract tumors. The strongest risk factors for recurrence and progression were association with a previous multi-recurrent bladder tumor and tumor location in the renal pelvis but these conditions were also the strongest risk factors for bilateral recurrence. Conservative treatment can also be recommended in these cases but only with compliant patients and close followup.

Purpose: We prospectively validated the association of local tumor stage and grade as a predictive factor for occult lymph node micrometastasis in patients with penile carcinoma and clinically negative lymph nodes., Materials and Methods: In a retrospective study of 66 patients we demonstrated the predictive value of the association of local tumor stage and grade for occult micrometastasis, identifying 3 risk groups. A therapy strategy was designed according to these risk groups. A total of 37 consecutive patients were included in a prospective study in which the same criteria for risk group allocation and the same therapeutic recommendations were used as in the retrospective study., Results: In the prospective study we noted positive lymph nodes in 11% of stage T1, 63% of stages T2-3, 15% of grade 1, 67% of grade 2 and 75% of grade 3 cases. The incidence of positive nodes was 0% in the low, 83.3% in the high and 33.3% in the intermediate risk group. These rates were similar to those in the retrospective study with no significant difference., Conclusions: The predictive value of the association of local tumor stage and grade for occult lymph node micrometastasis was validated in a prospective study. This factor allows the differentiation of 3 risk groups of patients with high reliability in the low and high risk groups. However, other prognostic factors are needed in the intermediate risk group to improve the prediction of lymph node involvement.

Purpose: We analyze the impact of a single mitomycin C instillation in patients with low risk superficial bladder cancer with short and long-term followup., Materials and Methods: A total of 131 patients with low risk superficial bladder cancer were included in a prospective randomized controlled trial. All patients had a 3 cm or less single, papillary, primary or recurrent tumor and were disease-free for more than 1 year. Patients with muscular invasion, G3 tumor or bladder carcinoma in situ on pathological examination were excluded from study. The tumor was completely resected before patients were randomized into 2 arms of no further treatment (control group) and a single immediate instillation of 30 mg mitomycin C (mitomycin C group). Recurrences were considered early within the first 2 years of followup., Results: At 24-month followup the recurrence-free interval was significantly increased, and recurrence, and recurrence and tumor per year rates were decreased in the mitomycin C compared to the control group. However, at long-term followup these differences were not statistically significant and the recurrence-free interval curves were parallel. A shorter hospital stay and catheterization period were noted in the mitomycin C group compared to the control group, which were not significant. Early recurrences were concentrated in the first year in the control but not in the mitomycin C group. A significant relationship between early and late recurrences was found in the mitomycin C but not in the control group., Conclusions: Our analysis confirms the positive effect of a single immediate mitomycin C instillation in patients with low risk superficial bladder cancer. This benefit is limited to early recurrence and is not maintained with long-term followup. Thus, this approach is an alternative to observation or endovesical chemotherapy. Our study also suggests that cell implantation as a mechanism of early recurrence can be controlled with a single mitomycin C instillation.

Purpose: We analyzed the long-term results of radical transurethral resection for the treatment of a large series of patients with muscle infiltrating bladder cancer entered into a prospective study to determine progression predictive factors., Materials and Methods: The study included 133 patients with invasive bladder cancer treated by radical transurethral resection who had negative biopsies of the muscle layer of the tumor bed. Followup was more than 5 years for all subjects and more than 10 years in 59 (44.4%). A comparative nonrandomized study was performed of a control group of 76 patients with invasive pathological stage pT2-3a, N0-3 bladder cancer treated by cystectomy. In those patients treated by radical transurethral resection univariate and multivariate analyses were performed to establish clinical progression predictive factors., Results: At 5 and 10 years of followup cause specific survival rates were 80.5 and 74.5%, and bladder preservation rates were 82.7 and 79.6%, respectively. No significant difference was noted in terms of cause specific survival, with respect to the control group. The initial presence of associated bladder carcinoma in situ was the only independent progression predictive factor., Conclusions: For patients with invasive bladder cancer radical transurethral resection is justified when the tumor is clinically limited to the muscular layer and when all biopsies of the periphery and depth of the tumor bed show muscular tissue negative for tumor cells. Patients with initial associated bladder carcinoma in situ should not be excluded from this treatment but endovesical bacillus Calmette-Guerin immunotherapy should be administered and a closer followup is recommended.

Objectives: To analyze the biologic behavior and etiologic mechanism of upper-tract involvement in patients with bladder cancer in situ (Tis) and its impact on management of these patients., Methods: One hundred thirty-eight patients with bladder Tis, 786 with superficial bladder cancer, and 179 patients with invasive bladder cancer treated by cystectomy were studied: 34 (24.6%), 18 (2.3%), and 7 (3.9%) developed upper-tract involvement in each group, respectively. Sixty-three patients with primary urothelial upper-tract tumors were also studied. Taking progression-free survival as an end point, univariate and multivariate analyses were performed., Results: The upper-tract recurrence rate was significantly higher in patients with bladder Tis than in patients with superficial bladder tumors (P <0.001); it was also significantly higher in patients treated with cystectomy because of bladder Tis compared with those treated because of invasive tumors (P <0.01). Patients with bladder Tis and upper-tract involvement showed high rates of upper-tract bilaterality (32.3%) and prostate involvement (67.4%). On pathologic examination, the upper tract showed predominantly superficial (Ta-T1-Tis) tumors (67.4%) and distal ureter location as the only finding (47%). In patients with bladder Tis, upper-tract involvement alone does not have a negative impact on the survival rate according to univariate and multivariate analysis (P = NS)., Conclusions: In patients with bladder Tis, upper-tract involvement represents a diffuse process; therefore, a close evaluation of both the prostate and the upper tract is recommended. Upper-tract involvement has no impact on bladder-preservation strategy. Many of these patients could also be offered a conservative management for the involved upper tract.

Purpose: The biological and therapeutic implications of extravesical involvement in patients with bladder carcinoma in situ were analyzed., Materials and Methods: Of 138 patients with bladder carcinoma in situ 87 (63%) had extravesical involvement, including the prostate in 53, the upper urinary tract in 11 and both structures in 23 (pan-urothelial involvement). With survival free of disease as an end point, univariate and multivariate analyses were done., Results: Patients with extravesical involvement had worse survival than those with bladder carcinoma in situ alone (p < 0.001). In multivariate analysis prostate involvement (p = 0.0007) and pan-urothelial involvement (p = 0.0001) were selected as significant variables. When pathological patterns were considered prostatic stromal invasion (p = 0.0002) was the only variable selected. With these data 3 patient groups with disease mortality risk were defined., Conclusions: Prostate involvement and pan-urothelial involvement behave as independent prognostic factors, with the latter probably reflecting an extremetly diffuse character of carcinoma in situ. However, the upper urinary tract had no influence on survival. In patients with upper urinary tract and/or prostatic involvement limited to the mucosa treatment can be conservative. Patients with ductal or stromal involvement should undergo radical treatment. For upper tract involvement conservative approaches may be considered if there are no radiological signs of invasion or low grade tumor.

Purpose: The prognostic value of prostate involvement in patients with superficial bladder cancer was analyzed., Materials and Methods: We studied 96 patients with prostate involvement. Taking progression-free survival rate as an end point, univariate and multivariate analyses were done., Results: The presence or absence of bladder carcinoma in situ is related to poor and good prognoses, respectively (p < 0.001). Stromal invasion (p < 0.001) and pan-urothelial involvement (p = 0.03) were also identified as independent factors of poor prognosis., Conclusions: Patients with tumor limited to the mucosa can be treated conservatively. Cystoprostatectomy can be performed in patients with ductal involvement. The prognosis of patients with stromal invasion is poor despite radical treatment.

We report 18 consecutive patients with testis cancer and retroperitoneal residual masses with normal tumor markers, who underwent lymphadenectomy. Aiming to preserve the antegrade ejaculation, we carried out surgical modifications which basically attempt to preserve: (1) both sympathetic lumbar trunks, (2) the superior hypogastric plexus and (3) some of the postganglionic branches. With a mean follow-up of 28.1 months (range 6-62 months), 15 (83.3%) of the 18 patients preserved ejaculation, without significant differences between ejaculation volumes before and after lymphadenectomy. At the present time, 3 of 4 possible patients have fathered children. Mass size seems to be an important predictive factor of ejaculation preservation. One patient relapsed in the retroperitoneal dissection area, representing a recurrence rate of 5.5%. The disease-free survival rate was 94.4%, and 1 patient died due to disease progression with lung recurrence. Thus preservation of ejaculation was possible in most of these patients.

A prospective study was done to evaluate treatment of patients with muscle-infiltrating bladder cancer by transurethral resection exclusively. Inclusion criteria for this study were histological confirmation of muscular bladder infiltration, endoscopic radical transurethral resection, disappearance of hardened areas after transurethral resection, and negative biopsies of the depth and periphery of the tumor bed. The study began in April 1981. The average followup in series 1 (April 1981 to December 1986, 59 patients) was 55.4 months. Actually, of the patients 31 (52.5%) are without evidence of recurrence and 28 (47.5%) have recurrent disease. Of the latter patients 11 (18.6%) had invasive bladder recurrence, including 7 (11.9%) who had recurrence at 3 months, which indicated clinical understaging. Three patients (5%) had metastases without bladder tumor. The remaining 14 patients (23.7%) had superficial bladder recurrence. The overall survival rate was 83% (49 of 59 patients) and 43 patients (72.8%) still retain the bladder. The present data are confirmed by the results of series 2 (December 1986 to August 1989). Therefore, the data would justify conservative management in a selected group of patients with muscle-infiltrating bladder cancer.

Of the 101 patients with penile cancer, we have analyzed 66 from whom we had enough information: 42 (63.3%) patients with corpora cavernosa invasion (T2-3) and 24 (36.6%) without (T1). With respect to the tumor grade, in 36 (54.3%) patients it was well differentiated (G I), in 23 (34.8%) moderately (G II) and in 7 (10.6%) poorly differentiated (G III). We also analyzed the inguinal lymph node condition. Of the 66 patients, 28 (42.4%) developed nodal metastases, and 38 (57.6%) were considered free of nodal metastases and disease with an average follow-up of 76.2 months (range 38-192). The presence of metastatic nodes was influenced by both tumor stage and grade with significant differences between T2-3 and T1 (p = 0.001) and between G II-III and G I (p < 0.01), but each of them alone was not a sufficiently reliable predictive factor. In order to associate local stages and tumor grades in relation to the presence of metastatic nodes, we checked that none of the patients with T1, G I (group 1) developed nodal metastases, and therefore, 'wait and see' should be the suitable approach. Twenty (80%) of the patients with T2-3, G II-III (group 2) developed metastatic lymph nodes, thus, in this group, an early lymphadenectomy should be performed. In the remaining 22 patients with T1, G II-III and T2, G I (group 3), 8 (36.4%) showed metastatic lymph nodes; in this group, other factors such as age, cultural level and obesity should be taken into account when deciding on lymphadenectomy.

Of our 276 patients with superficial bladder carcinoma, 242 were male, and 36 of these had recurrence in prostatic urethra, 26 with macroscopic tumors, and 10 with tumors in situ (TIS). These recurrences represent an incidence of 13.3%, with an average follow-up of 34.3 months. When the urethral tumor was limited to the mucosa, we chose conservative therapy, and the patients entered a random program with Mitomycin or Adriamycin administered endovesically. With this program, we could control the disease in 59.3% of the patients. However, 22.2% of them had recurrence with prostatic stromal infiltration, so that we performed a more exhaustive exploration of the prostate, taking biopsies not only at the 5 and 7 o'clock positions, but also making a wider resection in order to find the incipient infiltration of the prostatic stroma, and trying to avoid a possible understaging. When the urethral tumor had infiltrated the prostatic stroma, we performed cystoprostatourethrectomy, getting a survival rate free of disease of 40%. An association with vesical TIS was detected in 61.1% of these patients, with terminal ureteral tumor in 8.3% and with the anterior urethra in 11.1%, showing the diffuse pattern of the disease. We conclude that when recurrence of prostatic urethra is present, it is necessary to monitor the whole urothelium during follow-up.

In a sample of 306 patients with superficial bladder tumors (Ta, Tl), 48 were affected by associated carcinoma in situ (TIS). We included 40 of them in a random program with Mitomycin C or Adriamycin, administered endovesically. We found that those patients with associated TIS whose progression rate had increased to 37.1% compared to 8.8% in the original series (p less than 0.01), had a worse prognosis. Besides, 10 of them required radical cystectomy. With this chemotherapy program, we achieved a high rate of complete response (70%), but its duration was limited by a recurrence rate of 42.9%, with a time free of disease of 26.2 months. In the whole group, the survival rate free of disease was 77.5%, with an average follow-up of 37.3 months. On the other hand, we found extravesical recurrences not only in the prostatic urethra (13; 32.5%) but also at the end of the ureter (3; 7.5%).

The present article studied the biological behaviour of T4a versus T4b tumors. Of 29 patients with T4a tumors, 24 were treated by radical cystectomy and 5 were treated by diversion alone on detecting pathologic gross adenopathies at laparotomy. Of these 10/28 (35.7%) are alive and tumor-free. Of 11 patients with T4b tumors, 7 were initially treated with systemic chemotherapy (6 M-VAC and 1 5-FU + ADM) which achieved a clinical response in 4; 1 (14.2%) was RCc. Posteriorly, all these patients underwent radical cystectomy that revealed 2 had RPp and 2 had tumor progression (N+), accounting for an RPp rate of 28.5% and tumor progression of 71.5%. Overall, with a mean follow-up of 13.3 months, only 1 patient is tumor free. The foregoing findings show the different behaviour of these two groups of patients with an incidence of tumor positive adenopathies of 48.2% and 72.7% and tumor-free survival of 35.7% and 9.0% for patients with T4a and T4b, respectively.