Long-term oncological and functional follow-up in low-dose-rate brachytherapy for prostate cancer: results from the prospective nationwide Swiss registry.

OBJECTIVE: To evaluate the long-term oncological, functional and toxicity outcomes of low-dose-rate brachytherapy (LDR-BT) in relation to risk factors and radiation dose in a prospective multicentre cohort. PATIENTS AND METHODS: Data of patients from 12 Swiss centres undergoing LDR-BT from September 2004 to March 2018 were prospectively collected. Patients with a follow-up of ≥3 months were analysed. Functional and oncological outcomes were assessed at ~6 weeks, 6 and 12 months after implantation and annually thereafter. LDR-BT was performed with 125 I seeds. Dosimetry was done 6 weeks after implantation based on the European Society for Radiotherapy and Oncology recommendations. The Kaplan-Meier method was used for biochemical recurrence-free survival (BRFS). A prostate-specific antigen (PSA) rise above the PSA nadir + 2 was defined as biochemical failure. Functional outcomes were assessed by urodynamic measurement parameters and questionnaires. RESULTS: Of 1580 patients in the database, 1291 (81.7%) were evaluable for therapy outcome. The median (range) follow-up was 37.1 (3.0-141.6) months. Better BRFS was found for Gleason score ≤3+4 (P = 0.03, log-rank test) and initial PSA level of <10 ng/mL (P < 0.001). D'Amico Risk groups were significantly associated with BRFS (P < 0.001), with a hazard ratio of 2.38 for intermediate- and high-risk patients vs low-risk patients. The radiation dose covering 90% of the prostate volume (D90) after 6 weeks was significantly lower in patients with recurrence. Functional outcomes returned close to baseline levels after 2-3 years. A major limitation of these findings is a substantial loss to follow-up. CONCLUSION: Our results are in line with other studies showing that LDR-BT is associated with good oncological outcomes together with good functional results.

PSA bounce after ¹²5I-brachytherapy for prostate cancer as a favorable prognosticator.

BACKGROUND: Permanent low-dose-rate brachytherapy (BT) with iodine 125 is an established curative treatment for localized prostate cancer. After treatment, prostate-specific antigen (PSA) kinetics may show a transient rise (PSA bounce). Our aim was to investigate the association of PSA bounce with biochemical control. PATIENTS AND METHODS: Patients treated with BT in Switzerland were registered in a prospective database. Only patients with a follow-up of at least 2 years were included in our analysis. Clinical follow-up and PSA measurements were assessed after 1.5, 3, 6, and 12 months, and annually thereafter. If PSA increased, additional follow-up visits were scheduled. Cases of PSA bounce were defined as a rise of at least 0.2 ng/ml above the initial PSA nadir with a subsequent decline to or below the initial nadir without treatment. Biochemical failure was defined as a rise to nadir + 2 ng/ml. RESULTS: Between March 2001 and November 2010, 713 patients with prostate cancer undergoing BT with at least 2 years of follow-up were registered. Median follow-up time was 41 months. Biochemical failure occurred in 28 patients (3.9 %). PSA bounce occurred in 173 (24.3 %) patients; only three (1.7 %) patients with PSA bounce developed biochemical failure, in contrast to 25 (4.6 %) patients without previous bounce (p < 0.05). The median time to bounce was 12 months, the median time to biochemical failure was 30 months. The median bounce increase was 0.78 ng/ml. Twenty-eight patients with bounce (16.5 %) had a transient PSA rise of + 2 ng/ml above the nadir. CONCLUSION: In most cases, an early increase in PSA after BT indicates PSA bounce and is associated with a lower risk of biochemical failure.

Radical cystectomy for bladder cancer today--a homogeneous series without neoadjuvant therapy.

PURPOSE: To investigate the effect of pelvic lymph node dissection and radical cystectomy for transitional cell cancer of the bladder on recurrence-free and overall survival, pelvic recurrences, and metastatic patterns in a homogeneous group. PATIENTS AND METHODS: A consecutive series of patients undergoing pelvic lymphadenectomy and radical cystectomy between 1985 and 2000 was analyzed. All patients were staged N0, M0 preoperatively, and no patient received neoadjuvant radio/chemotherapy. Pathologic characteristics based on the 1997 tumor-node-metastasis system, recurrence-free/overall survival, and metastatic patterns were determined. RESULTS: Five hundred seven patients (age 66 +/- 12 years) with a mean follow-up time of 45 months (range, 0.1 to 176 months) were analyzed. Five-year recurrence-free and overall survival were, respectively, 73% and 62% for patients with organ-confined, lymph node-negative tumors (n = 217; < or = pT2, pN0) and 56% and 49% for non-organ-confined, lymph node-negative tumors (n = 166; > pT2, pN0). Positive lymph nodes were found in 124 (24%) patients who had a 5-year recurrence-free (33%) or overall (26%) survival. Isolated local recurrences were observed in 3% of patients with organ-confined tumors (< or = pT2, pN0), 11% with non-organ-confined tumors (> pT2, pN0), and 13% with positive lymph nodes (any pT, pN+). Distant metastases developed in 25% of patients with organ-confined tumors, 37% with non-organ-confined tumors, and 51% with positive lymph nodes. CONCLUSION: Despite negative preoperative staging, pelvic lymphadenectomy and cystectomy for bladder cancer reveal a high percentage of unsuspected nodal metastases (24%) that have a 25% chance for long-term survival. This procedure also ensures a low pelvic recurrence rate even in lymph node-positive patients, and patients with locally advanced cancer have a 56% probability of 5-year recurrence-free survival.

Symptoms suggestive of chronic pelvic pain syndrome in an urban population: prevalence and associations with lower urinary tract symptoms and erectile function.

PURPOSE: We determined the prevalence of symptoms suggestive of chronic pelvic pain syndrome in an urban population and assessed associations with lower urinary tract symptoms and erectile dysfunction. MATERIALS AND METHODS: Men participating in a voluntary health examination free of charge that was organized by the Department of Preventive Health of the City of Vienna were analyzed. All participants completed 3 validated questionnaires on chronic pelvic pain syndrome (National Institutes of Health-Chronic Prostatitis Symptom Index), lower urinary tract symptoms (International Prostate Symptom Score) and erectile dysfunction (International Index of Erectile Function-5). RESULTS: A total of 1,765 men with a mean +/- SD age of 46.3 +/- 0.3 years (range 20 to 79) entered this study. The mean National Institutes of Health-Chronic Prostatitis Symptom Index score increased from 4.0 +/- 0.3 in the youngest age group of 20 to 29-year-old men to 6.3 +/- 0.6 in those 70 to 79 years old. The overall prevalence of symptoms suggestive of chronic pelvic pain syndrome, defined by a pain score of 4 or greater and perineal/ejaculatory pain, was 2.7% and it revealed no age dependence, such as the pain score. In contrast, urinary symptom and quality of life scores increased with age. International Index of Erectile Function-5 score was 20.6 +/- 0.3 for men without chronic pelvic pain symptoms vs 18.3 +/- 0.7 for men with mild symptoms and 16.5 +/- 1.1 for men with moderate/severe symptoms. A National Institutes of Health-Chronic Prostatitis Symptom Index score in the upper quartile was associated with 8.3-fold increased odds of erectile dysfunction. CONCLUSIONS: The prevalence of symptoms suggestive of chronic pelvic pain syndrome in this large cohort of men participating in a health screening project was 2.7% and it revealed no age dependence. Our study suggests that chronic pelvic pain syndrome has a negative impact on erectile function.

Lasers for lower urinary tract symptoms secondary to benign prostatic hyperplasia: when is the fuss worth it?

In the recent past, several endoscopic procedures using laser technology have evolved for the treatment of benign prostatic hyperplasia. The term "laser treatment of the prostate" comprises a variety of different application systems, different laser wavelengths, and different surgical techniques to eliminate bladder outlet obstruction. The aim of laser prostatectomy is to be less invasive than transurethral electroresection, but equally effective. Promising short-term results led to a booming laser decade in the 1990s, stimulating the development of several devices. However, the emergence of medium-term data has shown that some of these techniques did not stand the test of time due to the lack of long-term efficacy, unacceptable morbidity, and high retreatment rates. Nevertheless, the results of transurethral resection of the prostate are challenged by some of the newer laser devices, putting the so-called "gold standard" into question.

Chronic pelvic pain syndrome and voiding dysfunction.

Chronic prostatitis/chronic pelvic pain syndrome is a disease that is mainly characterized by three parameters: pain in the suprapubic and pelvic area, presence or absence of white blood cells in expressed prostatic secretions, and voiding disorders of various degrees. The causative factors underlying this very common condition are poorly understood. Therapeutic options (ie, antimicrobial treatment) often are based on the presence of an inflammatory reaction in the expressed prostatic secretions, but the benefit of recurring or prolonged courses of antimicrobial agents is highly variable. Observations have been made regarding functional and structural changes in the lower urinary tract that are suggestive to have an impact on the pathogenesis of chronic pelvic pain syndrome.

Cooled transurethral microwave thermotherapy for intractable chronic prostatitis--results of a pilot study after 1 year.

OBJECTIVES: To evaluate the side effects, tolerability, and efficacy of transurethral microwave thermotherapy with urethral cooling (cooled TUMT) for chronic prostatitis/chronic pelvic pain syndrome in a prospective feasibility trial. Cooled TUMT, using the Targis system from Urologix, is an established treatment option for benign prostatic hyperplasia (BPH) with minimal side effects. METHODS: Patients with intractable chronic prostatitis/chronic pelvic pain syndrome and symptoms for more than 3 of the 6 months before treatment (National Institutes of Health-Chronic Prostatitis Symptom Index [NIH-CPSI] pain score of at least 8) were randomized to cooled TUMT at an intraprostatic temperature of either approximately 55 degrees C or approximately 70 degrees C. Tolerability, side effects, and efficacy were measured with standard diagnostic tests, including the NIH-CPSI. Subgroup analysis was performed to evaluate the effects with and without BPH comorbidity. RESULTS: A total of 42 patients were included in the study; 39 patients successfully completed treatment and 35 completed follow-up through 12 months. The baseline versus 12-month mean NIH-CPSI score was total score 23.4 +/- 6.4 versus 11.5 +/- 10.2 (improvement in mean value of 51%), pain score 11.5 +/- 2.8 versus 4.6 +/- 4.9 (improvement in mean value of 60%), quality-of-life impact score 7.2 +/- 2.9 versus 3.8 +/- 3.8 (improvement in mean value of 47%; all P <0.0001), and urinary score 4.7 +/- 2.8 versus 3.1 +/- 3.0 (improvement in mean value of 34%; P = 0.0079). Treatment discomfort was within the ranges reported for patients with Targis-treated BPH. Two patients had reduced sperm motility. Side effects were minimal and transient, resolved spontaneously or with medication, and were similar regardless of treatment temperature or BPH comorbidity. CONCLUSIONS: Cooled TUMT appears to be promising for intractable chronic prostatitis with or without BPH. Longer follow-up and a larger trial are required to evaluate the fertility impact and longer term durability further.

Urinary urgency and frequency, and chronic urethral and/or pelvic pain in females. Can doxycycline help?

PURPOSE: Persistent urinary urgency and frequency, and chronic urethral and/or pelvic pain in women are often a diagnostic and therapeutic challenge. This can be frustrating for patients and physicians. The search for an infectious agent often proves futile and after multiple ineffective treatment regimens patients may be classified as having interstitial cystitis or referred to a psychiatrist as the last option. We evaluated whether treatment with doxycycline of the patient and her sexual partner would be beneficial. MATERIALS AND METHODS: Women presenting with a history of urinary urgency and frequency, and chronic urethral and/or pelvic pain often associated with dyspareunia and/or a history of recurrent urinary tract infection were evaluated. Initial examinations included urethral and cervical/vaginal swabs, serum analysis, urine examination and culture, and bladder barbitage. A total of 103 women with a median age of 46 years (range 21 to 84) and with a median symptoms history of 60 months (range 3 to 480) were included. All patients had trigonal leukoplakia at cystoscopy, in 15% an infectious organism was identified and 30% had leukocyturia. All were treated with doxycyclines, and a vaginal antimicrobic and/or antimycotic agent following the same regimen, including treatment of the sexual partner. RESULTS: After treatment with doxycycline 71% of the women were symptom-free or had a subjective decrease in symptoms. CONCLUSIONS: Treatment with doxycycline is effective in more than two-thirds of patients complaining of persistent frequency and urgency, chronic urethral and/or pelvic pain, and dyspareunia as well as a history of recurrent urinary tract infections. In women with negative urinary cultures but a history of urgency/frequency probative treatment with doxycycline is justified and endoscopic findings may support the hypothesis of chronic infection. This should be done especially before contemplating psychiatric treatment or diagnosing the patient with interstitial cystitis. We attribute this high success rate to simultaneous treatment of the sexual partner, who may be an asymptomatic carrier, although this remains to be proved.

Non-inflammatory chronic pelvic pain syndrome can be caused by bladder neck hypertrophy.

PURPOSE: Little is known about the etiology of the non-inflammatory Chronic Pelvic Pain Syndrome (CPPS, NIH category IIIb). We conducted this study to determine whether endoscopic and urodynamic evaluation provide objectively measurable parameters that may support the rationale of therapeutic strategies for patients who failed to respond to medical treatment of non-inflammatory CPPS. MATERIALS AND METHODS: The 48 patients included in this study fulfilled the NIH criteria for non-inflammatory chronic pelvic pain syndrome category IIIb. All patients had received multiple courses of antimicrobial and/or anti-inflammatory drugs, but suffered recurrent symptoms. An endoscopic and urodynamic evaluation was performed after any medical treatment had been discontinued for at least 6 weeks. RESULTS: At urethrocystoscopy, no patient had endoscopic evidence of obstruction due to urethral stricture, but 29 patients (60%) were found to have significant bladder neck hypertrophy. At urodynamic evaluation, these 29 patients had an increased detrusor opening pressure DOP (49 vs. 29 cmH(2)O), an increased detrusor pressure at maximal flow P(det,Q(max)) (55 vs. 34 cmH(2)O), a decreased maximal flow Q(max) (10 vs. 17 ml/s) and an increased postvoid residual urine PVR (67 vs. 17 ml) when compared to the 19 patients with a normal appearing bladder neck. These differences were statistically significant (p<0.05). When assessed with the NIH Chronic Prostatitis Symptom Index (CPSI) the two groups showed no difference in the domains of pain and quality of life impact but urinary symptoms were significantly more pronounced in the presence of bladder neck alterations. CONCLUSIONS: Patients with non-inflammatory CPPS who fail to respond to medical treatment with antibiotics and/or anti-inflammatory drugs may have morphological alterations in form of bladder neck hypertrophy. This can be suspected when urinary symptoms, residual urine and decreased Q(max) are present. These can be assessed by non-invasive methods. Endoscopic and/or urodynamic evaluation seem to be justified in these patients in order to establish the diagnosis, consider alpha-adrenergic blockade and avoid unnecessary antibiotic treatment.

Holmium laser enucleation of the prostate combined with electrocautery resection: the mushroom technique.

PURPOSE: The holmium laser allows bloodless enucleation of the prostate. A problem is how to remove a whole enucleated, free floating, large prostatic lobe from the bladder. A mechanical morcellator has been used to achieve tissue fragmentation but aspiration of and damage to the bladder wall are risks. Using the mushroom technique holmium laser enucleation and electrocautery resection can be combined without compromising the bloodless advantages of the laser procedure. MATERIALS AND METHODS: We treated 156 patients with benign prostatic hyperplasia using a holmium laser with the mushroom technique. Preoperatively all patients were assessed using the International Prostate Symptom Score, maximum urine flow, ultrasound estimation of prostate volume and post-void residual urine, and pressure flow study. Laser enucleation of the prostatic lobes was performed at 66 W. Instead of releasing the lobes into the bladder they were left attached at the bladder neck by a narrow mushroom-like pedicle. At that point the vascular supply was almost completely interrupted and the lobes could easily be electroresected into small pieces without bleeding. Patients were followed 6, 12 and 24 months after the procedure. RESULTS: No patient had significant blood loss or signs of the transurethral resection syndrome. A total of 19 patients were treated while under oral anticoagulation without major bleeding problems. Complete followup was available on 125 patients. Median baseline International Prostate Symptom Score decreased from 20 to 3 at 6 months (p <0.05) and remained stable at 12 and 24 months. Median maximum urine flow increased from 8 to 20 ml. per second at 6, 12 and 24 months (p <0.05). Median baseline post-void residual urine decreased from 190 to 30 ml. at 6 months (p <0.05) and remained low at 20 and 30 ml. at 12 and 24 months, respectively. Urodynamic evaluation preoperatively and 6 months postoperatively was available in 83 cases. Relief of obstruction was documented with a statistically significant decrease in median detrusor pressure at maximum urine flow from 87 to 48 cm. water (p <0.05). CONCLUSIONS: Combining holmium laser enucleation and prostate electroresection with the mushroom technique is safe, efficient and bloodless surgical treatment for benign prostatic hyperplasia with sustained relief of obstruction. With this technique there is no need for additional devices, such as a mechanical tissue morcellator.

Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve.

PURPOSE: We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) for distal ureteral calculi with the HM3 (Dornier Medical Systems, Inc.) lithotriptor. MATERIALS AND METHODS: A total of 585 consecutive patients with distal ureteral calculi were treated with ESWL using an unmodified HM3 lithotriptor. Of these patients 67 referred for treatment only for whom no followup was available were excluded from further analysis. The remaining 518 cases were followed until they were radiologically documented to be stone-free or considered treatment failures. Before ESWL additional procedures were performed in 144 patients, including stone push back, ureteral catheter or Double-J (Medical Engineering Corp., New York, New York) stent placement, percutaneous nephrostomy, ureteral endoscopic maneuvers or stone basket manipulation. A total of 374 patients needed no preliminary treatment before ESWL. RESULTS: Of the 518 patients 469 (91%) were successfully treated with 1 ESWL session, while 49 (9%) needed 2 or 3. Manipulation after ESWL was performed in 22 cases, including stent placement, percutaneous nephrostomy, ureteral endoscopic stone removal and a stone basket procedure. On day 1 after ESWL 327 patients (63%) were stone-free, 158 (30%) had less than 5 mm. fragments and 33 (7%) had more than 5 mm. fragments. At 3 months the stone-free rate increased to 97%. CONCLUSIONS: These data show that ESWL for distal ureteral calculi with the powerful unmodified HM3 lithotriptor has a high success rate with a low rate of minimally traumatic manipulations before and after intervention. Results in terms of the re-treatment and stone-free rates are superior to those of any other second or third generation lithotriptor and comparable to the results of the best ureteroscopic series.

A prospective randomized trial comparing 2 lithotriptors for stone disintegration and induced renal trauma.

PURPOSE: We compare the efficacy and resulting kidney trauma of the HM3 (Dornier Medical Systems, Inc., Marietta, Georgia) and Lithostar Plus (Siemens, Issaquah, Washington) lithotriptors in a prospective randomized trial treating calix and renal pelvis stones. MATERIALS AND METHODS: Patients with a solitary renal pelvic stone 2 cm. or less in diameter or a solitary calix stone 1 cm. or less in diameter were randomized for treatment with the HM3 or Lithostar Plus. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasound 1 day and 3 months after treatment. Kidney trauma was determined by measurement of N-acetyl-beta-glucosaminidase and beta-galactosidase (NAG) in pretreatment urine and 4, 12-hour urine samples collected within the first 2 days after extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc.). RESULTS: Of 167 patients with 176 stones 91 were randomized to the HM3 and 85 to the Lithostar Plus lithotriptor group. The preoperative stone burden was comparable in both groups. On postoperative day 1 patients treated with the HM3 or Lithostar Plus were stone-free or had fragments 2 mm. or less (91% and 65%, p <0.001), 3 to 5 mm. (8% and 25%, p = 0.003) and 6 mm. or greater (1% and 10%, p = 0.008), respectively. Patients treated with the HM3 had less posttreatment dilatation of the collecting system (p = 0.01). Obstructive pyelonephritis occurred in 1% of the HM3 and 8% of the Lithostar Plus group (p = 0.02). Re-treatment rate was 4% in the HM3 and 13% in the Lithostar Plus group (p = 0.05). Mean excretion of urinary NAG per treatment (including re-treatments) was comparable in both groups but NAG excretion in relation to stone volume and shock wave number 12 to 24 hours after ESWL was significantly higher in the HM3 group (p <0.05). At 3-months postoperatively 89% of the patients treated with the HM3 and 87% treated with the Lithostar plus were stone-free with no dilatation of the collecting system. CONCLUSIONS: This prospectively randomized study indicated that the HM3 is still the gold standard in regard to disintegration of pelvicaliceal stones. Stone disintegration with the HM3 is better with fewer shock waves, re-treatment rate is lower, and posttreatment dilatation of the collecting system and complications such as obstructive pyelonephritis are less than those with the Lithostar Plus. ESWL induced kidney trauma is minor and resolves within 2 days. The HM3 delivers more energy per shock wave into the kidney as assessed by urinary NAG.

Primary T1G3 bladder cancer: organ preserving approach or immediate cystectomy?

PURPOSE: In this retrospective nonrandomized study we compared the long-term outcome in patients with newly diagnosed stage T1G3 bladder cancer treated with transurethral resection and bacillus Calmette-Guerin or immediate cystectomy. MATERIALS AND METHODS: Of 121 patients with a median age of 67 years (range 36 to 88) diagnosed with primary T1G3 bladder cancer between 1976 and 1999, 92 were treated by transureteral resection with additional intravesical bacillus Calmette-Guerin and 29 were treated with immediate cystectomy. RESULTS: Of the 92 patients treated with an organ preserving approach 29 remained disease-free, local recurrence developed in 33 (36%) and progression developed in 30 (33%) at a median followup of 6.9 years (range 0.6 to 16.5). Of these 92 patients 27 (29%) underwent deferred cystectomy at a median of 12.9 months (range 4.8 to 136), of whom 10 (37%) with a median postoperative followup of 19 months (range 2 to 173) died of progressive disease with a median survival of 13 months (range 3 to 34) after cystectomy. The majority of patients who died of progressive disease refused cystectomy, were referred too late for cystectomy, were inoperable or had upper urinary tract disease. Six of the 29 patients (21%) undergoing immediate cystectomy had progression at a median of 13.2 months (range 5.5 to 37). Overall and tumor specific survival at 5 years in patients treated with an organ preserving approach was 69% and 80%, and in those treated with immediate cystectomy it was 54% and 69%, respectively. CONCLUSIONS: The results of this analysis demonstrate that the concept of an organ preserving approach is acceptable and spares the bladder in approximately half of the patients with primary T1G3 bladder cancer. Of the patients 30% require deferred cystectomy, making meticulous, close followup mandatory.

Two-year experience with the german-translated version of the NIH-CPSI in patients with CP/CPPS.

OBJECTIVES: To examine, after psychometric evaluation and validation of the translated National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the practical value of this questionnaire in a routine diagnostic prostatitis setup for patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The NIH-CPSI is a well-accepted tool for the symptomatic evaluation of patients with CP/CPPS. The recently translated German version has not yet been validated in detail. METHODS: A total of 137 consecutive patients attending a prostatitis outpatient department were classified according to the internationally accepted NIH consensus classification into CP/CPPS NIH type IIIA (n = 53; mean age 43.2 years) and IIIB (n = 84; mean age 43.4 years). For psychometric analysis, the overall type III group was evaluated for reliability and validity of the German NIH-CPSI. The psychometric properties of the translated NIH-CPSI were compared with those of the original English version. In addition, the total scores of all men and separately for CP/CPPS NIH types IIIA and IIIB were evaluated. RESULTS: The German NIH-CPSI was reliable, with an alpha coefficient for the overall index and its subscales of between 0.60 and 0.74. However, the internal consistency of the pain subdomain was lower in our translated version (alpha 0.60) compared with the original English version (alpha 0.86). In this cohort, men with NIH type IIIB CP/CPPS were significantly (P = 0.03) more symptomatic in the total index compared with men with NIH type IIIA CP/CPPS. CONCLUSIONS: The German version of the NIH-CPSI has a relatively high reliability and face and construct validity overall. A validated translated NIH-CPSI is suggested as a standardized tool to quantify chronic pelvic pain symptoms for different countries and languages.

Long-term outcome of ileal conduit diversion.

PURPOSE: Ileal conduit is considered a safe procedure and the gold standard to which newer forms of urinary diversion should be compared, although few long-term results are known. We analyzed a consecutive series of patients who lived a minimum of 5 years after ileal conduit diversion. MATERIALS AND METHODS: A total of 412 patients underwent ileal conduit diversion between 1971 and 1995 at our institution. We analyzed all conduit related complications occurring later than 3 months after surgery in 131 long-term survivors (survival 5 years or greater). RESULTS: Median followup was 98 months (range 60 to 354). Overall 192 conduit related complications developed in 87 of 131 (66%) patients. The most frequent complications were related to kidney function/morphology in 35 patients (27%), stoma in 32 (24%), bowel in 32 (24%), symptomatic urinary tract infection (including pyelonephritis) in 30 (23%), conduit/ureteral anastomosis in 18 (14%) and urolithiasis in 12 (9%). Within the first 5 years complications developed in 45% of patients. This percentage increased to 50%, 54% and 94% in those surviving 10, 15 and longer than 15 years, respectively. In this last group 50% had upper urinary tract changes and 38% had urolithiasis, for which the respective numbers after 5 years were 12% and 17%. CONCLUSIONS: This study demonstrates a high conduit related complication rate in long-term survivors and underlines the need for vigorous long-term followup. Only studies lasting more than 1 decade cover the entire morbidity spectrum.

Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution.

PURPOSE: We assessed factors influencing urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. MATERIALS AND METHODS: Of 381 consecutive men undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution between April 1985 and June 2003, 331 (87%) met the inclusion criteria and were enrolled in the analysis. Kaplan-Meier models and multivariate analysis applying Cox regression were used to evaluate factors influencing postoperative urinary continence and erectile function. RESULTS: In univariate analysis, attempted nerve sparing and age younger than 65 years were significantly associated with better daytime (p = 0.002 and p = 0.007, respectively) and nighttime continence (p = 0.036 and p = 0.005, respectively). In multivariate analysis the rate of daytime continence was significantly higher in patients with attempted nerve sparing (hazards ratio [HR] 1.4, 95% confidence interval [CI] 1.05-1.87) and nighttime continence was significantly better in patients younger than 65 years (HR 1.39, 95% CI 1.07-1.8). Daytime continence was significantly better (p <0.0001) and was achieved more quickly than nighttime continence (p <0.0001). The time to achieve daytime continence was shorter for patients with attempted nerve sparing (p = 0.012). In multivariate analysis erectile function recovered significantly more often in patients with attempted nerve sparing (HR 2.59, 95% CI 1.24-5.39) and in those younger than 65 years (HR 2.98, 95% CI 1.83-4.85). CONCLUSIONS: After radical cystoprostatectomy and ileal orthotopic bladder substitution, attempted nerve sparing and age younger than 65 years are associated with improved urinary continence. Attempted nerve sparing has the greatest impact on daytime continence and age has the greatest impact on nighttime continence. Attempted nerve sparing and younger age are both associated with more frequent recovery of erectile function.