[An extremely rare case of multiple recurrences of urothelial carcinoma in an ileal neobladder: a case report and review of the literature]. / Ein äußerst seltener Fall von multiplen Rezidiven eines Urothelzellkarzinoms in einer ilealen Neoblase: Fallbericht und Literaturübersicht.

In up to 18% of patients, recurrence is observed after curative radical cystectomy. Tumour recurrence occurs in most cases in the locoregional lymph node, as well as in the remaining urinary tract, but very rarely in the orthotopic neobladder. We report a case of multiple recurrence of urothelial carcinoma solely in the orthotopic neobladder of a male patient, 10 years after surgery, without involvement of the urethra or upper urinary tract. Therefore, the patient underwent resection of the neobladder with conversion to a sigmoid conduit. Nevertheless approximately 6 months later the patient developed widespread metastases and died a few months later. Currently, no guidelines are available for the treatment of these rare cases. We present our experience, together with revision of the current literature on this issue.

[Sigmoid colon conduit volvulus: an extremely rare complication of a sigmoid colon conduit]. / Sigmakonduit Volvulus: eine extrem seltene Komplikation eines Sigmakonduit.

We report the case of an 84-year-old man with the rare diagnosis of a volvulus of an incontinent sigmoid colon urinary conduit after radical cystoprostatectomy due to urinary bladder cancer. To the best of our knowledge, this is the first case in literature of a volvulus of a sigmoid colon conduit.

[From an enterovesical fistula to mammary carcinoma]. / Von einer enterovesikalen Fistel zum Mammakarzinom.

We report a case of a 83-year-old woman with the initial diagnosis of an occult invasive lobular breast carcinoma due to gastrointestinal metastasis with an entervesical fistula.

Transarterial Embolization in the Management of Intractable Haemorrhage.

INTRODUCTION: The purpose of this study was to evaluate the effectiveness and long-term results of selective transarterial iliac embolization (STIE) in patients with intractable bladder haemorrhage (IBH). METHODS: Twenty-five patients with a median age of 84 (range 65-94) years underwent STIE because of IBH between 2002 and 2020. The median follow-up time was 3 (mean 13.9) months. Patients were treated because of bleeding bladder or prostate cancer, radiation-induced haemorrhagic cystitis, and other conditions. Success was defined as technical success (feasibility to embolize bilateral hypogastric arteries or neoplastic arteries) and as clinical success (absence of further or additional therapy). RESULTS: Twenty-five patients with a median age of 84 years with a median hospital stay of 7 days were embolized at our institution. In total, 60% required additional therapy. Only 20% had minor complications, but no complication major was seen; 60% needed an additional therapy because of continuous bleeding. Our 30-day, 90-day, 6-month, and 12-month mortality rates were 28, 44, 64, and 76%, respectively. CONCLUSIONS: STIE in IBH is a safe, well-tolerated, and feasible procedure for palliating haematuria patients in poor general condition. Major complications are very rarely seen. However, patients often need additional therapy after STIE.

Efficacy and Safety of Two Fosfomycin Regimens as Antimicrobial Prophylaxis for Transrectal Prostate Biopsy: A Randomised Study.

PURPOSE: Prostate biopsy is the gold standard for prostate cancer diagnosis; unfortunately, this procedure is not free from complications. Recent studies have shown an increase in antibiotic resistance. The aim of our prospective randomized study was to evaluate the efficacy and safety of a prostate biopsy prophylaxis protocol using 2 vs. 3 fosfomycin doses. METHODS: Two hundred and ninety-seven patients undergoing transrectal systematic ultrasound (US)-guided (n = 277) or transrectal fusion prostate biopsy (n = 20) were prospectively evaluated and randomized by date of birth, to receive 2 (even years, group A) versus 3 doses of fosfomycin (odd years, group B), and prospectively evaluated. RESULTS: Two hundred and ninety-seven patients were randomized to group A (n = 162) or group B (n = 135). The 2 groups were comparable with respect to age, comorbidity, PSA value, prostate volume, operative time and urine culture results. Out of 297 patients, 44 (14.8%) developed complications after the procedure; 2.7% (8/297) of patients developed fever >38° requiring hospitalization (6 [3.7%] in group A and 2 [1.5%] in group B, p = 0.29). Patients who underwent fusion biopsy were more frequently readmitted in comparison with patients undergoing US-guided prostate biopsy (p = 0.000). CONCLUSION: The low fever and prostatitis rate suggest that fosfomycin prophylaxis is safe and efficient. There is no significant difference in clinical outcome between the 2 dosage regimens.

Elderly patients undergoing cystectomy, comparing preoperative American Society of Anesthesiology and Eastern Cooperative Oncology Group scores and operative approaches.

OBJECTIVE: To evaluate preoperative scoring systems and operative management and their relation to complications in patients older than 75 years undergoing cystectomy at two academic institutions. METHODS: In total, 212 patients aged 75-95 years with muscle invasive bladder cancer underwent cystectomy at the University of Utah and Central Hospital of Bolzano, Italy. The rates of Grade 3 Clavien-Dindo complications and above in radical cystectomy patients (n = 199) were compared using Eastern Cooperative Oncology Group Scores and American Society of Anesthesiologists Physical Status Classification. The rates of Grade 3 Clavien-Dindo complications and above were also compared by urinary diversion type. Logistic regression was used to control for source institution. RESULTS: In total, 199 cases were included in the primary analysis. Neither of the preoperative scoring systems were predictive for identification of radical cystectomy patients with ⩾Grade 3 Clavien-Dindo complications. In secondary analysis (n = 212, including partial cystectomy), none of the urinary diversion types associated with radical cystectomy had a significantly different rate of complications. However, partial cystectomy (n = 13) had a significantly lower rate of complications. CONCLUSION: Complication rates among elderly patients undergoing cystectomy for muscle invasive bladder cancer were very high. For patients who are approved for surgery after the history and physical exam, none of our objective metrics adequately predicted operative risk. A unique diversion procedure described by the Bolzano group, uretero-ureterocutaneostomy, had equivalent complication rates to the more common diversion procedures. It also appears based on outcomes in this cohort that partial cystectomy is a particularly favorable option within the elderly population in terms of perioperative morbidity.

[Urethral sarcoma 14 years after brachytherapy of the prostate gland]. / Urethrasarkom 14 Jahre nach Prostata-Brachytherapie.

We report a case of an 83-year-old male patient with the rare diagnosis of a urethral sarcoma.

Malignant mesothelioma of tunica vaginalis testis: Report of a very rare case with review of the literature.

INTRODUCTION: Mesothelioma of the tunica vaginalis testis is a extremely rare tumor and represents 0.3 to 0.5% of all malignant mesotheliomas. Exposure to asbestos often precedes illness. Because of its low incidence and nonspecific clinical presentation, it is mostly diagnosed accidentally during surgery for other reasons and the prognosis is usually poor. We present a case of a patient with a mesothelioma of tunica vaginalis testis, diagnosed secondarily during hydrocele surgery, with long-term survival after radical surgery. MATERIALS AND METHODS: a 40 years old patient was admitted to our department for routine surgery of a left hydrocele. During the operation a frozen section analysis was requested because of the unusual nodular thickening of the tunica vaginalis: the examination revealed a diffuse malignant mesothelioma with epithelioid structure and tubular-papillary proliferation. Therefore a left hemi-scrotectomy with left inguinal lymph node dissection was performed. RESULTS: The definitive histology confirmed the previous report of diffuse malignant mesothelioma with angio-invasion but normal testicle findings and negative lymph nodes. No metastases were found on the CT-scan. For the first 2 years a CT was repeated every 4 months, for other 3 years every 6 months and then yearly. Six years after surgery the patient is classified as no evidence of disease. CONCLUSIONS: malignant mesothelioma of the tunica vaginalis testis is a rare entity, often initially thought to be a hydrocele or an epididymal cyst. An aggressive approach with hemiscrotectomy with or without inguinal and retroperitoneal lymphadenectomy can reduce the risk of recurrence.

90-Day Mortality after Radical Cystectomy for Bladder Cancer: Prognostic Factors in a Multicenter Case Series.

OBJECTIVES: To identify preoperative risk factors for 90-day mortality and to validate existing nomograms in a multicenter series of patients undergoing radical cystectomy (RC). MATERIALS AND METHODS: We evaluated 90-day mortality in 475 patients following RC and urinary diversion at 2 Italian institutions and validated Aziz and Isbarn nomogram. Univariable logistic models assessed the predictive ability of operative volume, age at intervention, gender, body mass index, carcinoma in situ at transurethral resection of the bladder, American Society of Anesthesiologist (ASA) score, Charlson Comorbidity Index, clinical stage and pathological stage (TNM). RESULTS: Of the total number of patients, 387 of them (81%) were male. The median age at RC was 71.8. The most frequent ASA score was 2 (53%). Twenty-five deaths occurred within 90 days (5.3%), all among patients who had undergone RC and incontinent urinary diversion. Risk was higher in patients with advanced disease (OR 2.4); moreover, 90-day mortality odd in 70-79-year-old patients was 13 times higher than those of younger patients (<70). Predictive accuracy using Isbarn's and Aziz's nomogram were 67 and 71%, respectively. CONCLUSIONS: Our multicenter study confirmed the moderate predictive value of the Aziz nomogram. Larger studies are needed to improve on existing nomograms with the aim of enhancing preoperative counseling.

Radical cystectomy: do we need standardization?

INTRODUCTION: The first series of radical cystectomy with a definition of surgical landmarks was published in 1949 and was characterized by a high perioperative mortality and a 5-year survival rate around 50%. Decades later, nevertheless many surgical progresses were made and the perioperative mortality dropped to 2,5%, this had not lead to an improvement of long term survival rates, also because a standardization of the procedure is still missing. Areas covered: Radical cystectomy is performed with different surgical techniques obmitting a standardization. The comparability of many studies is therefore difficult or havely compromised. A paragon with other diciplines was made emphazing that there high surgical quality is defined, measured and controlled. A systematic literature search was made selecting finally 76 article adressing this issue. Expert commentary: Surgical guidelines in uro-oncology are vague and a definition of surgical quality is missing. A view outside of the box could be very helpful. This is a plea for a change.

Urinary cytology in bladder cancer: why is it still relevant?

Bladder carcinoma is the most common malignancy of the urinary tract and cystoscopy with cytology is currently considered the gold standard for the detection and surveillance of primary tumors and for the follow-up of patients after transurethral resection. Even if cytology has a low sensitivity especially in low-grade bladder carcinomas, the high specificity and the inexpensive nature of the equipment required, justify performing it. The greatest value of cytology for patients with low-grade, nonmuscle-invasive bladder cancer (NMIBC) is the detection of those lesions that may progress to high-grade urothelial carcinoma.

Urinary diversion: tailored solutions for individual patients.

PURPOSE OF REVIEW: Various urinary diversions are at disposition for reconstructive surgery after cystectomy. The chosen diversion has a strong impact on patients' life regarding complications and quality of life. The purpose of this review is to summarize the current tendency to adapt surgical solutions to individual needs of the patient. RECENT FINDINGS: Tailored surgery requires that the surgeon has been trained in the handling of all gut segments. Only in this case can he react to anatomical variants, patient comorbidities and oncological circumstances, as well as to the prognosis and the social circumstances of the patient with a tailored diversion. Changing demography and ageing populations with increasing incidence of muscle invasive bladder cancer request new, less invasive methods of urinary diversions. There is little evidence as to which is the best urinary diversion due to a lack of well designed studies. SUMMARY: The ileum conduit is still the most used urinary diversion worldwide. However, there are multiple techniques available to us, which guarantee the safest solution in combination with the highest quality of life for the construction of tailored urinary diversion.

Comparison of complications from radical cystectomy between old-old versus oldest-old patients.

INTRODUCTION: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. MATERIALS AND METHODS: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. RESULTS: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. CONCLUSIONS: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients.

Long-term follow-up of intermediate-risk non-muscle invasive bladder cancer sub-classified by multi-coloured FISH.

AIM: To examine the long-term follow-up of patients with that previously underwent risk stratification based on multicolour FISH testing. PATIENTS AND METHODS: On 81 patients with intermediate-risk urothelial carcinoma, a multicolour-FISH was performed. Patients were sub-divided into low- and high-risk groups based on chromosomal patterns. Univariate analysis, using Mantel-Cox log-rank test for disease-free, progression-free survival and overall survival, was employed to determine the prognostic significance of FISH analysis. Survival times were calculated according to the Kaplan-Meier product-limit method and multivariate analysis using Cox proportional hazards regression model. RESULTS: The univariate Mantel-Cox log-rank test showed significant differences between the low-risk and the high-risk group for disease-free survival (p=0.005) and overall survival (p=0.038), but not for progression-free survival (p=0.129). CONCLUSION: Our long-term follow-up data appear to be able to divide tumors into low and high risk groups for recurrence based on molecular/genetic changes observed with FISH.

Perforation during TUR of bladder tumours influences the natural history of superficial bladder cancer.

OBJECTIVES: Bladder perforation is the second most common complication during transurethral resection of bladder tumours. It is unknown whether perforation affects the natural history of the tumour through cell seeding. The aim of this study was to study the impact of perforation on the oncologic outcomes of bladder carcinoma. MATERIALS AND METHODS: Between 2003 and 2007, 926 consecutive patients underwent transurethral resection of bladder tumours at our institution; 327 cases were staged ≥ pT2 and were treated immediately with cystectomy and/or multimodal therapy and therefore excluded from the study. An additional 34 cases without urothelial carcinoma were excluded. Of the remaining 565 patients with non-muscle invasive bladder cancer, 457 (80.8 %) were male and 108 (19.2 %) were female with a mean age of 69.5 years in men and 67.3 years in women. Thirty-seven patients (6.5 %) experienced bladder perforation at the time of tumour resection. This group of patients (Group 1) was compared to the remaining 528 patients (Group 2) who did not experience a bladder perforation. RESULTS: Patients with bladder wall perforation experienced a shorter disease-free survival in both univariate (p = 0.003) and multivariate analyses (p = 0.006). In addition, subsequent recurrences revealed stage progression of recurrent disease (p = 0.05) and trended to a higher number of cystectomies in the perforated group of patients (p = 0.06). Nevertheless, perforation did not appear to influence overall survival (p = 0.127) or cancer-specific survival (p = 0.141). CONCLUSION: The results indicate that bladder perforation during resection of superficial bladder tumours is burdened by a shortened disease-free survival and T-stage progression.

Comparison of radical cystectomy with conservative treatment in geriatric (≥80) patients with muscle-invasive bladder cancer.

INTRODUCTION: The aim of this study was to compare overall survival in elderly patients (≥ 80 years) with muscle-invasive bladder cancer (MIBC) undergoing either radical cystectomy (RC) or conservative treatment. MATERIAL AND METHODS: We performed a retrospective, comparative analysis of overall- and cancer-specific survival in octagenarians with MIBC (≥ pT2) submitted to RC or conservative treatment. Uni- and multivariable Cox regression analysis were performed to assess predictors of overall survival. Cumulative hospital stay was also analyzed for all patients. RESULTS: The RC-group consisted of 33 patients with a mean age of 82.3 years (IQR 80.4-85.4 years) and the bladder preservation a cohort of 35 patients aged 83.8 years (IQR 81.8-88.2 years). No difference was detectable for overall survival (15.9 months versus 9.5 months; p = 0.18) and cancer-specific survival (23.5 months versus 19.5 months p = 0.71) or 90-day mortality (6.1% versus 14.3%; p = 0.43) between the two groups. Patients who received conservative treatment had a shorter cumulative length of hospital stay (p = 0.001). Age at the time of transurethral resection of the bladder (TUR-B) was an independent predictor of the overall survival (p = 0.004). CONCLUSIONS: In this retrospective study, no clear survival benefit was observed for patients ≥80 years submitted either to radical cystectomy or conservative treatment. There was however a trend favoring radical cystectomy but this did not approach statistical significance. Octagenarians that underwent RC however spent more of their remaining lifetime in the hospital than those treated conservatively.

Cytology as an alternative to frozen section at the time of nephron-sparing surgery to evaluate surgical margin status.

OBJECTIVE: To evaluate quick-staining cytology as an alternative method to intraoperative frozen sectioning after nephron-sparing nephrectomy. MATERIALS AND METHODS: Eighty-two partial nephrectomies were performed with intraoperative quick-staining cytology and frozen section evaluation. The results of both were compared with permanent histology as the gold standard. RESULTS: After partial nephrectomy, permanent histologic surgical margins were positive in 8 of 82 (9.7%), cytology in 10 of 82 (12%), and frozen sectioning in 4 of 82 (5%). In comparison with permanent histologic examination, sensitivity of the cytologic examination was 87.5%, positive predictive value 70%, specificity 95.9%, and negative predictive value 98.6%. Kappa values (κ) revealed a good level of agreement between intraoperative cytology and final histologic examination (κ = 0.751; P <.0001). In comparison with permanent histology, sensitivity of frozen sections was 50%, specificity 100%, positive predictive value 100%, and negative predictive value 95%. Of the 8 cases with positive margin on permanent histologic examination, 7 were cytologically positive and only 4 positive on frozen sectioning. Two patients had a local recurrence on follow-up, of which both were correctly identified on quick-staining cytology. The quick-staining cytologic evaluations were completed in <4 minutes. CONCLUSION: Quick-staining cytology is rapid, highly sensitive, and specific to evaluate intraoperative surgical margins at partial nephrectomy. It reduces diagnostic time, could be used as alternative to intraoperative frozen section, and warrants further investigation.

Comparison of Radical Cystectomy with Conservative Treatment in Geriatric ( 80) Patients with Muscle-Invasive Bladder Cancer

Introduction The aim of this study was to compare overall survival in elderly patients (≥ 80 years) with muscle-invasive bladder cancer (MIBC) undergoing either radical cystectomy (RC) or conservative treatment. Material and Methods We performed a retrospective, comparative analysis of overall- and cancer-specific survival in octagenarians with MIBC (≥ pT2) submitted to RC or conservative treatment. Uni- and multivariable Cox regression analysis were performed to assess predictors of overall survival. Cumulative hospital stay was also analyzed for all patients. Results The RC-group consisted of 33 patients with a mean age of 82.3 years (IQR 80.4-85.4 years) and the bladder preservation a cohort of 35 patients aged 83.8 years (IQR 81.8-88.2 years). No difference was detectable for overall survival (15.9 months versus 9.5 months; p = 0.18) and cancer-specific survival (23.5 months versus 19.5 months p = 0.71) or 90-day mortality (6.1% versus 14.3%; p = 0.43) between the two groups. Patients who received conservative treatment had a shorter cumulative length of hospital stay (p = 0.001). Age at the time of transurethral resection of the bladder (TUR-B) was an independent predictor of the overall survival (p = 0.004). Conclusions In this retrospective study, no clear survival benefit was observed for patients ≥ 80 years submitted either to radical cystectomy or conservative treatment. There was however a trend favoring radical cystectomy but this did not approach statistical significance. Octagenarians that underwent RC however spent more of their remaining lifetime in the hospital than those treated conservatively. .

uCyt+/ImmunoCyt and cytology in the detection of urothelial carcinoma: an update on 7422 analyses.

BACKGROUND: The aim of the current study was to report the results of 7422 uCyt+/ImmunoCyt and cytology analyses that were performed over the course of 9 years at the study institution for the evaluation and follow-up of patients with urothelial carcinoma. METHODS: Between January 2002 and March 2011, 2217 patients with a mean age of 69.5 years (range, 15 years-99 years) were enrolled in the current study. All patients seen for the follow-up of bladder and/or upper tract urothelial cancer as well as those with a history that was suspicious for bladder cancer were recruited. In all patients, a voided urinary cytology and uCyt+/ImmunoCyt test was performed. Patients underwent routine cystoscopy as well as cystoscopy when cytology and/or the uCyt+/ImmunoCyt test yielded positive results. Lesions that were detected cystoscopically were biopsied and removed transurethrally. A total of 7422 uCyt+/ImmunoCyt and cytology analyses were performed. RESULTS: Of the 7422 uCyt+/ImmunoCyt tests and cytologies that were performed, 7075 (95.3%) were considered adequate. A total of 578 patients (with 1156 analyses) underwent biopsy and 728 (63%) samples had a histologically proven urothelial carcinoma. Overall sensitivity was 34.5% for cytology, 68.1% for uCyt+/ImmunoCyt, and 72.8% for the 2 tests combined. Overall specificity was 97.9% for cytology, 72.3% for uCyt+/ImmunoCyt, and 71.9% for the 2 tests combined. Cytology and the uCyt+/ImmunoCyt test together had an overall sensitivity of 72.8%, with 59% for grade 1, 77% for grade 2, and 90% for grade 3 tumors (according to the 1973 World Health Organization grading classification system). CONCLUSIONS: On the basis of their 9-year experience, the authors confirm the value of uCyt+/ImmunoCyt and cytology analyses in the follow-up of patients with non-muscle-invasive urothelial cancer. This could potentially reduce the number and cost of routine cystoscopic examinations in patients who are followed for bladder carcinoma. Cancer (Cancer Cytopathol) 2013;121:392-397. © 2013 American Cancer Society.

The Role of C-Choline-PET/CT-Guided Secondary Lymphadenectomy in Patients with PSA Failure after Radical Prostatectomy: Lessons Learned from Eight Cases.

Introduction. (11)C-choline-PET/CT is a promising technique for detection/restaging of patients with biochemical failure (BF) after curative therapy for prostate cancer (PCA). The aim of this paper was to evaluate the PSA response in patients with BF after radical prostatectomy (RP) who underwent secondary lymphadenectomy (LAD) due to (11)C-choline-PET/CT findings. Material and Methods. Eight patients with BF and positive lymph nodes in (11)C-choline-PET/CT after RP were retrospectively included in the study. Extended LAD until the common iliac arteries was performed in all patients. Results. Six of 8 patients had histologically proven lymph node metastases. Four patients showed an initial PSA reduction after LAD, and in 4 patients the PSA increased. Two of the latter had no histological lymph node metastases. Conclusions. Because 50% of our patients showed an initial PSA response, our data suggest that positive (11)C-choline-PET/CT after RP and BF could help to select patients that could benefit from secondary LAD.