Positive surgical margins after radical prostatectomy: What should we care about?

PURPOSE: Positive surgical margins (PSMs) after radical prostatectomy (RP) are a known factor associated with biochemical recurrence (BCR) and raise the issue of adjuvant treatment by radiotherapy versus salvage treatment at recurrence. To help this choice, our study aimed to analyze BCR-free survival and factors associated with BCR in patients with PSM and undetectable postoperative prostate-specific antigen (PSA). METHODS: Between 2005 and 2008, 630 patients had RP for localized prostate cancer in our center. We included patients with PSM, uninvaded nods, undetectable postoperative PSA and no adjuvant treatment. The 5-year BCR-free survival was calculated using Kaplan-Meier method. Logistic regression models were used to determine the factors associated with BCR in univariate and multivariate analyses (Cox model). RESULTS: The PSM rate was 32.7 % (n = 206 patients), and 110 patients corresponded to the inclusion criteria. The median follow-up was 72 months. The BCR rate was 30 % with a 5-year BCR-free survival of 83.9 %. The factors significantly associated with BCR were preoperative PSA, predominance and percentage of Gleason 4, tumor volume, PSM length and predominance of Gleason 4 at the margin. In the multivariate analysis, the remaining two significant factors were PSM length [OR 4.35, 95 % CI (1.011-1.421), p = 0.037] and tumor volume [OR 4.29, 95 % CI (1.011-1.483), p = 0.038]. CONCLUSION: Over a 5-year follow-up, only one-third of patients experienced BCR. It might be reasonable to postpone adjuvant radiotherapy for patients with PSM and undetectable PSA after RP. Tumor volume and PSM length were associated with BCR and should be taken into account in the postoperative treatment management.

Long-term women-reported quality of life after radical cystectomy and orthotopic ileal neobladder reconstruction.

BACKGROUND: The purpose of this study was to determine health-related quality of life (HRQoL) among long-term disease-free survivors in women who underwent radical cystectomy (RC) for urothelial carcinoma and orthotopic ileal neobladder (ONB) reconstruction, using validated patient-reported outcome instruments. METHODS: From 2000 to 2011, a total of 46 women with urothelial bladder carcinoma had RC and ONB at our institution; 31 (67 %) eligible women completed 3 validated questionnaires: the medical outcome study short form 12 (SF-12), the urinary symptom profile, and the Contilife, respectively evaluating general HRQoL, voiding function, and urinary incontinence specific HRQoL. Unadjusted analyses were performed to analyze standardized measures of HRQoL and voiding symptoms; p < 0.05 was considered significant. RESULTS: The mean follow-up was 5.7 years; 24 women (77 %) considered their health as good, very good, or excellent. The SF-12 physical and mental scores were not significantly different between the population study and the general population (p > 0.05). A total of 20 women (65 %) declared to be fully continent. Daytime incontinence, nighttime incontinence, and hypercontinence were reported by 26, 29, and 31 % of women, respectively. On unadjusted analysis, incontinence was associated with age > 65 years at the time of surgery (p < 0.001). Hypercontinence was not associated with any variable. CONCLUSIONS: This study suggests that in the setting of radical cystectomy in women, ileal neobladder reconstruction provides long-term satisfaction with maintained HRQoL. For properly selected women, orthotopic neobladder can be considered an appropriate diversion choice.

Perivesical fat invasion in bladder cancer: implications for prognosis comparing pT2b, pT3a and pT3b stages and consequences for adjuvant chemotherapy indications.

UNLABELLED: Study Type--Therapy (retrospective cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? The more that bladder cancer progresses from the urothelium to the outside of the bladder the worse the prognosis. To date, the use of adjuvant chemotherapy has not been completely defined. The present study clarifies the prognosis and benefits of adjuvant chemotherapy for different stages of bladder cancer that invade perivesical fat. OBJECTIVE: • To assess the prognosis of pT2b, pT3a and pT3b bladder cancers after radical cystectomy (RC) in order to define potential situations where chemotherapy may be of benefit. PATIENTS AND METHODS: • Between 1985 and 2009, 903 patients underwent a RC and pelvic bilateral lymphadenectomy in an Institutional Referral Centre. • In all, 87 patients (9.6%) had a pT2b tumour, 111 patients (12.3%) a pT3a tumour, and 129 patients (14.3%) a pT3b tumour. • The median (range) overall follow-up was 23 (1-350) months. • Overall (OS), disease-specific (DSS), metastases-free (MFS) and local recurrence-free survival (LRFS) was estimated and compared using Kaplan-Meier plots and log-rank test. RESULTS: • The 5-year survivals pT2b and pT3a were similar for LRFS (86% vs 84%), MFS (69% vs 63%), DSS (72% vs 70%) and OS (66% vs 61%), and the prognosis was better than for pT3b stage tumours (69%, 44%, 40%, and 31% respectively). • In pN0 disease, MFS differences between pT2b-pT3a and pT3b tumours were not significant in patients who had received adjuvant chemotherapy (MSF of 87%, 69% and 56%, respectively) while they were significant in patients without adjuvant chemotherapy (MFS of 70%, 68% and 42%, respectively). CONCLUSIONS: • Bladder cancers invading perivesical tissue macroscopically have a greater propensity to produce lymph node metastases, local recurrence, and have lower MFS, DSS, and OS. In pN0 disease, pT3b tumours may receive more benefit from adjuvant chemotherapy. • Our results could be a useful for selecting patients for adjuvant chemotherapy.

Patterns of local recurrence after radical cystectomy in a contemporary series of patients with muscle-invasive bladder cancer.

PURPOSE: To describe the epidemiology, clinical features, and prognostic factors of local recurrence (LR) in a large case series of patients treated by radical cystectomy (RC) for bladder cancer. METHODS: A retrospective study was conducted on 903 patients treated in a single tertiary reference center. All cases of LR were identified. Descriptive analysis was performed on the clinical features, evolution, and overall mortality of these patients. Prognostic factors of LR were assessed using the Mann-Whitney test for continuous variables and the χ(2) test for categorical variables. RESULTS: Fifty-three patients were diagnosed with LR during follow-up (5.9 %). One patient had concomitant distant metastasis. Pain was the most frequent symptom leading to diagnosis. Mean time interval from RC to LR was 14.4 ± 13 months (1-64) with 50 % of cases diagnosed in the first postoperative year. Overall median survival of patients diagnosed with LR was 9 months [95 % confidence interval (6-11)]. Advanced pathological stage (T3 or T4) and lymph-node invasion were associated with increased LR rate in univariate and multivariate analysis. Presence of squamous cell carcinoma (SCC) was associated with a poorer prognosis after LR compared to pure urothelial carcinoma (p = 0.04). None of the parameters tested was associated with time interval between RC and LR diagnosis. CONCLUSIONS: LR is not uncommon, favored by high pathological stage (T3/T4), and has a very bad prognosis, particularly when SCC is present. LR must be carefully tracked during follow-up after RC, and optimal management of these cases remains to be determined.

The Z-shaped ileal neobladder after radical cystectomy: an 18 years experience with 329 patients.

UNLABELLED: Study Type - Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To evaluate the results in terms of functional results and morbidity of Z-shaped ileal neobladder performed in a single center. PATIENTS AND METHODS: 329 consecutive male patients who had an orthotopic bladder replacement using the Z-shaped ileal neobladder between May 1990 and January 2009. RESULTS: The mean age of the patients was 64.4 ± 9.6 years, with a mean follow-up of 59.4 ± 55 months. Eighty-three early complications in 80/294 patients (27.2%) occurred. The average Clavian rate of these early complications was 2.24. Among these, 12 complications in 12 patients (4.1%) were pouch-related, and 3 reoperations were required. Two patients died from cardiac complications. Sixty-three late complications in 60/294 patients (20.4%) were recorded. The average Clavian rate of these late complications was 2.98. Among these, 47 complications in 45/294 patients (15.3%) were pouch-related, and 18 reoperations were required, essentially for ureteral anastomosis stricture. Satisfactory daytime urinary continence was achieved in 92% of patients. Daytime continence was obtained within, on average, 6.8 ± 16.4 months. The interval between each daytime urination was 2.6 ± 0.8 h (median = 2.5 [1-5] h). Forty-four (15%) patients developed metabolic acidosis which only required oral medication. Satisfactory nocturnal urinary continence was achieved in 87% of patients. Night-time continence was obtained within, on average, 10.8 ± 22.4 months. Hyper-continence with subsequent need for CISC was observed in 4%. CONCLUSION: In our series of 329 patients, compared with the other techniques, the Z-shaped ileal neobladder had an 'expected' complication rate for this high risk surgery with satisfactory daytime and night-time continence in nine out of ten patients.

[Evaluation of sexuality and erectile function of candidates for radical prostatectomy]. / Evaluation de la sexualité et de la fonction erectile des patients candidats a une prostatectomie radicale.

OBJECTIVES: To evaluate sexuality and erectile function of candidates for radical prostatectomy in order to assess the place of nerve-sparing surgery in the preoperative discussion. MATERIAL AND METHODS: From June 2004 to January 2005, 75 consecutive patients, candidates for radical prostatectomy, were prospectively evaluated. Their erectile function and sexuality were evaluated after announcing the diagnosis. Patients completed the IIEF (International Index of Erectile Function), EQS (Erection Quality Scale) and the sexual satisfaction score (SSS). The mean age of the patients was 65 years and 50% were younger than 65. RESULTS: Erectile dysfunction according to the IIEF-5 scale was observed in 64% of cases (43% of patients younger than 65 and 84% of patients over 65). Erectile dysfunction was considered to be severe in 5% of young patients versus 34% of patients over 65. The majority of patients (69%) had a sexual activity more than twice a month. Only 31% of patients under 65 and 8% of older patients considered their erections to be very satisfactory according to the EQS. Despite this high frequency of erectile dysfunction in men over the age of 65, sexual satisfaction was not influenced by erectile dysfunction. In contrast, patients younger than 65, erectile dysfunction clearly altered the SST sexual satisfaction score. CONCLUSION: Erectile dysfunction was present in a large proportion of candidates for radical prostatectomy. The presence of erectile dysfunction in patients over the age of 65 did not modify their sexual satisfaction score. A detailed clinical interview concerning sexuality should be conducted to select patients likely to benefit from nerve-sparing surgery. Nerve-sparing surgery would be beneficial in young patients in whom sexual satisfaction is dependent on erectile function. In the older men, erectile dysfunction can be present without affecting sexual satisfaction.

[Value of new prostate cancer markers: alpha methylacyl CoA racemase (P504S) and p63]. / Intérêt des nouveaux marqueurs histologiques du cancer de prostate: alpha méthylacyl CoA racemase (P504S) et p63.

The diagnosis of prostate cancer is based on histological examination of prostatic biopsies using histological criteria identified on standard stains. In certain lesions mimicking prostate cancer, the pathologist must perform immunohistochemical studies looking for loss of basal cells and antibodies directed against cytokeratin CK 903 (34bE12) or CK5/6, which sometimes give inconclusive results leading to a diagnosis of suspicious site. The discovery of overexpression of alpha-méthylacyl CoA racemase in prostate cancer using a microarray technique has allowed the development and marketing of an antibody (P504S /AMACR) which, in combination with a new basal cell marker (p63), is a very valuable tool for the pathologist in the management of suspicious sites and cancers less than 1 mm in diameter detected on prostatic biopsies.

Trends in renal function after radical cystectomy and ileal conduit diversion: new insights regarding estimated glomerular filtration rate variations.

INTRODUCTION: Our objectives were to evaluate the long-term renal function after radical cystectomy (RC) and ileal conduit diversion (ICD) and to analyze year-by-year the estimated glomerular filtration rate (eGFR) and morphologic upper urinary tract changes. PATIENTS AND METHODS: We retrospectively identified 226 patients who had undergone RC and ICD from 1980 to 2008, with regular postoperative follow-up visits. The eGFR was calculated using the Modification of Diet in Renal Disease equation at baseline and during follow-up. A decrease in renal function was defined as > 1 mL/min/1.73 m(2) annually. RESULTS: The median follow-up period after RC was 91 months (range, 61-235 months). The median eGFR decreased from 66 mL/min/1.73 m(2) (range, 17-139 mL/min/1.73 m(2)) to 59 mL/min/1.73 m(2) (range, 33-102 mL/min/1.73 m(2)). A rapid decline in renal function occurred during the first 2 postoperative years (-9 mL/min/1.73 m(2) and -4 mL/min/1.73 m(2) in the first and second year, respectively), with a moderate to slight decrease in the subsequent years. Urinary obstruction was diagnosed in 51 patients (23%). Among the patients who underwent prompt surgical treatment, we did not find any association with the eGFR decline (P = .8). CONCLUSION: Patients with urinary ICD have a lifelong risk of chronic kidney disease. Regular monitoring of renal function and the morphologic upper urinary tract will permit early diagnosis and treatment of modifiable factors, avoiding irreversible kidney damage.

[Value of the antibody cocktail anti p63 + anti p504s for the diagnosis of prostatic cancer]. / Apport d'un cocktail d'anticorps anti-(p63 + p504s) dans le diagnostic de cancer de prostate.

UNLABELLED: Numerous lesions of the prostate, such as atrophy, adenomatous atypical hyperplasia (adenosis) or PIN can be misdiagnosed with prostatic cancer, and confused with ASAP, leading to perform additional biopsies. In such lesions, the pathologist can perform an immunohistochemical study with the anti-high molecular weight cytokeratin antibody CK903 (34bE12), which confirms the absence of basal cells and supports the diagnosis of prostatic cancer. AIM OF THE STUDY: To compare markers of basal cells (cytokeratin 5/6, p63) and the marker of prostatic carcinomatous glands (p504s) or alpha methylacyl-CoA racemase (AMACR). MATERIAL AND METHODS: Retrospective study of 44 cases of paraffin-embedded prostatic specimens (36 biopsies, 4 PER, 1 adenomectomy and 3 radical prostatectomies), consisting in 20 cases of prostatic carcinomas (2 intraductal, 12 Gleason 6 (3+3), 4 Gleason 7 (4+3), 2 Gleason 8 (4+4)), 11 ASAP, 9 PIN (2 low grade, 7 high grade (2 isolated)), and 10 benign lesions (8 atrophy, 1 atypical adenomatous hyperplasia and 1 case of clear cell cribriform hyperplasia). All cases were tested with antibodies to CK 5/6, and with a cocktail to p63 and p504s, after heat antigenic retrieval on NEXES Ventana processor. RESULTS: Basal cells of normal prostatic glands stained with CK5/6 and p63 in 91,3% and 100% of cases, independently from the fixation procedure (Bouin or Formalin). Carcinomas had a p63-/p504s+ profile, PIN were p63+/p504s+, and benign lesions were p63+/p504s-. We observed an increase in sensitivity: p63/p504s (100%), CK5/6 (80%), p63 (90%), p504s (95%), and specificity: p53/p504s (90%), CK5/6 (87.5%), p63 (90.5%), p504s (90.9%). CONCLUSION: Our results show that the use of a cocktail to p63/p504s is more specific than the use of CK5/6 alone this technique supports a diagnosis of prostatic cancer in 40% of cases previously considered as ASAP.

[Superficial grade G2 tumors of the bladder: recurrence, progression, prognosis]. / Tumeurs superficielles de vessie de grade G2: récidive, progression, pronostic.

OBJECTIVE: The primary objective of this study was to describe the course of a series of grade 2 noninvasive urothelial carcinomas and to determine their prognosis by establishing recurrence, progression and mortality rates The initial histological and endoscopic characteristics were analysed in order to identify risk factors for recurrence and progression towards detrusor invasion. MATERIAL AND METHODS: This retrospective study was conducted on 75 patients with initially grade 2 superficial bladder tumours. Tumours were initially multifocal in 47% of cases and were classified as follows: 52 pTa tumours (69%) and 23 pT1 tumours (31%). The mean follow-up was 58 months. RESULTS: After the initial endoscopic resection, 26 patients (3.9%) received adjuvant therapy by intravesical instillations. The overall recurrence and progression rates in this series were 67% and 7%, respectively. Twelve patients (16%) underwent cystectomy. The specific mortality rate was 2.6%. Among the initial prognostic criteria, only the multifocal nature was identified as a risk factor for recurrence and progression towards detrusor invasion. CONCLUSION: This study confirmed the uncertain prognosis of grade 2 superficial bladder tumours. These tumours have a high recurrence risk with a cystectomy rate of 16%. These tumours require surveillance identical to that of high-grade tumours, at least half-yearly for the first 3 years then annually thereafter.

Percutaneous core biopsy for renal masses: indications, accuracy and results.

PURPOSE: We evaluated the results, accuracy and clinical incidence of our standard procedure of percutaneous biopsy for solid renal masses. MATERIALS AND METHODS: From March 1999 to April 2005, 119 percutaneous core biopsies of renal masses were performed. Biopsies were proposed when there was no formal evidence for a carcinoma diagnosis on computerized tomography. RESULTS: Benign lesions were diagnosed in 24 biopsies (20.1%), including oncocytoma in 13, angiomyolipoma in 5 and chronic pyelonephritis in 5. Malignancy was identified in 70 biopsies (58.8%), including 57 renal carcinomas (conventional renal cell in 41, papillary in 12 and chromophobe in 4), 4 transitional cell carcinomas, 8 metastases and 1 lymphoma. For 25 biopsies (21%) no accurate diagnosis was possible, including 12 that showed inflammatory tissue and 13 with normal or necrotic tissue. These inconclusive biopsies prompted repeat biopsy in 13 patients, in whom a total of 11 malignant lesions were diagnosed. A total of 64 nephrectomies were performed with a biopsy accuracy for histopathological tumor type and Fuhrman nuclear grade of 86% and 46%, respectively. A period of watchful waiting was proposed for 31 patients (34.2%) and no renal malignancies were found. Computerized tomography showed stabilization or disappearance of the initial renal mass. CONCLUSIONS: Percutaneous renal tumor biopsies are safe, cost-effective and often conclusive for an acute histological diagnosis. This procedure could be decisive for choosing the optimal treatment, particularly to avoid nephrectomy for benign lesions. Biopsies should not be considered a routine procedure but they could be indicated when there is a lack of radiological evidence in elective patients.

Diagnostic utility of a p63/alpha-methyl coenzyme A racemase (p504s) cocktail in ambiguous lesions of the prostate upon needle biopsy.

OBJECTIVE: To investigate the potential utility of a new combined immunostaining technique for diagnosing prostate cancer from histological analysis of needle biopsy specimens. MATERIALS AND METHODS: Tissue was immunostained with a combination of antibodies against a basal cell marker (p63), and an enzyme commonly overexpressed in prostate cancer (p504s), on 63 small prostate cancer foci (<1 mm) and 109 cases of ambiguous lesions observed in needle biopsies. RESULTS: After p63/p504s immunostaining, 93% of the ambiguous lesions (102/109) were classified. The final diagnoses retained were: 92 prostate cancers, seven atypical small acinar proliferations suspected of being malignant but undiagnosed, 21 prostatic intraepithelial neoplasia, five atypical adenomatous hyperplasia, and 36 atrophic benign mimickers of cancer. CONCLUSIONS: Combining p504s as a positive marker for prostate cancer and p63 as a negative marker might improve diagnostic performance, sensitivity and specificity, and lead to fewer false-negative results. This simple immunostaining procedure should reduce the percentage of residual ambiguous lesions and the need for additional biopsies.

Prostatic capsule- and seminal-sparing cystectomy for bladder carcinoma: initial results for selected patients.

OBJECTIVE: To evaluate the oncological outcome and functional results of prostate-sparing cystectomy (PSC), proposed for treating bladder cancer, used since 1999 in our institution in an attempt to preserve male sexuality and to increase continence after cystectomy. PATIENTS AND METHODS: Between January 1999 and December 2001, 111 men were candidates for cystectomy; 42 were selected for a prostatic capsule- and seminal-sparing cystectomy with orthotopic urinary diversion. All patients had clinically organ-confined tumours (clinical stage

Efficacy and safety of a novel combination of L-arginine glutamate and yohimbine hydrochloride: a new oral therapy for erectile dysfunction.

PURPOSE: The goal of this double-blind, placebo-controlled, three-way crossover, randomized clinical trial was to compare the efficacy and safety of the combination of 6g of L-arginine glutamate and 6 mg of yohimbine hydrochloride (AY) with that of 6 mg of yohimbine hydrochloride (YP) alone and that of placebo (PP) alone, for the treatment of erectile dysfunction (ED). MATERIALS AND METHODS: Forty-five patients were included in this study. During each of the 2-week, crossover periods, drug was administered orally, one to two hours before intended sexual intercourse. The primary endpoint was change in the Erectile Function Domain score of the International Index of Erectile Function (IIEF). The secondary endpoints were patient and investigator assessments of treatment success. RESULTS: At the end of each treatment period, the Erectile Function Domain scores for AY, YP and PP were 17.2+/-7.17, 15.4+/-6.49 and 14.1+/-6.56, respectively. The difference between AY and PP was statistically significant (p=0.006). When stratified according to baseline scores over 14, those patients with mild to moderate MED had a better Erectile Function Domain response to treatment (AY=22.2+/-4.99, YP=18.2+/-5.59, PP=16.9+/-6.91, respectively) than those with scores 14 and below (AY=12.4+/-5.48, YP=12.7+/-6.25, PP=11.4+/-5.02, respectively). Investigators' and patients' assessment of efficacy was significantly improved by YP over PP. CONCLUSIONS: This pilot study shows that the on-demand oral administration of the L-arginine glutamate 6g and 6 mg yohimbine combination is effective in improving erectile function in patients with mild to moderate ED. It appears to be a promising addition to first-line therapy for ED.

Major complex pelvic arteriovenous malformation in a patient with Down syndrome.

Pelvic arteriovenous malformations (AVM) are rare, and the treatment of this condition presents an interesting challenge. We report the first case of a major AVM in a patient with Down syndrome which was revealed by a massive hematuria. Arteriography showed a bilateral complex iliac artery malformation. The first proximal embolization (unilateral) did not prevent bladder hemorrhage, and the second distal (bilateral) immobilization produced bladder necrosis. However, the patient died despite an emergency cystectomy.

Extracorporeal shock wave therapy in the treatment of Peyronie's disease: experience with standard lithotriptor (siemens-multiline).

OBJECTIVES: To assess in a prospective study whether extracorporeal shock wave therapy (ESWT) using a standard radioscopic location lithotriptor is effective in the treatment of Peyronie's disease. METHODS: Fifty-four patients were included in this prospective study. Before and after treatment, the angulation was calculated by auto-photography. Pain severity was assessed by a visual analog pain scale. A self-evaluation questionnaire (International Index of Erectile Function) was used. All patients had symptoms (35 had pain during erection and 51 angulation greater than 20 degrees ). The mean disease duration was 16 months. The mean angulation before treatment was 48 degrees (range 10 degrees to 100 degrees ). Twenty-four patients had erectile dysfunction (questionnaire score less than 18). The Multiline Siemens lithotriptor was used. The plaque was located by palpation, and 1 mL of contrast agent was injected. Scopic visualization was used. Each patient received a minimum of one session of ESWT (3000 shock waves, 7 kJ) applied to a flaccid penis. RESULTS: All patients completed the protocol. The tolerance and safety were excellent. Of the 35 patients with pain on erection, 31 (91%) noticed relief immediately after ESWT (mean reduction 2.9 on the visual analog pain scale) (P <0.00001). For 29 patients (53.7%), an improvement in angulation (greater than 10 degrees ) was observed, with a mean reduction of 31 degrees (P <0.001). For patients with erectile dysfunction, only 6 (25%) had an increased questionnaire score (greater than 4). Twenty-five patients thought the plaque was smoother. CONCLUSIONS: ESWT with a standard lithotriptor (without the mobile arm) in Peyronie's disease is a feasible, safe, and effective treatment for pain on erection and significantly improves the penile angle.

After cystectomy, is it justified to perform a bladder replacement for patients with lymph node positive bladder cancer?

PURPOSE: After cystectomy for bladder cancer, when pelvic lymph nodes are positive, bladder replacement remains controversial. The aim of this study was to evaluate the outcome of patients who underwent neobladder replacement despite bladder cancer metastasis to the regional lymph nodes. MATERIALS AND METHODS: From 1981 to 1997, a total of 504 consecutive cystectomies for bladder cancer were performed at our institution. For 150 patients, pelvic lymphadenectomy were positive, nevertheless 71 patients underwent a neobladder replacement (50 N1 and 21 N2). The distribution of patients by clinical stage, according to the TNM 97 classification, was 4 T1, 14 T2, 32 T3 and 21 T4. No patient showed signs of metastasis on diagnosis. RESULTS: Five-year disease specific survival rate of the entire group (71 patients) was 46%. With a mean follow-up of 8.3 years (3.2-20 years), 25 patients (35%) were alive and free of disease (72% with day continence), five patients were alive with recurrence (three bone metastasis, one chest metastasis and one with local recurrence), 41 patients died, (three non-cystectomy related). Of the 46 patients who recurred, a total of eight patients had local recurrence. For five patients, a severe dysfunction of the plasty appeared: two needed definitive bladder drainage until they died, one patient became totally incontinent, one patient needed a conversion of the plasty to Bricker ileal conduit. For the remaining patient the tumor involvement provoked recto-plasty-cutaneous fistula. All these five patients died in the 6 months after the plasty dysfunction appeared. CONCLUSIONS: Although prognosis in bladder cancer metastasis to the regional lymph nodes has been reported to be poor, this study demonstrates that after cystectomy, it is justified to propose a neobladder replacement to well selected patients. Local recurrence only occurred in 11% of patients and there was no damage to enteroplasty function for nearly half of the patients, and considering benefit to the quality of life, orthotopic bladder substitution should be considered as the preferential diversion in this patient population.