Risk Factors For Urethral Recurrence Research Articles

Incidence, risk factors and outcomes of urethral recurrence after radical cystectomy for bladder cancer: A systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis assessing the incidence and risk factors of urethral recurrence (UR) as well as summarizing data on survival outcomes in patients with UR after radical cystectomy (RC) for bladder cancer. The MEDLINE and EMBASE databases were searched in February 2021 for studies of patients with UR after RC. Incidence and risk factors of UR were the primary endpoints. The secondary endpoint was survival outcomes in patients who experienced UR. Twenty-one studies, comprising 9,435 patients, were included in the quantitative synthesis. Orthotopic neobladder (ONB) diversion was associated with a decreased probability of UR compared to non-ONB (pooled OR: 0.44, 95% CI: 0.31-0.61, P < 0.001) and male patients had a significantly higher risk of UR compared to female patients (pooled OR: 3.16, 95% CI: 1.83-5.47, P < 0.001). Among risk factors, prostatic urethral or prostatic stromal involvement (pooled HR: 5.44, 95% CI: 3.58-8.26, P < 0.001; pooled HR: 5.90, 95% CI: 1.82-19.17, P = 0.003, respectively) and tumor multifocality (pooled HR: 2.97, 95% CI: 2.05-4.29, P < 0.001) were associated with worse urethral recurrence-free survival. Neither tumor stage (P = 0.63) nor CIS (P = 0.72) were associated with worse urethral recurrence-free survival. Patients with UR had a 5-year CSS that varied from 47% to 63% and an OS - from 40% to 74%; UR did not appear to be related to worse survival outcomes. Male patients treated with non-ONB diversion as well as patients with prostatic involvement and tumor multifocality seem to be at the highest risk of UR after RC. Risk-adjusted standardized surveillance protocols should be developed into clinical practice after RC.

Urethral recurrence following radical cystectomy: Risk factors and outcomes.

416 Background: Urethral recurrence (UR) has been reported to occur in up to 5% of patients following radical cystectomy (RC). Debate continues regarding the utility of screening for UR after RC. Moreover, oncologic outcomes of patients with UR remain incompletely described, and reports have been limited by small cohort sizes. Herein, we evaluated risk factors for UR as well as cancer-specific survival (CSS) and overall survival (OS) among patients with UR. Methods: We reviewed our institutional RC registry to identify patients with UR following RC. Logistic regression was used to assess risk factors for UR. Kaplan-Meier and Cox proportional hazard regression were used to compare outcomes in those with UR diagnosis prompted by symptoms versus those with asymptomatic UR diagnosed on surveillance cytology. Results: Overall, 2930 patients underwent RC from 1980-2018, with a median post-operative follow-up of 4.9 years (IQR 1.6-11.0), of whom 144 (4.9%) were subsequently diagnosed with UR. Prostatic urethral involvement at RC (odds ratio [OR] 5.75 [3.67-9.01], p &lt; 0.0001) and higher pT-stage (OR 3.57 [2.07-6.14], p &lt; 0.0001) were associated with an increased risk of UR, whereas receipt of continent urinary diversion (OR 0.34 [0.20-0.58], p &lt; 0.0001) was associated with a decreased risk of UR. A total of 72/144 (50%) patients were diagnosed with UR based on symptoms, and 104/144 (72.2%) patients with UR underwent subsequent urethrectomy. Patients with symptomatic recurrence had higher tumor stage on urethrectomy than those with asymptomatic recurrence (≥pT2 in 13.1% vs 3.1%, p = 0.007). At a median follow-up of 2.6 years (IQR 1.0-7.1) after UR, 68 of the patients with UR died of urothelial carcinoma. Kaplan-Meier analyses suggest longer median overall and cancer-specific survival for patients with UR detected by cytology than those presenting with symptoms (p = 0.05 for both). On multivariable analyses, patients who experienced UR had significantly increased risk of cancer-specific (hazard ratio [HR] 1.93 [95% confidence interval 1.50-2.50), p &lt; 0.0001) and all-cause mortality (HR 1.34 [1.13-1.65], p = 0.001). Conclusions: Approximately 5% of patient undergoing RC experience UR, with higher pT-stage and prostatic urethral involvement increasing the risk of UR. Asymptomatic detection of UR was associated with lower pathologic stage at urethrectomy as well as longer cancer-specific and overall survival, supporting urethral surveillance after RC.

Risk Factors for Urethral Recurrence in Men After Radical Cystectomy with Orthotopic Urinary Diversion for Urothelial Carcinoma: A Retrospective Cohort Study.

PurposeTo evaluate the risk factors affecting urethral recurrence (UR) in men after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).Materials and MethodsWe retrospectively reviewed 348 men who underwent RC with IONB for bladder cancer between January 2010 and December 2017. Clinicopathologic characteristics, including tumor location (trigone and/or bladder neck), prostatic urethral and/or stromal involvement, presence of carcinoma in situ (CIS), pathologic T and N stage, and urethral resection margin status, were identified. Kaplan–Meier survival analysis was used to illustrate urethral recurrence-free survival (URFS), and Cox proportional hazard models were applied to identify factors predicting UR.ResultsOf the 348 patients, UR was identified in 7 (2.0%) patients during the mean follow-up of 33.3 months. The 2-, 3-, and 5-year URFS rates were 97.6%, 96.3%, and 93.8%, respectively. On multivariable analysis, prostatic urethral involvement (P = 0.033, hazard ratio: 6.25, 95% confidence interval: 1.06–36.96) was an independent predictor of UR. When patients were divided according to prostatic urethral involvement (negative vs positive), the 2- and 3-year URFS rates were significantly different (93.8% and 96.8%, respectively, vs 92.0% and 92.0%, respectively; P = 0.020). All 7 patients with UR underwent transurethral surgery and maintained their IONB.ConclusionIn this series, UR occurred in approximately 2% of men after RC with IONB. Prostatic urethral involvement was the only significant prognostic factor for UR. Follow-up strategies considering UR risk should be adopted to facilitate early detection in those at high risk of UR.

603 - Risk factors of urethral recurrence in men after radical cystectomy with orthotopic urinary diversion for urothelial carcinoma

603 - Risk factors of urethral recurrence in men after radical cystectomy with orthotopic urinary diversion for urothelial carcinoma

Risk factors of urethral recurrences following radical cystectomy for bladder cancer

Objective To evaluated the risk factors of urethral recurrence (UR) following radical cystectomy (RC)in patients with bladder urothelial carcinoma. Methods The clinical data of 350 male patients who underwent RC between January 2005 and January 2013 were retrospectively analyzed. The mean age was 63 years (rang 46-76) years. 176 cases had the history of non-muscle-invasive bladder cancer.15 cases were were found the tumor invasion into the prostatic urethral. The way of urinary diversion after RC included 172 cases were orthotopic neobladder, 90 cases were cutaneous diversion and 88 cases were ileal couduitin. 331 cases underwent preoperation intravesical instillation.36 cases underwent systemic chemotherapy after operation.148 cases were found the multiple tumor lesions, which was more than 2 sites. The pathological stage was more than T2 satge in 189 cases. And 177 cases were diagnosed as high-grade urothelial carcinoma. Multivariate Cox regression analyses were used to evaluate the risk factors associated with the UR. Results There were 350 cases in this study, UR was observed in 28 cases (8%). On multivariate Cox regression analyses, previous history of NMIBC (HR=15.205, 95%CI 3.718-62.180, P<0.001), prostate urethral involvement(HR=5.233, 95%CI 1.106-24.754, P=0.037) and Non-orthotopic neobladder(HR=6.656, 95%CI 1.840-24.077, P=0.004)which the operation of cutaneous diversion and ileal couduit , were independent risk factors of UR following RC. Intravesical instillation before operation (HR=0.470, 95%CI 0.010-0.217, P<0.001) was the protective factor of the UR. Conclusions Previous history of NMIBC, prostatic urethral involvement and Non-orthotopic neobladder were independent risk factors of UR. Intravesical instillation before operation was protective factor of UR. Urethrectomy for patients with high risk factors and intravesical instillation before operation were important. Key words: Bladder cancer; Urothelial carcinoma; Radical Cystectomy; Risk factors

MP38-18 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY: REVISITING THE INCIDENCE AND PREDICTORS IN A LARGE CONTEMPORARY SERIES

INTRODUCTION AND OBJECTIVES: There is paucity of data about the incidence and predictors of urethral recurrence after radical cystectomy. We opt to identify risk factors of urethral recurrence stratified by gender in a large contemporary series. In addition, sub-analysis for male patients underwent orthotopic bladder substitution (OBS) was performed to determine the risk of urethral recurrence and potential urinary conversion. METHODS: The electronic records of 3208 patients underwent radical cystectomy between 1988 and 2010 were reviewed. Patients0 demographics and pathological results were retrieved and were evaluated for the potentiality of urethral recurrence stratified by gender. Univariate and multivariate time-to-event analyses were performed to identify potential predictors. RESULTS: A total of 686 patients were excluded because of perioperative mortality, missed follow up or incomplete records. Of the study cohort, 2050 males were available for analysis. Urethral recurrence occurred in 59 (2.9%) patients over a median (IQR) follow up of 24 (34) months. On multivariate analysis, prostatic stromal invasion (Hazards ratio [HR]: 6.4; 95%Confidence interval [CI]: 3.412; p<0.001), tumors at the trigone (HR: 2.1; 95%CI: 14.3; p1⁄40.02), and multicentricity (HR: 2.4; 95%CI: 1.3-4.3; p1⁄40.002) were independent predictors. A total 472 females were available for analysis of whom 8 (1.7%) developed urethral recurrence over a median (IQR) follow up of 40 (64) months. None of the patients0 demographics or histopathological criteria was significantly associated with urethral recurrence. Subanalysis of 1098 male patients underwent OBS revealed that only multicentricity was independent predictor for urethral recurrence (HR: 4.2; 95%: 1.6-10.9; p1⁄40.003). CONCLUSIONS: Urethral recurrence in males and females after radical cystectomy is relatively rare and occurs in 2.9% and 1.7%, respectively. In addition to prostatic stromal invasion, tumors at the trigone and multicentricity were independent predictors of urethral recurrence in males. Only multicentricity was independent predictor for males undergoing OBS. This information is crucial in preoperative counselling and planning of follow up.

Urethral recurrence in women with orthotopic bladder substitutes: A multi-institutional study

ObjectivesTo evaluate risk factors for urethral recurrence (UR) in women with neobladder. Material and methodsFrom 1994 to 2011, 297 women (median age = 54y; interquartile range: 47–57) underwent radical cystectomy with ileal neobladder for bladder cancer in 4 centers. None of the patients had bladder neck involvement at preoperative assessment. Univariable and multivariable analyses were used to estimate recurrence-free survival and overall survival. The median follow-up was 64 months (interquartile range: 25–116). ResultsOf the 297 patients, 81 developed recurrence (27%). The 10- and 15-year recurrence-free survival rates were 66% and 66%, respectively. The 10- and 15-year overall survival rates were 57% and 55%, respectively. UR occurred in 2 patients (0.6%) with solitary urethral, 4 (1.2%) with concomitant urethral and distant recurrence, and 1 with concomitant urethral and local recurrence (0.3%). Bladder tumors were located at the trigone in 27 patients (9.1%). None of these patients developed UR. Lymph node tumor involvement was present in 60 patients (20.2%). On univariable and multivariable analyses, pathologic tumor and nodal stage were independent predictors for the overall risk of recurrence. UR was associated with a positive final urethral margin status (P<0.001) whereas no significant associations were found for carcinoma in situ, pathologic tumor and nodal stage, and bladder trigone involvement. ConclusionsIn this series, only 0.6% of women developed solitary UR. A positive final urethral margin was associated with an increased risk of UR. Women with involvement of the bladder trigone were not at higher risk of UR.

Patterns, risks and outcomes of urethral recurrence after radical cystectomy for urothelial cancer; over 20 year single center experience

Purpose: To evaluate the factors affecting urethral recurrence after radical cystectomy for bladder cancer and relationship between urinary diversion type and urethral recurrence rates. Patients and methods: In our 504 radical cystectomy series, 287 male patients whose final pathological were urothelial carcinoma were included in the study. The relationship between urethral recurrence and pathological stage, grade, lymph node involvement and diversion type was researched in addition to risk factors for urethral recurrence. Results: A Total of 287 patients. Orthotopic continent urinary diversion (OCD) and ileal conduit (IC) was performed after radical cystectomy in 141 (49.1%) and 146 (50.9%) patients respectively. Urethral recurrence was observed in 11 (3.8%) patients and urethral recurrence rates in OCD and IC groups were 1.4% and 6.2% (p = 0.034). Pathological stages of recurrent patients were 2 pT1, 1 pT2 and 8 pT4 respectively (p < 0.001). Urethral recurrence was significantly lower in OCD group when compared to IC group (p = 0.036). When all parameters were analyzed using Cox multivariate regression analysis, the most important factor that affects urethral recurrence was pathological T stage (p < 0.001). Risk factors for urethral recurrence were present in 92 patients. Urethral recurrence rates in patients with and without risk factors were 8.69% and 1.53% (p < 0.01). Conclusions: In this study, pathological stage was found to be the most important factor affecting urethral recurrence and prostatic stromal invasion was an important prognostic factor in these cases. Although risk factors for urethral recurrence were similar in both groups, urethral recurrence rates were significantly lower in OCD group when compared to IC group.

S117: Patterns, risks and outcomes of urethral recurrence after radical cystectomy for urothelial cancer; over 20 year single center experience

Purpose: To evaluate the factors affecting urethral recurrence after radical cystectomy for bladder cancer and relationship between urinary diversion type and urethral recurrence rates. Patients and methods: In our 504 radical cystectomy series, 287 male patients whose final pathological were urothelial carcinoma were included in the study. The relationship between urethral recurrence and pathological stage, grade, lymph node involvement and diversion type was researched in addition to risk factors for urethral recurrence. Results: A Total of 287 patients. Orthotopic continent urinary diversion (OCD) and ileal conduit (IC) was performed after radical cystectomy in 141 (49.1%) and 146 (50.9%) patients respectively. Urethral recurrence was observed in 11 (3.8%) patients and urethral recurrence rates in OCD and IC groups were 1.4% and 6.2% (p ¼ 0.034). Pathological stages of recurrent patients were 2 pT1, 1 pT2 and 8 pT4 respectively (p < 0.001). Urethral recurrence was significantly lower in OCD group when compared to IC group (p ¼ 0.036). When all parameters were analyzed using Cox multivariate regression analysis, the most important factor that affects urethral recurrence was pathological T stage (p < 0.001). Risk factors for urethral recurrence were present in 92 patients. Urethral recurrence rates in patients with and without risk factors were 8.69% and 1.53% (p < 0.01). Conclusions: In this study, pathological stage was found to be the most important factor affecting urethral recurrence and prostatic stromal invasion was an important prognostic factor in these cases. Although risk factors for urethral recurrence were similar in both groups, urethral recurrence rates were significantly lower in OCD group when compared to IC group.

608 A multi-institutional study on risk factors of urethral recurrence in female patients with ileal neobladder

608 A multi-institutional study on risk factors of urethral recurrence in female patients with ileal neobladder

Management of the male urethra before and after cystectomy: From the prophylactic urethrectomy to the intraoperative frozen section biopsy of the urethral margin

ContextDecision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. ObjectiveTo analyze the changes produced in the management of the urethra from the beginning of the cystectomy up to the present moment. Evidence acquisitionAnalysis of original articles and reviews obtained through a search in PubMed, related with the risk factors of urethral recurrence (UR) and with the management of the urethra in patients subjected to radical cystectomy. Evidence synthesisAt first, many authors recommended urethrectomy simultaneously with cystectomy. The identification of risk factors of the bladder tumor related with the appearance of UR limited the indication of prophylactic urethrectomy in patients with multifocal disease and with prostate tumor involvement. The development of orthotopic bladder substitutes (OBS) complicated the situation. The involvement the prostatic urethral tumor was maintained as the principal risk factor for UR, which then gave importance to its pre-cystectomy staging. Series of OBS observed a lower incidence of UR regarding patients with skin derivations, even in cases with prostatic urethral involvement. Prostatic urethral involvement stopped being a contraindication for OBS when the frozen section biopsy of the urethral margin was negative. ConclusionsCurrently, most authors agree that the intraoperative frozen section biopsy of the urethral margin will determine whether an OBS or urethrectomy should be performed. In spite of this, we have very few series in which this approach has been systematically used and with sufficient follow-up.

Actitud con la uretra antes y durante la cistectomía en el varón: de la uretrectomía profiláctica a la biopsia por congelación del margen uretral

Context Decision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. Objective To analyze the changes produced in the management of the urethra from the beginning of the cystectomy up to the present moment. Evidence acquisition Analysis of original articles and reviews obtained through a search in PubMed, related with the risk factors of urethral recurrence (UR) and with the management of the urethra in patients subjected to radical cystectomy. Evidence synthesis At first, many authors recommended urethrectomy simultaneously with cystectomy. The identification of risk factors of the bladder tumor related with the appearance of UR limited the indication of prophylactic urethrectomy in patients with multifocal disease and with prostate tumor involvement. The development of orthotopic bladder substitutes (OBS) complicated the situation. The involvement the prostatic urethral tumor was maintained as the principal risk factor for UR, which then gave importance to its pre-cystectomy staging. Series of OBS observed a lower incidence of UR regarding patients with skin derivations, even in cases with prostatic urethral involvement. Prostatic urethral involvement stopped being a contraindication for OBS when the frozen section biopsy of the urethral margin was negative. Conclusions Currently, most authors agree that the intraoperative frozen section biopsy of the urethral margin will determine whether an OBS or urethrectomy should be performed. In spite of this, we have very few series in which this approach has been systematically used and with sufficient follow-up.

1605 RISK FACTORS FOR UPPER URINARY TRACT AND URETHRAL RECURRENCES AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive1 Apr 20111605 RISK FACTORS FOR UPPER URINARY TRACT AND URETHRAL RECURRENCES AFTER RADICAL CYSTECTOMY Polat Turker, Peter J. Bostrom, Marcelo L. Wroclawski, Tuomas Mirtti, Martti Nurmi, Neil E. Fleshner, Antonio Finelli, Michael A. Jewett, and Alexandre R. Zlotta Polat TurkerPolat Turker Toronto, Canada More articles by this author , Peter J. BostromPeter J. Bostrom Toronto, Canada More articles by this author , Marcelo L. WroclawskiMarcelo L. Wroclawski Toronto, Canada More articles by this author , Tuomas MirttiTuomas Mirtti Helsinki, Finland More articles by this author , Martti NurmiMartti Nurmi Turku, Finland More articles by this author , Neil E. FleshnerNeil E. Fleshner Toronto, Canada More articles by this author , Antonio FinelliAntonio Finelli Toronto, Canada More articles by this author , Michael A. JewettMichael A. Jewett Toronto, Canada More articles by this author , and Alexandre R. ZlottaAlexandre R. Zlotta Toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2710AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrences in the upper urinary tract (UUTrec) and urethra (urethrec) following radical cystectomy (RC) for transitional cell carcinoma of the bladder are often recognized after symptomatic presentation and impact patient's survival. Accurate predictive risk factors would aid in designing individually tailored follow-up (FU) protocols. METHODS 635 consecutive patients undergoing RC for urothelial BC without neoadjuvant chemotherapy at University Health Network, Toronto, Canada (1992–2008) and University of Turku, Turku, Finland (1986–2005) were studied. The rates of UUT and urethral recurrences were analyzed. Patients with urethrectomy were excluded from urethral recurrences analysis. Clinicopathological variables associated with recurrence were evaluated using the fÓ2-test. The Kaplan-Meier method was used to analyze survival. RESULTS Mean FU was 45 months (0–264). Among the 635 RC patients, 22(3%) had an UUT recurrence and among the 559 patients without urethrectomy during RC 17(3%) suffered from a urethral recurrence. Median time to UUTrec was 20 months (3–84 mo) and to urethrec was 30 months (10–96 mo). Male gender (p=0.035), T2 or higher primary stage (0.014), concomitant CIS (p=0.014) and prostatic urethra involvement (p=0.021) were significant risk factors for UUTrec. T2 or higher primary stage (p=0.001), pathological stage higher than T2 (p=0.03) and prostatic urethra involvement (p=0.05) were significant risk factors for urethral recurrence. Disease specific and overall survival of UUTrec were poorer than urethrec (43 vs 74% at 10 years, p=0.047). CONCLUSIONS The risk of UUT or urethral recurrence is relatively low after RC when selection of patients has been performed prior to surgery. Efforts should be made to recognise prostatic urethra involvement and presence of CIS prior to RC. We found that patients with urethral recurrence had lower mortality rates than described in some previous series and may be often salvaged but both UTCC and urethral recurrences remain challenging to manage. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e644 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Polat Turker Toronto, Canada More articles by this author Peter J. Bostrom Toronto, Canada More articles by this author Marcelo L. Wroclawski Toronto, Canada More articles by this author Tuomas Mirtti Helsinki, Finland More articles by this author Martti Nurmi Turku, Finland More articles by this author Neil E. Fleshner Toronto, Canada More articles by this author Antonio Finelli Toronto, Canada More articles by this author Michael A. Jewett Toronto, Canada More articles by this author Alexandre R. Zlotta Toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Risk Factor for Urethral Recurrence after Radical Cystectomy in Patients with Transitional Cell Carcinoma of the Bladder

Purpose: We evaluated the incidence and risk factors for urethral recurrence following radical cystectomy and urinary diversion in transitional cell carcinoma. Patients and Methods: A retrospective review was performed of the 412 consecutive patients who underwent radical cystectomy and urinary diversion for transitional cell carcinoma of the bladder between 1986 and 2004. A total of 294 patients were enrolled in this study. We investigated the impact of various clinical and pathological features on urethral recurrence by univariate and multivariate analysis. Results: Urethral recurrence developed in 13 patients (4.4%) and the 5-year urethral recurrence-free probability was 94.9%. On univariate analysis, positive urethral margin, prostatic stromal invasion, and prostatic urethral involvement had a significant influence on urethral recurrence (p < 0.05). The other clinical and pathological features were not significantly associated with urethral recurrence (p > 0.05). A multivariate Cox proportional hazard model revealed that a positive urethral margin (hazards ratio (HR) = 18.33, p < 0.001), prostatic urethral involvement (HR = 7.95, p < 0.001), and prostatic stromal invasion (HR = 5.80, p = 0.018) were independent risk factors for urethral recurrence. Conclusion: A positive urethral margin is considered an absolute indication for prophylactic urethrectomy. In addition, more careful patient selection is necessary for orthotopic urinary diversion in patients with prostatic urethral involvement and prostatic stromal invasion.

What is the ratio of urethral recurrence risk after radical cystoprostatectomy for bladder cancer?

There is always a risk of urethral recurrence after radical cystoprostatectomy in patients with bladder transitional cell cancer. Taking these risk factors of urethral recurrence into account, orthotopic neobladders or urinary diversions without using the urethra are performed. But urethral tumour recurrence occurs much less than the expected. We assessed the etiological factors that affect the urethral recurrence in orthotopic and nonorthotopic urinary diversion cases. Sixty-four patients with bladder cancer who underwent radical cystoprostatectomy and urinary diversion between 1994 and 2002 were included this study. Conventional risk factors effecting the selection of operation type and urethral recurrence were evaluated in these patients. Cystoscopy and biopsy were done and pathologic specimen was obtained preoperatively, and cystoscopy and urethral washout cytology were done postoperatively. Routine bladder biopsies were done in uncertain cases at follow-up. Risk factors increasing the urethral recurrence are as follows: papillary and multiple tumours, tumour invading bladder neck and trigone, extensive CIS, prostatic stromal and urethral invasion, positive surgical margin and history of upper urinary tract tumour. In 31 patients having one or more of these criteria, continent nonorthotopic urinary diversion was performed, but 33 patients without these risk factors underwent orthotopic urinary diversion. Simultaneous urethrectomy was not done in any of these patients. Among the patients who underwent radical cystoprostatectomy, none was with positive surgical margin in the distal end of the prostatic urethra. In preoperative cystoscopy, tumoural mass was seen near to collum in eight patients and in the prostatic urethra in three patients. Histopathological examination of cystoprostatectomy specimen displayed transient epithelial cell carcinoma of prostatic urethra in three patients, transient epithelial cell metaplasia inside the prostate in five patients and invasion to the urothelium of bladder neck in three patients. There were not any transient epithelial cell cancer metastases in prostatic stroma in any of these patients. One patient underwent urethrectomy, since atypical cells were observed in postradical prostatectomy urethral washout cytology but there was no tumour found in pathological examination of the specimen. Therefore, urethral tumour recurrence did not occur after 25 months follow up. These findings suggest that some of the conventional risk factors of urethral recurrence were exaggerated. We may also conclude that there is no need for prophylactic urethrectomy unless there is urethral cancer or cancer in the surgical margin. But if utilization of urethra is planned, evaluation of prostatic stroma by TUR biopsies and urethral anastomose margin by frozen section during the operation is necessary.

THE MANAGEMENT OF URETHRAL TRANSITIONAL CELL CARCINOMA AFTER RADICAL CYSTECTOMY FOR INVASIVE BLADDER CANCER

Previous reports have identified risk factors for urethral recurrence following radical cystectomy for transitional cell carcinoma (TCC). However, reports of the clinical presentation, treatment and outcome in these patients are lacking. We report our experience with the diagnosis, management and outcome of urethral TCC after radical cystectomy for bladder cancer. A database of 1,054 patients who underwent radical cystectomy and urinary diversion for TCC from 1971 to 1997 was retrospectively reviewed. All patients with urethral TCC after surgery were identified. Urethral TCC was diagnosed in 47 men a median of 18.5 months (range 2 to 116) after cystectomy with 20 (42%) diagnosed within 1 year. Symptomatic recurrence developed in 24 of 42 evaluable patients (57%), 21 had bloody urethral discharge and 7 had pain or a palpable mass. A total of 13 patients (31%) were asymptomatic with abnormal cytology. The remaining 5 patients underwent prophylactic urethrectomy based on cystectomy pathology. Overall 41 patients underwent urethrectomy, which was total in 36 and distal with perineal urethrostomy in 5, including later conversion to total urethrectomy in 2. Overall at a median followup of 26 months (range 3 to 275) since diagnosis 36 of 47 patients (76%) were dead, including 25 of metastatic disease. Only 10 patients (21%) remained disease-free. Median overall survival in patients with urethral TCC after radical cystectomy was only 28 months after the diagnosis of urethral TCC. Urethral stage (superficial vs invasive disease) at diagnosis was the most import predictor of overall survival in this cohort of patients. Most patients with urethral recurrence present with symptoms. However, screening cytology alone still detects a significant proportion. The median survival of patients with urethral TCC after radical cystectomy is only 28 months after diagnosis. Urethral stage (superficial vs invasive disease) at diagnosis is the most import predictor of overall survival in this cohort of patients.

Urethral recurrence following neobladder in bladder cancer patients.

Risk factors of urethral recurrence after neobladder in bladder cancer patients were studied. Between 1977 and 2001, 73 patients (male 58, female 15) underwent neobladder as a treatment for bladder cancer. The observation time after cystectomy ranged from 2 to 254 months (median 60.5). Ten (17.2%) of 58 male patients had urethral recurrence and of the 10, 8 patients had multiple bladder cancers including bladder neck. Urethral recurrence was found by macrohematuria, follow-up cystourethroscopy, and inguinal lymph node swelling. Only one who complained of macrohematuria had positive urinary cytology. Of 58 male patients, 5 underwent total nephroureterectomy for renal pelvic or ureteral cancer before radical cystectomy, and 3 of the 5 had urethral recurrence. Two of 10 patients with urethral recurrence died with cancer, and they had renal pelvic or ureteral cancer. The five-year cause specific survival was 83% for patients with urethral recurrence, and 79% for those without urethral recurrence, respectively. Urethral recurrence did not have a significant effect on survival. The patients with multiple bladder cancers including bladder neck, and renal pelvic or ureteral cancer before radical cystectomy, have high risks for urethral recurrence. Urinary cytology has limited value for the detection of urethral recurrence.

URETHRAL RECURRENCE AFTER RADICAL RADIOTHERAPY FOR BLADDER CANCER

Following cystectomy for bladder cancer, orthotopic reconstruction may result in a decreased risk of urethral recurrence compared to cutaneous diversion. We evaluate the rate of urethral recurrence after radical external beam radiotherapy. We reviewed the records of 214 men who had received radical radiotherapy at a single center from 1990 to 1995. Patients treated with chemotherapy were excluded from study. A total of 214 men (median age 69 years, range 39 to 86) underwent radical radiotherapy for cure. Tumor stages were T1 in 7%, T2 in 41%, T3 in 42% and T4a in 10% of the patients. Median followup was 32 months (range 1 month to 8.4 years) and 5-year survival rate was 30%. Urethral recurrence developed in 7 (3.2%) cases and was detected within 18 months (median 10 months, range 3 months to 5 years) of followup in 5. In 2 of these 7 cases recurrence developed in the prostatic urethra, and when these 2 cases were excluded from analysis the recurrence rate decreased to 2.3%. A total of 64 men completed 5-year followup, with a 4.7% rate of urethral recurrence (3.1% excluding prostatic urethral recurrence). Multifocal disease, bladder neck involvement, prostatic disease and cis were possible risk factors for urethral recurrence. The risk of urethral recurrence after radical radiotherapy for transitional cell carcinoma of the bladder is comparable with that reported after orthotopic reconstruction. It is not possible to exclude completely that men at higher risk were offered cystectomy, but the data are consistent with the suggestion that continued contact with urine may be protective.

Urethral Recurrence of Transitional Cell Carcinoma of the Bladder

Objective: The management of the male urethra after cystectomy for bladder cancer continues to be a dilemma. Patients who undergo a cystectomy require either urinary diversion or bladder substitution. Therefore, the use of the urethra to ensure voiding is important. On the other hand, the probable risk of urethral carcinoma recurrence is generally estimated at approximately 10%. The aim of this study was to assess the predictive value of preoperative urethral biopsies, and of frozen sections during cystoprostatectomy, in patients with invasive bladder cancer. Methods: From 1982 to 1986, 118 male patients underwent a cystoprostatectomy for transitional cell carcinoma of the bladder. All patients underwent endoscopic latero-montanal biopsies 2 weeks preoperatively and urethral frozen cut section during radical prostatocystectomy. Results: Carcinoma was observed in 12 patients on both examinations. All patients underwent en bloc urethrectomy during cystectomy. In the remaining 106 patients, the frozen cut margin was negative (including 9 with positive latero-montanal biopsies), and these patients had the urethra preserved. After a 10-year minimum follow-up, no recurrence was observed in these patients with negative frozen cut section. No significant risk factors for urethral recurrence were found. Latero-montanal biopsies did not reveal a positive specificity, and this procedure was later abandoned in our institution (in 1986). Conclusions: The urethral frozen section was the only guideline used for simultaneously performing the urethrectomy. All male patients with negative frozen cut sections should be considered candidates for bladder substitution. A prophylactic urethrectomy is only indicated in patients with carcinoma (minimum carcinoma in situ) in the frozen urethral margin section during cystectomy.

Urethral recurrence after cystoprostatectomy for bladder carcinoma.

Eighty-nine male patients underwent cystoprostatectomy for bladder carcinoma. Prophylactic urethrectomy was performed only on 7 patients whose tumour extended to or beyond the bladder neck. During the follow-up period 9 of 82 patients (11%) developed a urethral recurrence. Eight out of these 9 patients had carcinoma in situ or multiple papillary tumours in the bladder. Of all those patients who had carcinoma in situ, either primary or concomitant with papillary tumour, 18% developed urethral recurrence. The corresponding figure for patients with multiple tumours in the bladder was 15%. Thus the presence of carcinoma in situ or multiple tumours in the bladder seem to be important risk factors for urethral recurrence after cystoprostatectomy.