Neobladder formation after pelvic irradiation

Objective  To assess the results of the use of the ileal neobladder in patients with previous pelvic irradiation. Methods  Between January 1986 and July 2008, 1,570 radical cystectomies and 1,002 ileal neobladders were performed at a single institution. From this series, 94 patients (6%) with prior pelvic irradiation were retrospectively identified. In 25 of these irradiated patients, an ileal neobladder was done. All complications within 90 days of surgery were defined and graded using a five-grade modification of the original Clavien system and stratified into 11 categories. Functional outcome data and late complications were reported. Results  Seventy-six percent of the neobladder patients versus 52% of the non-neobladder patients developed complications occurring within 90 days of surgery. However, grade 3–5 complications were less frequent in the neobladder group. Unusual and serious late complications have been observed. Nineteen out of 25 neobladder patients enjoy perfect night and day time continence. Three out of seven female and 1/18 male patients suffer from treatment refractory severe stress incontinence. One male and one female patients are primarily hypercontinent. Conclusions  Salvage surgery (cystoprostatectomy, anterior exenteration) followed by orthotopic lower urinary tract reconstruction can be a safe, effective procedure that can provide a well functioning lower urinary tract in properly selected patients with defunctionalized bladder, tumor recurrence or de novo bladder cancer after definitive radiation therapy. Prerequisits for the neobladder as procedure of choice are good renal function, perfect preoperative continence, no recurrent gastrointestinal or gynecologic tumor, no fistula formation, and no severe damage of the small bowel.     

正位回结肠和回肠膀胱替代术尿控差异的对照研究

目的：通过根治性膀胱全切术后回结肠和回肠正位膀胱替代术的临床观察,重点评价两种术式的尿控及其对上尿路的影响及机制。方法：从2002～2006年期间行标准的根治性膀胱全切术后行正位膀胱替代术中选取获得随访的膀胱癌患者31例,其中17例采用回结肠新膀胱重建术（Le Bag术）,14例采用回肠新膀胱重建术（Studer术）。术后3个月内（近期）和3个月后（远期）观察相关并发症和尿控情况,并行尿动力学检查和静脉肾盂造影或B超检查。结果：回结肠新膀胱组手术后并发症率为11．8％（2／17）;回肠新膀胱组并发症率为14．3％（2／14）。虽然回结肠新膀胱组3个月后白天完全获得尿控76．4％（13／17）．低于回肠新膀胱组92．8％（13／14）,但统计学差异不显著;而夜间社会性尿控回肠新膀胱组7I．4％（10／14）,显著高于回结肠新膀胱组35．3％（6／17）。尿动力学结果表明两组间的尿流率、功能尿道长度、最大尿道压和新膀胱压力无明显差异,但回结肠新膀胱组容量高于回肠新膀胱组,而顺应性则低于回肠新膀胱组。此外。回结肠新膀胱组的上尿路扩张发生率为11．8％（2／17）,略高于回肠新膀胱组0（0／14）。结论：虽然回结肠新膀胱在近期能获得较大容量,但由于回结肠新膀胱顺应性较回肠新膀胱低,因而在获得满意的尿控和对上尿路的保护上,回肠新膀胱更具优势。     

Orthotopic ileocolic neobladder reconstruction following radical cystectomy: history, technique and results of the Johns Hopkins experience, 1986-1998

Reconstruction of the lower urinary tract using intestinal segments has become a standard component of the treatment of patients with bladder cancer. A variety of intestinal segments can be successfully used for this purpose. Between 1986 and 1998, the authors have used a composite ileocolic segment for neobladder reconstruction in patients desiring orthotopic reconstruction of the lower urinary tract. The early and late complication rates are 11% and 30%, respectively. Forty-five percent of men are potent postoperatively. Seventy-six percent of patients are continent both day and night. Three percent of our patients experience nocturnal enuresis, and 15% perform clean intermittent catheterization. Bothersome daytime stress urinary incontinence occurs in 3% of patients evaluated for this report. Although no contemporary studies demonstrate the superiority of a particular bowel segment for lower urinary tract reconstruction, the authors' long-term experience with the ileocolic neobladder suggests that this composite segment provides excellent results for lower urinary tract reconstruction after radical cystectomy.     

Orthotopic urinary diversion with the ileal neobladder

Orthotopic lower urinary tract reconstruction is the procedure of choice in appropriately selected men and women requiring cystectomy. Despite extensive experience with this technique, no consensus exists regarding which intestinal segment or reservoir configuration provides the best results. Consequently, various bowel segments and neobladder designs have been described. In 1988, Hautmann and colleagues initially described the ileal neobladder as a safe, reliable method of orthotopic urinary diversion. In this article, we describe our technique and experience with the modified ileal neobladder.     

Rectal gastrointestinal stromal tumor with metastasis to the penis: Case report and review of literature

We report the case of a 51-year-old gentleman with previously diagnosed gastrointestinal stromal tumor (GIST) of the rectum with metastasis to the penis. The patient underwent abdominoperineal resection of the primary tumor with negative margins and completed a three-year course of imatinib mesylate (Gleevec). Forty months after resection of his rectal tumor, the patient presented to his urologist with worsening testicular pain, mild lower urinary tract obstructive symptoms, and nocturia. A pelvic MRI revealed the presence of an ill-defined mass in the right perineum extending from the base of the penis to the penoscrotal junction. Biopsy of this mass was consistent with metastatic GIST. To our knowledge, this is the first report of metastatic GIST to the penis.     

Long-term results of standard procedures in urology: the ileal neobladder

Over the past 20 years orthotopic urinary reconstruction with the techniques developed at Ulm and Bern has become a widely accepted form of urinary diversion. So far, both centers together have performed more than 1,300 orthotopic bladder substitutions with an overall rate of neobladder formation in 58% of all cystectomized patients. Today, the absolute contraindications for this procedure are urinary stress incontinence, damaged rhabdosphincter, severely impaired renal and liver function, severe intestinal diseases or an oncologic situation requiring urethrectomy. In patients treated for transitional cell carcinoma of the bladder, the rate of urethral recurrence in both centers was 1.5 and 5%, respectively, and the rate of upper urinary tract recurrence was 2–3%. Local tumor recurrence usually did not affect neobladder function. The rate of outlet obstruction by local recurrence was 2%, that of gross hematuria 1%, and of entero-reservoir fistulas 1–2%. Daytime continence at 12 months was 92%, while nighttime continence was lower around 80%. Transient or permanent urinary retention was seen in 11–12% of male patients. In both series, long-term upper urinary tract safety was good. The risk of stenoses of the uretero-intestinal anastomosis with consecutive loss of renal function decreased with the introduction of non-refluxing implantation techniques. The rate of long-term metabolic complications remains low when adequate substitution with sodium bicarbonate is guaranteed in patients with impaired renal function. Patient selection and meticulous postoperative follow-up contributed to achieve good long-term results after cystectomy and orthotopic ileal neobladder substitution of the two large series of patients from the Universities of Ulm and Bern.     

机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱的临床疗效分析

目的探讨机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱患者的尿控和肿瘤学预后。 方法以2017年5月至2019年6月连续进行的10例机器人辅助根治性膀胱切除+回肠原位新膀胱术患者为研究对象，男9例，女1例，年龄（63±11）岁，极高危非肌层浸润膀胱癌5例，肌层浸润性膀胱癌5例；术后随访时间为12～37个月。记录手术视频、术后90 d内并发症、随访期间患者的尿控恢复、分肾功能、上尿路影像学结构改变以及肿瘤学预后。 结果10例患者均顺利完成全腹腔镜下机器人辅助根治性膀胱切除回肠原位新膀胱手术，手术时间（584±56）min，出血量（655±275）ml，术后进食时间1～3 d；1例患者术后6个月行切口疝修复术，其余无Ⅲ级以上并发症。5例（50%）患者术后6～12个月尿流动力学检查提示最大尿流率及平均尿流率分别为（6.3±4.5）ml/s、1.80（0.30）ml/s，术后新膀胱充盈尿量及残余尿量分别为（525±273）ml、161（227）ml，患者日间完全控尿9例（90%），夜间完全控尿8例（80%）。随访期间，发现4侧肾盂轻度扩张，监测分肾功能正常。1例患者术后18个月出现肺转移，其余患者未发现局部复发及转移。 结论"紫砂壶型"回肠原位新膀胱是在Studer型、VIP型回肠新膀胱基础上的储尿囊成型技术改进，术后新膀胱功能良好，能有效保护上尿路形态，恢复排尿功能。     

Management of tuberculous-contracted bladder with bilateral duplex collecting system: a case report with modified robotic urinary tract reconstructive surgery

Tuberculous bladder contracture with a bilateral duplicated collecting system is rare. According to anatomic variation, the surgical treatment strategy is highly individualized. We illustrate our robotic technique of urinary tract reconstruction. A 19-year-old girl with a history of pulmonary tuberculosis (TB) as a young child presented with a complaint of increasing frequency of micturition, nocturia, urgency, and urge incontinence starting at the age of 17. Clinical and imaging examinations demonstrated tuberculous contracted bladder with a bilateral duplex collecting system. The patient underwent a robot-assisted Institute of Urology Peking University (IUPU) orthotopic ileal neobladder reconstruction. This is a modified urinary tract reconstructive method, including resection of the end of the duplex ureters and diseased contracted bladder with preservation of the proximal urethra and bladder neck, ileal harvesting and IUPU strategy to reconstruct an ileal neobladder, uretero-ileal anastomosis and neobladder-bladder neck anastomosis. The patient remained symptom-free without recurrence of TB and had improved renal function during the one-year follow-up after surgery. Thus, our robot-assisted IUPU orthotopic ileal neobladder reconstruction method is an effective approach for this benign case. It can effectively increase bladder capacity, reduce intravesical pressure, and improve symptoms such as urination frequency and urgency.     

Replacement enterocystoplasty in man (except Hautmann): principles and technical considerations

Orthotopic urinary reservoir using a bowel segment has become the most favoured form of diversion after radical cystectomy. Ideal neobladder has to (i) store the urine with a low pressure bladder substitute, (ii) protect the upper urinary tract and (iii) provide a better quality of life enabling volitional voiding. A lot of techniques have bee described to construct a reservoir, however, all of them are based on the principle of intestinal loop detubulation. Many intestinal segments have been used, but ileum seems to be preferred in Europe. The upper urinary tract is mainly protected by a low neobladder pressure, rather than an additional antireflux flap-valve-type implantation technique which may increase the risk of uretero-enteric stricture. No significant difference in functional outcome can be observed among the several techniques. In selected cases, orthotopic bladder replacement is well tolerated and feasible and appears to be the gold standard after cystectomy.     

改良全膀胱切除-原位回肠新膀胱术治疗膀胱癌的临床疗效(附12例报告)

目的：评价改良全膀胱切除方法和原位回肠新膀胱术的临床疗效。方法：对12例膀胱癌患者行改良全膀胱切除术．顺行分离膀胱顶部、侧壁上半部、底部,切断输尿管后改逆行分离。示指紧贴前列腺包膜将前列腺与直肠分开后,向上向外将膀胱颈部侧韧带和精囊尾的纤维束钩于示指掌握之中,切断并结扎。女性患者保留内生殖器及尿道内口。尿流改道采用原位回肠新膀胱术,并就手术并发症、术后控尿排尿情况、新膀胱容量、影像学和生化检查进行随访,随访时间8～62个月,平均35个月。结果：切除膀胱时间平均80min,术中平均出血450ml。原位回肠新膀胱控尿、排尿良好,术后静脉尿路造影、B超检查未见上尿路扩张,膀胱造影未发现输尿管反流,血生化检查正常,未发现新膀胱或尿道肿瘤复发。结论：改良膀胱切除术-原位回肠新膀胱术是治疗浸润性膀胱癌的理想方法。     

Incidence and significance of positive urine cultures in patients with an orthotopic neobladder

PURPOSE: With an intact normal bladder bacterial colonization is uncommon unless intermittent catheterization is instituted. Because intestine, which is normally colonized with bacteria, is used to form an orthotopic neobladder, we determined whether patients with orthotopic urinary diversion are at increased risk for urinary tract infection and urosepsis. MATERIALS AND METHODS: A total of 66 patients who received an orthotopic neobladder after radical cystectomy were prospectively evaluated with urinalysis and culture 2 months to 4 years postoperatively. No patient was on suppressive antibiotics unless they had recurrent urinary tract infections. RESULTS: A total of 55 voided normally and 11 performed intermittent catheterization at least once daily due to high post-void residual urine. Of the patients who voided normally 78% had at least 1 positive urinalysis. If a patient had a positive urinalysis, bacteria was identified on culture in 50%. Overall 26 (39%) and 8 (12%) patients had a urinary tract infection and urosepsis, respectively. The estimated 5-year probability of urinary tract infection and urosepsis for patients who voided independently were 58% and 18%, respectively. Urine culture with greater than 100,000 cfu bacteria and female gender were the only factors predictive of urinary tract infection on multivariate analysis. Recurrent urinary tract infection was the only predictor for urosepsis. Intermittent catheterization or hydronephrosis was not related to urinary tract infection or urosepsis. CONCLUSIONS: The presence of small bowel intestine appears to promote asymptomatic bacterial colonization but urosepsis rarely occurs unless the patient has recurrent urinary tract infections. Prophylactic antibiotics are recommended only for patients with recurring urinary tract infections but treating a positive urinary culture in the absence of specific voiding symptoms is not advocated in this patient population.     

Onkologische Beckenchirurgie unter urologischen Gesichtspunkten

The aim of the treatment of invasive bladder cancer with radical cystectomy and subsequent urinary diversion is to combine a safe oncological procedure with a satisfactory quality of life. Radical cystectomy is the treatment of choice for all patients with recurrent or multifocal high grade T1 bladder cancer, T1 tumors with high risk of progression, failure of Bacillus Calmette-Guérin treatment and muscle-invasive bladder cancer. Radical cystectomy offers excellent recurrence-free and cancer-specific survival rates as well as local tumor control in patients with organ-confined and node-negative diseases. Tumor control in non-organ-confined tumors is still satisfactory with long term recurrence-free survival (RFS) rates of about 50%. Nerve-sparing cystectomy is of importance for lower urinary tract function, including continence rates after orthotopic urinary diversion and for sexual function in males and females. Orthotopic urinary reconstruction using a neobladder achieves good continence rates. Overall quality of life after radical cystectomy remains good in most patients irrespective of the type of urinary diversion.     

肠膀胱腺瘤1例报告并文献复习

目的：分析肠膀胱肿瘤的发病原因和诊治。方法：报告1例膀胱癌根治、直肠代膀胱、结肠造口术后8年肠膀胱发生绒毛状腺瘤伴高级别上皮瘤样变的临床资料,并复习相关文献予以讨论。结果：肠膀胱肿瘤多发生在肠膀胱术后10年,临床表现常为肉眼血尿,肿瘤多生长在输尿管一肠吻合缘,良性肿瘤行肿瘤电切术,预后良好。结论：肠膀胱肿瘤的发展过程中,肠膀胱经历了形态学和分子学的改变,较早诊断可获得较好的疗效,对肠膀胱术后的患者临床上应严密随访。     

改良腹腔镜根治性膀胱切除术加Studer原位回肠新膀胱重建初步研究

目的:总结11例腹腔镜根治性膀胱切除、标准淋巴结清扫加Studer原位回肠新膀胱重建的经验,评价此术式肿瘤学结果与功能性结果。方法:2008年7月～2011年5月,选择11例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除加下腹壁小切口行Studer原位回肠新膀胱重建术,对手术时间、淋巴结数量、围手术期并发症、出血量、输血量、生存率、上尿路形态与功能、控尿情况进行分析。结果:平均手术时间为6.17(5.5～7.5)h,平均出血量为300(0～800)ml,仅1例输血400ml,平均清扫淋巴结数15(5～30)个,无围手术期死亡,围手术期并发症发生率为18.19%(2/11)。上尿路检查,提示18.19%(2/11)术后拔出双J管后出现双侧肾盂及输尿管的轻度暂时性扩张,其中1例血肌酐上升。随访15(1～67)个月,1例鳞癌死于广泛转移,91%(10/11)无复发生存。患者日间完全控尿率达到90%(9/10);夜间完全控尿率70%(7/10),小于1块尿垫20%(2/10)。结论:选择适当病例行改良的腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行Studer原位回肠新膀胱重建术取得了满意肿瘤学与功能性结果;Studer原位回肠新膀胱顺向蠕动输入袢能够保护上尿路形态与功能。     

Jejunal GIST masquerading as an ovarian mass: A case report

Introduction and importanceGastrointestinal stromal tumors (GIST) are rare mesenchymal tumors originating in the wall of the gastrointestinal tract. Jejunal GIST is the rarest subtype. Large GIST can present with an abdominopelvic mass which can be preoperatively misdiagnosed as a gynecological tumor.Case historyA 44-year regularly menstruating woman presented with lower abdominal pain which was diagnosed as a malignant ovarian tumor preoperatively with an MRI. However, intraoperatively, a lobulated mass was present in the abdominal cavity arising from a jejunal portion of the small intestine. With an intraoperative diagnosis of jejunal GIST, the mass was excised and jejunum anastomosed. Histopathology examination report showed GIST which was further confirmed by immunohistochemistry.DiscussionGIST presenting as a large abdominopelvic mass can mimic a gynecological tumor. Contrast-enhanced CT scan is the preferred imaging modality for the evaluation of patients with suspected GIST to determine the extent of the tumor, the presence or absence of metastatic disease alongside evaluation of the possibility of complete resection. Adjuvant imatinib therapy following complete excision can decrease the disease recurrence.ConclusionGynecologists should keep in mind that primary gastrointestinal tumors can present as a pelvic mass. A proper histopathological examination helps to confirm the diagnosis. Complete surgical removal of the tumor should be obtained as it determines the prognosis of the disease.     

Orthotopic Lower Urinary Tract Reconstruction in Women Using the Kock Ileal Neobladder: Updated Experience in 34 Patients

Purpose

Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction at our institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients.

Materials and Methods

Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70).

Results

There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ.Complete daytime and nighttime continence was reported by 29 (88%) and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming.

Conclusions

The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy.     

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??Paying attention to several issues about endoscopic treatment of gastrointestinal stromal tumor ZHONG Yun-shi, QI Zhi-peng, SHI Qiang. Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
Corresponding author: ZHONG Yun-shi, E-mail: zhongamy2002@126.com
Abstract Gastrointestinal stromal tumor (GIST), a kind of relatively rare gastrointestinal tumor, is the most common mesenchymal tumors of the gastrointestinal tract. GIST originated from gastrointestinal muscularis propria and muscularis mucosae and can occur in any part of the digestive tract. GIST is not sensitive to radiotherapy or chemotherapy and complete surgical resection of GIST is considered to have curative effect. However, in recent years, endoscopic resection is increasingly accepted and has been applied to treat the local GIST without lymph node metastasis, owning to the techniques of endoscopic resection is safer, more effective, faster recovery with satisfactory surgical outcome.     

A case report of urinary reconstruction by ileal neobladder performed 16 years after total cystectomy for bladder cancer

We report a 59-year old male patient who successfully underwent urinary reconstruction by ileal neobladder that was performed 16 years after total cystectomy and ureterocutaneostomy for bladder cancer. He had been suffering from refractory contact dermatitis around the ureterocutaneostomy stoma and was referred to our hospital. In 2003, bilateral percutaneous nephrostomy was performed together with ureteral ligation at the most distal part. However recurrent pyelonephritis developed afterward because of nephrostomy catheter troubles and the patient's quality of life was markedly impaired. Then urinary reconstruction was planned in 2005. Because the urethra had not been resected and remained intact, ileal neobladder (Hautmann's method) was successfully created and he was free from nephrostomy catheter. Postoperatively there has been no recurrence of pyelonephritis. Long time insertion of nephrostomy catheter causes several complications, such as urinary tract infection and formation of urinary stones. To preserve renal function and improve quality of life, every chance for urinary reconstruction should be sought in those patients who suffer from upper urinary tract catheter troubles.     

Voiding dysfunction in the orthotopic neobladder

The orthotopic neobladder has become the preferred method of handling the urinary tract after removal of the bladder in men and women. However, an improved quality of life compared to urinary diversion fails to be realized when voiding dysfunction arises. These difficulties with urination range from retention to incontinence. Voiding dysfunction following neobladder construction that persists beyond 6–12 months warrants fluoro-urodynamic evaluation to determine the cause and plan therapy. Although colonic, ileocolonic, gastric, and ileal neobladders have all been deemed acceptable, the S or W-configured, spheroidal shaped neobladders created from ileum are the most popular. Voiding pressures and micturition patterns depend on the type, length, and configuration of bowel segment harvested. These variables also determine the risk of voiding dysfunction, along with the choice of surgical technique, and the age and sex of the patient. Urinary retention is more common in women, especially after urethral nerve sparing. Obstruction is often due to inferior displacement of the bladder neck, which can angulate the urethra. Daytime stress incontinence arises from reduced urethral outlet resistance accentuated by low neobladder capacity, reduced compliance, or elevated neobladder pressures. Night-time incontinence develops as a consequence of absent sensation that permits excessive nocturnal volumes to overcome the impaired continence mechanisms of the bladder outlet. This situation is exacerbated by the loss of physiological storage reflexes. Therapy for retention rests primarily with intermittent self-catheterization. Stress urinary incontinence can be treated with periurethral bulking agents or an artificial urethral sphincter. Nocturnal enuresis is often effectively managed by the use of an alarm clock to awaken the patient several times per night. Knowledge of the pathogenesis and identification of risk factors implies that prevention through proper design of the neobladder, meticulous surgical technique, and patient selection is paramount.     

Ileal neobladder and local recurrence of bladder cancer: patterns of failure and impact on function in men

PURPOSE: Creation of an ileal neobladder has become a standard procedure in patients undergoing cystectomy for invasive bladder cancer. We evaluated the impact of local recurrence on ileal neobladder function and survival. MATERIALS AND METHODS: Between April 1986 and February 1997, 357 men underwent radical cystectomy and ileal neobladder substitution at our institution. We retrospectively reviewed the records of these patients to determine patterns of local recurrence and survival rates. RESULTS: Local recurrence developed in 43 of the 357 patients (12%), in whom median survival plus or minus standard deviation was 17 +/- 1.6 months and median time to recurrence was 10 months (range 2 to 41). Of the 43 patients with local recurrence at followup 36 had local advanced cancer on the final pathological evaluation (stage pT3a or node positive, or greater). A total of 17 patients (43%) had concomitant distant metastasis. Of the 43 patients 3 are alive at 36, 48 and 147 months, respectively. Death was due to disease in 36 cases, chemotherapy related complications in 3 and another cause in 1. Of the 43 patients 40 maintained good neobladder function. Local recurrence interfered with the upper urinary tract in 24 cases, neobladder in 10 and intestinal tract in 7. The neobladder was removed only in 1 patient due to a neovesical intestinal fistula. CONCLUSIONS: The local recurrence rate after orthotopic urinary reconstruction is 12%. Survival after local recurrence is diagnosed is limited despite multimodality therapy. However, most patients may anticipate normal neobladder function even in the presence of recurrent disease or until death. Thus, creating orthotopic diversion after cystectomy in patients with locally advanced bladder cancer, including macroscopically or microscopically positive lymph nodes, is safe.