The natural history of condyloma in children

OBJECTIVES: To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion. METHODS: Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra). RESULTS: Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. CONCLUSIONS: We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.     

Pelvic exenteration for malignant melanomas of the vagina or urethra with over 3 mm of invasion

Pelvic exenteration has usually been employed as salvage treatment for gynecologic malignancies which have failed primary radiotherapy. The therapeutic mainstay for vulvar melanomas has become wide local excision with or without concurrent regional node dissection. Patients with primary melanoma of the vagina who undergo exenteration as primary therapy may experience 50% 5-year survival if the pelvic nodes are free of metastases. However, the overall 5-year survival for vaginal melanoma is 15%. In our patient population, there have been four patients with vaginal or urethral melanomas treated primarily with pelvic exenteration. The purpose of this study was to report that patients with vaginal or urethral melanomas over 3 mm in thickness may benefit from primary pelvic exenteration. Four patients underwent pelvic exenteration at Indiana University Medical Center for malignant melanoma of the vagina or urethra between 1986 and 1992. The pathologic specimens of all patients were analyzed for thickness, growth pattern, and nodal metastases. Patient age ranged from 50 to 71. Thickness of the melanomas ranged from > 3 to 12 mm. All four patients underwent exenterations, three total and one anterior. All patients had negative pelvic and inguinal nodes at the time of surgery. None of the patients has experienced a recurrence. Three of four patients are alive without evidence of disease at 31 to 97 months following their exenteration. One patient died postoperatively of cardiopulmonary complications. Patients with melanomas of the vagina and female urethra, greater than 3 mm in thickness, may benefit from primary pelvic exenteration.     

Genetic association of bovine lymphocyte antigen DRB3 alleles with immunological traits of Holstein cattle

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.     

The ileal neobladder to the female urethra

In the author's opinion, in the properly selected woman undergoing radical cystectomy for transitional cell carcinoma of the bladder, the ileal neobladder to the female urethra is a viable option. Ten years of experience with 23 patients have led to a nerve and urethral support cystectomy technique with the ileal neobladder anastomosed to the proximal urethra. Even then, however, retention in 20% of patients rather than the expected incontinence is the critical issue. Incontinence has never been a problem. The advent of orthotopic lower urinary reconstruction in women is a major achievement in the evolution of urinary diversion. With our increasing understanding of the continence mechanism in women and with increasing evidence that the female urethra can be safely preserved after cystectomy, orthotopic lower urinary tract reconstruction by the ileal neobladder can now be offered safely not only to men but also to women undergoing cystectomy with superb functional results.     

Does prostate transitional cell carcinoma preclude orthotopic bladder reconstruction after radical cystoprostatectomy for bladder cancer?

PURPOSE: We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death. MATERIALS AND METHODS: The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented. RESULTS: Of 81 patients 70 were evaluable (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death. CONCLUSIONS: The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

Urethral duplication in children: surgical treatment and results

PURPOSE: Urethral duplication is a rare congenital anomaly. We report the clinical presentation, imaging findings and surgical treatment in 7 boys with incomplete sagittal duplication of the urethra. MATERIALS AND METHODS: Duplication involved hypospadias in 5 cases (group 1) and a bifid urethra with an accessory preanal tract (Y duplication) in 2 (group 2). Group 1 was treated with 1-stage urethroplasty, including marsupialization of the dorsal orthotopic urethra, ventral-to-dorsal urethrourethrostomy and penile island flap onlay repair to cover the open dorsal urethra. In contrast, group 2 was treated with 2-stage urethral reconstruction with detachment and mobilization of the accessory preanal branch in association with a scrotal tubed neourethra followed by urethroplasty, as in group 1. In all cases the dorsal penile urethra was located between the corpora cavernosa and surrounded by the tunica albuginea. RESULTS: A urethrocutaneous fistula developed in 1 of the 5 group 1 patients. In group 2, 1 patient had recurrent penoscrotal meatal stenosis after the 1-stage procedure and 1 had a urethral diverticulum with calculi at the scrotal tubed neourethra 7 years after urethral reconstruction. Six of the 7 patients now void spontaneously through a meatus located normally at the tip of the glans. The remaining patient with a neurogenic bladder is on intermittent catheterization via appendicovesicostomy due to difficult catheterization of the irregular and sensitive neourethra. CONCLUSIONS: While the ideal surgical management of urethral duplication anomalies remains uncertain, we used a combination of surgical techniques to correct this severe malformation.     

Urethral reconstruction by pedicled labial flap in the treatment of extensive urethral lesions after obstetrical injury. Apropos of 34 cases

Reported here is our experience with a new procedure using a pedicled labial flap for urethral reconstruction in patients treated for extensive urethral damage after obstetrical injury. From January 1992 to January 1996, 31 cases of urethral damage in African female patients, with an average age of 18-years-old were treated by pedicled labial urethroplasty. This procedure was done by using a pedicled flap obtained from the major labia. The flap was then introduced as in a tunnel beneath the vaginal epithelium reaching the damaged urethra. A variety of techniques were used: the patch to lengthen sufficiency (13 cases), or the tubularized flap following complete reconstruction of the urethra (21 cases). Good quality urine continence was obtained by using the suburethral Martius' sling procedure. In 6 cases, we combined the treatment with a colposuspension procedure. The average follow-up is 14 months (ranging from 6 to 37 months). Recovery of normal micturition with absence of urinary leak was obtained in 21/30 cases (70%). While 5 moderate failures occurred, 4 cases were considered complete failures. In view of the high success rate, the authors consider that the one-stage procedure by the use of a pedicled labial flap is a choice treatment and highly suitable procedure for the management of extensive urethral cervical damage after obstetrical injury.     

The effect of urinary tract reconstruction on neurologically impaired women previously treated with an indwelling urethral catheter

PURPOSE: We investigated the changes in sexuality and quality of life that evolve after lower urinary tract reconstruction in neurologically impaired women previously treated with an indwelling urethral catheter. MATERIALS AND METHODS: A total of 18 neurologically impaired women treated with an indwelling urethral catheter underwent bladder reconstruction. Pubovaginal sling urethral compression was required to restore perineal dryness in 13 patients and was the only operation required in conjunction with intermittent catheterization in 3. Eight patients underwent ileocystostomy, that is creation of a "bladder chimney," and 4 underwent augmentation cystoplasty with creation of a continent catheterizable stoma. In 3 patients ileocystoplasty alone with intermittent urethral catheterization was performed. All patients were followed 6 to 40 months (mean 18) after reconstructive surgery using a 9-part questionnaire to score numerically the effect of surgical reconstruction on sexuality and quality of life issues. RESULTS: On a scale of 0 (worst) to 5 (best) mean score for self-esteem improved from 1 preoperatively to 4 postoperatively, self-image from 1 to 4, sexual desire from 2 to 4 and ability to cope with disability from 1 to 4, respectively. In 4 of the 15 women who were sexually active preoperatively the frequency of sexual intercourse doubled from a mean of 3 to 6 times per month, respectively, and all 4 women reported improved sexual satisfaction. All 13 patients with pelvic pain and 5 with symptoms of autonomic dysreflexia noticed significant improvement if not complete resolution of the symptoms. CONCLUSIONS: Neurogenic lower urinary tract dysfunction treated with an indwelling urethral catheter is detrimental to sexuality and quality of life in neurologically impaired women. Urinary tract reconstruction restores not only quality of life but also sexuality by improving self-image, self-esteem and the ability to cope. Indwelling catheterization as a method of long-term urinary treatment should be avoided in women.     

A transpubic approach for reconstructive surgery of genitourinary injuries and congenital malformations

Four children were operated on by the transpubic approach for injury to the vagina or urethra and to correct malformations within the pelvis minor. One boy had posttraumatic stricture of the urethra, and a girl presented with disruption of the urethra and vagina. One of two boys who had congenital malformations was treated for epispadias and incontinence; the other for a large urethral diverticulum caused by anal atresia. Total reconstruction was achieved, and no complications of symphysis restoration were observed.     

Echographic diagnosis of female urethral diverticulum

OBJECTIVE: To describe the utility of transrectal ultrasound as an alternative imaging technique in the diagnosis of diverticulum of the female urethra. METHODS/RESULTS: A 35-year-old female that had been initially diagnosed as having a benign tumor of the vagina is described. The voiding cystogram, positive pressure urethrography with a double balloon catheter and urethroscopy were falsely negative for urethral diverticulum of the female urethra. Subsequent evaluation by transrectal ultrasound disclosed on oval-shaped, anechoic lesion located posteriorly to base of the bladder. CONCLUSIONS: Transrectal ultrasound could be the diagnostic imaging technique of choice in patients suspected as having diverticulum of the female urethra.     

Transitional carcinomas of the urinary tract: synchronous and metachronous lesions

OBJECTIVE: The urothelium is a pseudostratified cylindrical epithelium that lines the calices, renal pelvis, urethers, bladder, part of the urethra and part of the prostate ducts. Transitional cell carcinoma (TCC) is a malignant neoplasia that can appear in any site where urothelium is present, being the bladder the most frequently affected organ. We performed an analysis of our experience and conducted a literature-based metanalysis to evaluate the coexistence of tumoral lesions at different locations in the urinary tract. MATERIAL AND METHODS: Between 1983 and 1993, 397 patients with TCC lesions involving the upper urinary tract (UUT), bladder, urethra or prostate, were diagnosed and treated. Coexistence, either synchronic or metachronic, of several lesions in different sites of the urinary tract was considered as a multiple tumor. RESULTS: Overall, 440 tumors were diagnosed in 397 patients. A single lesion appeared in 360 patients, while 37 presented multiple locations with a total of 79 tumors. The lesions were located at the following levels: 17 renal, 21 uretheral, 372 vesical, 13 in the urethra and 17 in the prostate ducts. According to the location, the frequency of single lesions was: UUT 58%, bladder 91%, urethra 8% and prostate ducts 35%. Synchronic UUT and intravesical tract tumors develops in 1% and 4% of patients with bladder TCC, respectively. Two percent of vesical tumors showed metachronic relationship with UUT tumors and the same rate was seen for intravesical lesions. CONCLUSIONS: Urothelial UUT tumors have a typical nosologic entity with specific features. Their coexistence with vesical tumors is frequent. When tumors of the bladder occur after a UUT tumor the interval of highest incidence between diagnoses is 2-3 years, and there are no histological risk factors among them for prognosis. Transitional cell prostatic urethral tumors are most often secondary to histologically similar, poor prognosis, bladder tumors, and usually synchronic.     

Comparative outcome analysis of laparoscopic colposuspension, abdominal colposuspension and vaginal needle suspension for female urinary incontinence

PURPOSE: The long-term surgical outcome of abdominal colposuspension, laparoscopic colposuspension and vaginal needle suspension for managing anatomical stress urinary incontinence in women was evaluated. MATERIALS AND METHODS: Three nonrandomized contemporaneous groups of 10 women each with anatomical stress urinary incontinence were treated with abdominal colposuspension, laparoscopic colposuspension or vaginal needle suspension. Immediate postoperative and subsequent outcomes were evaluated using a 10-point questionnaire annually up to 36 months. RESULTS: Immediately after surgery the laparoscopic colposuspension group required less analgesia as well as briefer catheterization and hospital stay. Continence rates 10 months postoperatively were 100% for the abdominal colposuspension group, 90% for the laparoscopic colposuspension group and 100% for the vaginal needle suspension group. At 36 months postoperatively these results had declined to 50, 40 and 20%, and satisfaction with surgical outcome was 60, 90 and 60%, respectively. CONCLUSIONS: Despite initially high success rates of these 3 surgical procedures based on the principle of retropubic suspension of the proximal portion of the urethra, responses to questionnaires given at longer postoperative intervals showed a sharp decline in success. We probably should redirect our treatment strategy for women with anatomical stress incontinence to include urethral coaptation and direct suburethral suspension.     

Experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma

We describe our experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma as an alternative to an indwelling catheter or supravesical diversion in 14 women and 4 men with various problems who could not perform intermittent urethral self-catheterization. The aim of management was also to provide, if possible, a competent urethra for additional access. Mean patient age was 37 years (range 22 to 75) and mean followup was 26 months (range 5 to 58). Preoperative management in the 11 wheelchair dependent women with neurological disease was an indwelling catheter in 7, urethral intermittent catheterization with the patient in the supine position in 3 and diapers in 1. Two women with a nonneurogenic bladder and a grossly incompetent urethra (1 after multiple incontinence and fistula repairs, and 1 after severe obstetrical trauma) wore diapers, while 1 with urinary retention and inability to perform self-catheterization had an indwelling catheter. The 4 men included 2 wheelchair dependent incontinent spinal cord injury patients who could not be managed with condom drainage, 1 with multiple anomalies who had trouble with self-catheterization, and 1 with an impassable postoperative stricture and a suprapubic tube. Surgery included anti-incontinence procedures in 10 patients and bladder neck closure in 3. A total of 15 patients required bladder augmentation in addition to the stoma and 3 had a stoma alone. Postoperative intervention was necessary in 4 women for stomal incontinence and in 2 of these bladder stones were removed simultaneously. One of these women was later treated for recurrent stones cystoscopically through the stoma. Overall, 17 of 18 patients are dry on intermittent stomal catheterization, with 1 lost to followup. We conclude that this procedure is a good alternative in patients with an end stage urethra or who cannot perform urethral catheterization because of physical disability. Establishing urethral continence and maintaining patency leaves a safety valve should the stoma fail. Since the bladder remains as a reservoir no ureteral surgery is necessary.     

New technique of vaginal reconstruction following anterior exenteration

Vaginal reconstruction is important in sexually active females undergoing anterior exenteration for malignant disease. We describe a technique for vaginal reconstruction used in two women who underwent radical cystectomy that required en bloc removal of the anterior vaginal wall. A polyglycolic acid mesh with a pedicle graft of greater omentum creates the anterior 270 degrees and the apex of the neovagina. The technique is simple and adds to the urologist's armamentarium of reconstructive procedures that improve quality of life following exenterative surgery.     

A new method of achieving total continence in vesico-urethro-vaginal fistula (circumferential fistula) with total urethral destruction--surgical technique

Twelve (12) cases of urethral reconstruction from the anterior bladder wall combined with primary urethropexy to achieve total continence in 67% circumferential fistulae in women is presented. These operations were performed transvaginally and the technique is described.     

ACL reconstruction in children with open physes

Flap reconstruction of the vulva and vagina following gynecological ablative procedures has become an integral part of the management of gynecological oncology patients. The benefits of flap reconstruction, including early primary healing, improved cosmesis over skin grafting, and prolonged secondary wound healing, have been well accepted. Additionally, the creation of a neovagina or neovulva often restores the sexual function and positive body image of the patient lost to radical procedures. The gracilis musculocutaneous flap has been used extensively in flap reconstruction but reports of partial flap necrosis and the need for extensive dissection of both thighs have led to alternative flap choices. The rectus musculocutaneous flap, with its hardier cutaneous blood supply, is often too bulky and difficult to inset delicately around the preserved urethral and vaginal cuff. The umbilicus has the required soft tissue, and its conically contoured depression allows for delicate insetting of the rectus abdominis musculocutaneous flap around the urethral cuff. We present 2 patients who underwent vertical rectus musculocutaneous flaps with umbilical soft tissue to restore urinary function and to create a cosmetic nonfunctional vagina.     

Membrano-bulbo-urethral junction stenosis. Posterior urethra obstruction due to extreme caliber disproportion in the male urethra

OBJECTIVE: Based on 4 cases of infravesical obstruction due to extreme caliber disproportion between the posterior urethra and the penile urethra, a pathophysiological mechanism for this dynamic obstruction is given and endoscopic treatment is described. SUBJECTS: Four cases of membrano-bulbo-urethral junction (MBUJ) stenosis, seen between September 1995 and April 1996, are described. Two boys had previous successful valve resection but still showed extreme ballooning of the posterior urethra. The other 2 boys showed bladder instability on urodynamics and the male variant of the spinning top urethra on voiding cystourethrography (VCUG). RESULTS: All cases were successfully treated by endoscopic incision at the 12 o'clock position of the kink between the posterior and the penile urethra which is seen when the full bladder is expressed. Disproportion in the posterior urethra, seen on VCUG, together with bad urinary flow measured on uroflowmetry raise the suspicion of MBUJ stenosis. CONCLUSION: Although rarely seen, extreme caliber disproportion in the male urethra can cause obstruction. Ballooning of the posterior urethra, caused by urethral valves, bladder instability resisted by voluntary sphincter contraction or congenital posterior urethral dilatation, creates an obstructive kink in the urethra comparable to some obstructions in ureteropelvic junction stenosis. If suspicion of such a form of obstruction arises, cystoscopy during pressure on the full bladder is mandatory in order to see the obstruction, descending as a membrane from the vault of the urethra.     

Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study

PURPOSE: The impact was determined on post-prostatectomy urinary incontinence of a technique preserving the anterior attachments of the proximal urethra to the posterior pubis by comparison to the results of other surgical methods. MATERIALS AND METHODS: Urinary continence in 51 patients undergoing preservation of the anterior urethral attachments was compared to that of 70 patients undergoing an anatomical prostatectomy with resection of the bladder neck, 55 patients with preservation of the bladder neck and 14 patients undergoing a dorsal vein gathering procedure. Comparisons were made for rate of total continence, time to return of continence, incidence of extra organ disease and operative blood loss. RESULTS: Total continence at 1 year was 84.3%, 89.1%, 85.7% and 100% respectively. Immediate total continence after catheter removal was seen in 25.5% after preservation of the anterior urethral attachments, 80.4% at 3 months compared to 41.4%, 50.9% and 50% at 3 months for anatomical prostatectomy with bladder neck resection, preservation and dorsal vein gathering. Clinical staging with the incidence of specimen confined disease was similar in all groups. Mean operative blood loss was 1,031 ml. for those patients undergoing anatomical prostatectomy compared to 681 ml. for those with preservation of the anterior urethral attachments. CONCLUSIONS: Preservation of the anterior urethral attachments results in improved urinary continence and lower operative blood loss without an increase in positive surgical margins.     

Transrectal sonography in the assessment of vaginal pathology: a preliminary study

PURPOSE: We assessed the value of transrectal sonography (TRUS) in the diagnosis of vaginal abnormalities. METHODS: Six women between 16 and 77 years old underwent TRUS with a biplanar probe equipped with 5-MHz axial sector and longitudinal linear transducers. Sagittal and axial images of the bladder, vagina, and urethra were obtained. Sonographic findings were compared with those from surgery. RESULTS: TRUS showed hematocolpos in 3 patients and cysts in 3 patients. Surgery confirmed the findings. Pathologic examination revealed 2 Gartner's cysts and 1 vaginal inclusion cyst. CONCLUSIONS: TRUS represents a valid diagnostic tool for the assessment of vaginal abnormalities because it accurately visualizes lesions and clearly shows anatomic relationships.     

Metabolism of quinine in children with global malnutrition

OBJECTIVE: To evaluate the frequency, predictive parameters and prognosis of urethral recurrence after cystoprostatectomy for urothelial bladder cancer. MATERIAL AND METHODS: From 1989 to 1994, 8 of a series of 185 patients (4.3%) treated by cystoprostatectomy for bladder carcinoma between 1988 and 1993 developed urethral recurrence revealed by urethral bleeding, with a follow-up of 6 to 36 months (m = 16). RESULTS: The initial bladder tumour was localized in 3 cases and multifocal in 5 cases. The posterior urethra was not involved in 5 cases, but presented lesions of CIS in 1 case and neoplastic infiltration also involving the prostate in 2 cases. These recurrences were treated by urethrectomy, as first-line treatment in 7 cases and after failure of endoscopic treatment in 1 case. A balanic recurrence required distal penectomy following insufficient urethral resection. The course was very rapidly unfavourable for 3 patients with generalized cancer and an intercurrent disease was fatal in 1 other case. With a follow-up of 12 to 44 months (m = 26), 4 patients are alive with no obvious signs of disease progression. CONCLUSION: The indications for prophylactic urethrectomy can be reserved to patients with positive urethral resection margins, provided all other cases are submitted to strict surveillance. In the context of a replacement bladder, it is essential to exclude neoplastic involvement of the posterior urethra or prostate, especially in patients previously treated by intravesical instillations.