Management of invasive carcinoma of bladder and abdominal aortic aneurysm (AAA); technique of radical total cystectomy and simultaneous AAA repair

BACKGROUND: There is no consensus on the optimal surgical treatment for patients with concomitant invasive carcinoma of bladder and abdominal aortic aneurysm (AAA). We experienced two patients who were treated successfully with simultaneous radical cystectomy and AAA repair. The techniques required for the combined procedure and case reports are discussed. PROCEDURE: The goal of the one-stage operation was to minimize the risk of graft infection without compromising postoperative morbidity and mortality secondary to carcinoma of bladder. Initially pelvic lymph node dissection and radical cystectomy were performed. We preferred retrograde cyctoprostatectomy because most of the cystectomy procedure can be performed without opening the peritoneal cavity and the extent of the retroperitoneal dissection can be minimal. A single-stoma ureterocutaneostomy was preferable urinary diversion. Urinary diversions which utilize intestine such as ileal conduit or ileal urinary reservoir may cause contamination of a graft with bowel content and should be avoided. Before or after urinary diversion, aneurysmal resection and a bifurcated graft replacement were performed. The replaced graft was wrapped with the aneurysmal wall. The major omentum was mobilized and fixed in front of the graft, thereby serving as a protective barrier of the graft. A Dacron graft which was sealed with rifampicin-bonding gelatin was used to further reduce the risk of graft infection. RESULT: Two male patients were treated with the one stage radical cystectomy and AAA repair. Single-stoma ureterocutaneostomy and bilateral ureterocutaneostomy were selected as a urinary diversion. No major postoperative complications, except for paralytic ileus in one case, were observed. CONCLUSION: Our experience and reports of others indicate that radical cystectomy and simultaneous AAA repair can be safely performed with less morbidity than staged operations for the management of concomitant invasive carcinoma of bladder and AAA.     

Repair of complex ureterovaginal and vesicovaginal fistulas with ileal cystoplasty and ureteric reimplantation into an antireflux ileal nipple valve--a case report

We report a case of a 59-year-old woman with bilateral ureterovaginal and vesicovaginal fistulas after radical total hysterectomy and bilateral salphingo-oophorectomy who failed transvesical repair of the vesicovaginal fistula. The bladder was extensively scarred, half of which had to be excised. This was replaced with an ileal cystoplasty with an antireflux ileal nipple valve into which the ureters were reimplanted. Continuity of the urinary tract was re-established without a urinary diversion or stoma.     

Proposal for using mechanical staplers with Polysorb in creation of orthotopic neobladder

After radical cysto-prostatectomy the bladder substitute is made from an ileal segment, opened along its antimesenteric border and folded; the results are in general good. The success of this procedure demands attention to detail, hemostasis and gentle handling of tissue so this surgery depends an unusual degree of commitment to meticulous technique. The very low rate complications, obtained with mechanical sutures in gastrointestinal surgery, incited the Authors using the staplers GIA and TA Polysorb for detubularized ileal segment. They are very manageable, easy to use and the follow-up shows the absence of urinary stone; so the team approach is less tedious and strenuous. The Authors present their results of 11 neobladder-staplers made with 35 cm of detubularized ileal segment without folding.     

Chromosome 16 in primary prostate cancer: a microsatellite analysis

OBJECTIVES: To evaluate whether orthotopic urinary diversion is a viable option for patients undergoing cystoprostatectomy for radio-recurrent prostate cancer (RRPC). METHODS: Between 1990 and 1996, we performed 34 salvage surgeries for RRPC, including 26 radical retropubic prostatectomies and 8 cystoprostatectomies. We determined the operative and postoperative complication rates and pathologic stage for the 8 patients undergoing cystoprostatectomy. RESULTS: Of the 8 patients in whom cystoprostatectomy was performed, 5 underwent ileal conduit diversion and 3 underwent orthotopic neobladder reconstruction. There were no intraoperative complications or perioperative mortalities. In the group with orthotopic neobladder, postoperative complications included pyelonephritis in 1 patient and prolonged ileus in another. In the group with ileal conduit, no short-term complications occurred; 1 patient developed an incisional hernia on long-term follow-up. All patients with neobladder reconstruction are continent during the day. One patient wears one pad at night. The other 2 are continent at night. CONCLUSIONS: Orthotopic urinary diversion is a valid option for selected patients with RRPC who require a cystoprostatectomy. This procedure can be performed with minimal complications, resulting in good continence and good quality of life.     

Complications of the afferent antireflux valve mechanism in the Kock ileal reservoir

PURPOSE: Since 1982 the Kock ileal reservoir has been the primary form of urinary diversion in patients requiring lower urinary tract reconstruction at our institution. The intussuscepted afferent nipple valve of the Kock ileal reservoir is designed to prevent reflux and protect the upper urinary tract. Problems associated specifically with the afferent antireflux valve have been few. We defined and characterized all complications associated with the Kock pouch antireflux nipple valve. MATERIALS AND METHODS: From November 1984 through July 1992, 802 patients underwent construction of a continent Kock ileal reservoir. All complications associated with the afferent antireflux valve in this group and their management were identified. RESULTS: Overall, 79 of 802 patients (9.8%) had a total of 84 complications of the afferent antireflux valve (10.4%), including formation of stones on staples securing the afferent nipple valve in 42 cases (5.2%), stenosis of the afferent valve in 35 (4.3%) and prolapse of the valve in 7 (0.9%). A total of 81 patients required surgical intervention to correct the afferent valve complication: 56 (7.0%) were treated endoscopically and 25 (3.1%) required open surgical revision. CONCLUSIONS: We report an overall complication rate of 10.4% associated with the afferent antireflux nipple valve in the Kock ileal reservoir. Most complications can be treated endoscopically without difficulty on an outpatient basis with the use of local sedation. With these results, and only a 3% incidence of open surgical correction of all afferent nipple problems, we encourage the continued use of the intussuscepted afferent nipple valve whenever continent urinary diversion is performed.     

Bone density and skeletal metabolism in patients with orthotopic ileal neobladder

The interposition of a bowel segment as a bladder substitute into the urinary tract may result in impaired calcium metabolism. We studied 25 male patients (aged 45 to 77 yr) who had undergone a Vescica Ileale Padovana (VIP) reconstruction following cystectomy 29 to 75 mo before. Bone mineral density of the spine and femur was measured by dual x-ray absorptiometry. Blood and 24-h urine samples were analyzed for the main parameters of bone metabolism. Sixteen healthy men were enrolled as a control group. Although blood pH did not differ between patients and control subjects, VIP subjects showed lower levels of plasma HCO3- (P < 0.005) and higher serum chloride (P < 0.001). Bone alkaline phosphatase was higher (P < 0.001), and urine calcium, phosphate, and creatinine levels were lower in VIP patients (P < 0.01, P < 0.01, and P < 0.05, respectively). Bone mineral density at the femoral neck (P < 0.03) and Ward's triangle (P < 0.05) was decreased in VIP patients. When subdivided according to time since operation, patients who had the ileal neobladder implanted for a shorter period of time showed lower blood pH (P < 0.03) and urine calcium (P < 0.05) levels and higher urinary hydroxyproline (P < 0.02). Duration of the ileal neobladder was positively correlated with PTH (r = 0.46, P < 0.03) and blood pH (r = 0.47, P < 0.02). Furthermore, pH values were positively correlated with urine calcium (r = 0.48, P < 0.02). In conclusion, in patients with ileal neobladder, a mild metabolic acidosis is responsible for an increased bone turnover and lower bone mass. Moreover, a decrease over time in the absorption capacity of the ileal pouch might result in calcium malabsorption, which represents an additional risk factor for reduced bone mass in these patients.     

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.     

Malone antegrade continence enema for adults with neurogenic bowel disease

PURPOSE: We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS: Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS: Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS: Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Selective bladder preservation by combination treatment of invasive bladder cancer

BACKGROUND: For patients with invasive bladder cancer the usual recommended treatment is radical cystectomy, although transurethral resection of the tumor, systemic chemotherapy, and radiotherapy are each effective in some patients. We sought to determine whether these treatments in combination might be as effective as radical cystectomy and thus might allow the bladder to be preserved and the cancer cured. METHODS: We enrolled 53 consecutive patients with muscle-invading bladder cancer (stages T2 through T4, NXM0) in a trial of transurethral surgery, combination chemotherapy, and irradiation (4000 cGy) with concurrent cisplatin administration. Urologic evaluation of the tumor response directed further therapy: radical cystectomy in the 8 patients who had incomplete responses, additional chemotherapy and radiotherapy (6480 cGy) in the 34 patients who had complete responses or who were unsuited for cystectomy, and alternative care in the 11 patients who could not tolerate either irradiation or chemotherapy. RESULTS: After a median follow-up of 48 months, 24 of the 53 patients (45 percent) were alive and free of detectable tumor. In 31 patients (58 percent) the bladder was free of invasive tumor and functioning well, even though in 9 (17 percent) a superficial tumor recurred and required further transurethral surgery and intravesical drug therapy. Of the 28 patients who had complete responses after initial treatment, 89 percent had functioning tumor-free bladders. CONCLUSIONS: Conservative combination treatment may be an acceptable alternative to immediate cystectomy in selected patients with bladder cancer, although a randomized clinical trial that included a group for simultaneous comparison would be required to produce definitive results.     

Urinary 1-hydroxypyrene concentrations in coke oven workers

We analyzed the long-term results and the quality of life in patients who received orthotopic lower urinary tract reconstruction using the Kock ileal neobladder. Between July 1990 and October 1993, 37 consecutive patients including 2 females received orthotopic hemi-Kock neobladder after radical cystectomy. In these patients, we analyzed the urinary continence, complications and urethral recurrence, and performed a questionnaire survey by mail. Good continence all day had been achieved in 71% of the patients 4 years after surgery. The rate of the pouch-related complications requiring reoperation was 27%. There was no urethral recurrence. Compared with preoperative conditions, 42% were not satisfied with urination. In these dissatisfied patients, the need to use pads in the daytime, sensation of residual urine and weak urine stream were significantly more frequent than in satisfied patients. In summary, the rate of complications was higher than that of other methods. However, the Kock orthotopic ileal neobladder is a stable procedure providing good function over the long-term.     

Amyloid beta-peptides inhibit Na+/K+-ATPase: tissue slices versus primary cultures

BACKGROUND: Urinary bladder augmentation is gaining popularity for the treatment of dysfunctional bladders in renal transplant patients. Although reported cases of adult and pediatric transplants into the augmented bladder have been favorable, the potential risk of urinary tract infection and graft failure under immunosuppression is still disputable. We report our experiences with 4 patients who underwent renal transplantation into an augmented bladder. METHODS: Between 1971 and 1996, 1275 renal transplants were performed at our institution. Of these transplants, 4 patients underwent renal transplantation into an augmented urinary bladder. Augmentation cystoplasty was performed before transplantation in 3 patients and 7 years after transplantation in the other patient. The bladder was augmented with an ileal segment in 3 patients and a ureter in the fourth patient. Graft function was assessed by the serum creatinine level. Fluorocystometrograms were performed in all patients at fixed intervals. RESULTS: Posttransplant renal function was satisfactory overall and no patient exhibited proteinuria. All patients except 1 acquired a large capacity low pressure bladder and remained continent with clean intermittent catheterization. One patient who underwent ureterocystoplasty is still incontinent because of his relatively small bladder capacity. Posttransplant pyelonephritis was documented in 3 patients during the follow-up period, but no other complications were observed. CONCLUSIONS: Our study demonstrates that renal transplantation into extensively reconstructed bladders can be safely performed with good success. Although urinary tract infection is a major consideration, we recommend pretransplant reconstruction not only to preserve graft function, but also to achieve urinary continence.     

Decreased sensitivity in the membranous urethra after orthotopic ileal bladder substitute

PURPOSE: The effect of cystoprostatectomy with orthotopic substitution on membranous urethral sensation and subsequent urinary continence is unknown. We determined the sensory threshold for electrical stimulation of the membranous urethra and correlated it with continence, nerve sparing surgical technique and potency. MATERIALS AND METHODS: The sensory threshold was measured in a control group of 35 men before radical prostatectomy or cystoprostatectomy and in 47 men after cystoprostatectomy and ileal bladder substitution. RESULTS: The sensory threshold of the membranous urethra was 9+/-2 in the control group compared to 27+/-11 mA. in the postoperative group (p<0.001). Patients with daytime continence had a threshold of 24+/-9 compared to 39+/-10 mA. in incontinent patients (p<0.001). We were unable to show any correlation between the sensory threshold in patients with (25+/-10 mA.) and without (31+/-11 mA.) attempted nerve sparing surgery (p = 0.1) nor between potent (25+/-12 mA.) and impotent (27+/-11 mA.) patients (p = 0.4). CONCLUSIONS: Sensitivity in the membranous urethra decreased in patients after cystoprostatectomy and ileal bladder substitution. Urethral sensitivity in the sphincter area was better in continent than incontinent patients. Since we were unable to find any correlation between the sensory threshold and nerve sparing surgery or potency, it may be assumed that at least part of the sensory fibers to the membranous urethra pass through the pudendal nerve and/or the intrapelvic extrapudendal nerve fibers.     

Impact of the prostatic apex on continence and urinary flow in patients with intestinal neobladders

OBJECTIVE: To determine the impact of preserving the prostatic apex on continence and urinary flow in patients with post-cystectomy intestinal bladder substitutes. PATIENTS AND METHODS: A total of 38 male patients underwent radical cystectomy for bladder carcinoma and construction of a neobladder from ileum [9], sigmoid [9] or an ileocaecal segment [20]. The intestinal reservoir was anastomosed to the membranous urethra in 25 patients and to the apical prostatic capsule in 13. A subjective evaluation of urinary continence, uroflowmetry and urethral pressure profilometry were performed 1-3 years after surgery. RESULTS: The only variable which showed a significant difference between patients with and without preservation of the prostatic apex was the functional profile length (P < 0.05). Conversely, there was no statistically significant difference in the continence result, peak flow rate and maximum urethral pressure between these two groups. However, there was a significant difference (P < 0.05) in peak flow rate among the three versions of neobladder in patients with a preserved prostatic apex (9.4 mL/s in ileal vs 15.8 mL/s in sigmoid and ileocaecal segments). CONCLUSION: Preservation of the prostatic apex does not improve urinary continence in patients with intestinal neobladders and may present an element obstructing the evacuation of ileal bladders.     

Neoadjuvant chemotherapy and bladder-sparing surgery for invasive bladder cancer: ten-year outcome

PURPOSE: To evaluate the 10-year outcome of patients with invasive (T2-3N0M0, staged according to the tumor, node, metastasis system) bladder cancer who responded completely to a combination of methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) chemotherapy followed by bladder-sparing surgery. PATIENTS AND METHODS: Of 111 surgical candidates who received neoadjuvant MVAC, 60 (54%) achieved a complete clinical response (T0) on transurethral resection (TUR) of the primary tumor site. Of these, 28 requested follow-up with TUR alone, 15 had a partial cystectomy, and 17 elected a radical cystectomy. The patients were followed up for a median of 10 years (range, 8 to 13 years). RESULTS: Of 43 patients who had bladder-sparing surgery, 32 (74%) are alive, which includes 25 (58%) with an intact functioning bladder. Twenty-four patients (56%) developed bladder tumor recurrences from 5 to 96 months, which were invasive in 13 (30%) and superficial in 11 (26%). Thirteen patients required a salvage cystectomy, of whom 6 died, which includes 4 (9%) from a new invasive neoplasm. Of the 17 patients who had radical cystectomy, 11 (65%) are alive. CONCLUSION: The majority of patients with invasive bladder tumors who achieve T0 status after neoadjuvant MVAC chemotherapy preserve their bladders for up to 10 years with bladder-sparing surgery. The bladder remains at risk for new invasive tumors. Cystectomy salvages the majority, but not all, of relapsing patients.     

Ureteroileal anastomotic strictures: an innovative approach with metallic stents

PURPOSE: We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion. MATERIALS AND METHODS: We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months. RESULTS: No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement. CONCLUSIONS: We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.     

Experience with the Mainz modification of ureterosigmoidostomy

BACKGROUND: The purpose of this study was to report experience with the revived surgical concept of ureterosigmoidostomy in its low pressure modification and to discuss its value within the current spectrum of urinary diversion. METHODS: Between February 1992 and September 1997 modified ureterosigmoidostomy (rectosigmoid pouch; Mainz pouch II) was performed in 34 patients aged 1.9-76.9 (mean 55.8) years as a primary urinary diversion after radical cystectomy for bladder cancer (n = 30) and benign conditions (bladder exstrophy, three patients; intractable urinary incontinence, one). All patients were followed prospectively according to a standard protocol including assessment of continence, renal function and acid-base balance. RESULTS: There were no perioperative deaths. In one patient dislocation of a ureteral stent in the early postoperative course required insertion of a percutaneous nephrostomy. All patients were continent during the day. One patient experienced night-time incontinence but rejected a conversion procedure. In one case ureterosigmoidostomy was replaced by an ileal conduit after several episodes of septicaemia. One nephrectomy was performed for ureterointestinal obstruction. Mild hyperchloraemic acidosis was seen in two patients. CONCLUSION: Bowel frequency and urge incontinence, the major weaknesses of classical ureterosigmoidostomy, can be overcome by detubularization of the rectum. As the modified procedure is quick, safe and easy to perform with highly satisfactory results, the rectosigmoid pouch has potential in reconstructive urology.     

Vascular access survival among incident hemodialysis patients in the United States

OBJECTIVES: To investigate: (i) if early psychosocial intervention after cystectomy for bladder cancer can assist psychosocial rehabilitation; (ii) if the outcome of such intervention correlates with the patient's psychological defensive strategies as revealed with the meta-contrast technique (MCT); and (iii) if the patient's general philosophical outlook is important in this context. PATIENTS AND METHODS: Of 50 patients who had undergone radical cystectomy for bladder cancer, 17 received an ileal conduit, 17 a continent urinary reservoir with abdominal stoma and 16 an orthotopic neobladder. Twenty-four of the patients were randomized to psychosocial intervention, comprising weekly counselling 4-9 weeks after surgery. All patients were then evaluated with the Sickness-Impact Profile (SIP) standard questionnaire and the MCT (a projective test of percept-genetic model) was used to reflect individual defensive strategies at the subconscious or unconscious level. The patient's general philosophical outlook was recorded before and after surgery. RESULTS: There was no significant difference in the results of the SIP between the intervention and the non-intervention group, as a whole or in its psychosocial dimension. However, intervention benefited patients with continent cutaneous diversion, whose scores on the psychosocial SIP dimension were lower than in the groups with ileal conduit diversion or orthotopic bladder replacement (P < 0.05). The MCT analysis of defensive strategies identified three clusters of patients characterized mainly by isolation and repression, repression and stereotypy or sensitivity and stereotypy. Analysis for cluster identification showed no significant SIP score differences between intervention and non-intervention groups. In an analysis of single defensive strategies, stereotypy was associated with higher total SIP score, but not significantly. Three clusters of philosophical outlook were identified; in one cluster, characterized by a belief in a supernatural power and philosophical interest, the psychosocial SIP scores were lower in the patients who obtained emotional support and the reverse in a cluster with contrary attitudes, although neither differences were significant. CONCLUSION: Psychosocial intervention assisted the psychosocial rehabilitation of patients with continent cutaneous urinary diversion. Defensive strategies and philosophical outlook generally did not influence the outcome of intervention. However, such programmes may be helpful for some patients, mainly those with a basically pessimistic disposition, a general interest in philosophical questions and often using defensive strategies of stereotypy and repression.     

Compare and contrast

We report a patient with squamous cell carcinoma that developed at the ureteroileal anastomosis and extended into the ileal conduit 11 years after a radical cystectomy for transitional cell carcinoma of the bladder. To our knowledge, this is the first report to document the development of a squamous cell carcinoma in an ileal conduit after a radical procedure for bladder cancer.     

Body composition changes measured by dual-energy X-ray absorptiometry in patients receiving home parenteral nutrition

Some patients with infiltrant vesical cancer can be treated successfully with radical cysto-prostatectomy and urinary by-pass and increasingly more authors publish successful results in series of selected patients over 70- and 80-year old. Between February 1988 and July 1996, 18 radical cystectomies with orthotopic urinary by-pass were performed in the Urology Service, Policlinico Vigo, in patients over 70 (range 70-84 years), with an operative mortality rate of 11%. 8 patients (44%) developed immediate complications and 9 patients (50%) presented distant complications. Overall mortality in our series was 33.3% and survival 66.6% after a mean follow-up of 30.7 months. We believe orthotopic-continent by-pass is a valid alternative with operative mortality and complication rates similar to those of ileal ducts, with the advantage for the patient of avoiding permanent urinary stoma.     

Primary, pure, large-cell neuroendocrine carcinoma of the urinary bladder

We report what to our knowledge is the first case in the English-language literature of a primary, pure, undifferentiated large-cell neuroendocrine carcinoma of the urinary bladder. To date, only one case of a large-cell neuroendocrine carcinoma was reported, and it was associated with an adenocarcinoma most likely of urachal origin. On the other hand, slightly more than 100 cases of undifferentiated small-cell carcinoma of the urinary bladder were reported, approximately one-half of which were associated with poorly differentiated transitional-cell carcinoma of the conventional type. The patient in our case was a 73-year-old man with a history of prostatic cancer treated with radiation therapy. He presented with hematuria, leading to the discovery of a solitary tumor on the dorsal wall of the urinary bladder. A diagnosis of large-cell neuroendocrine carcinoma was made, supported by immunohistochemical reactivity for chromogranin, neuron-specific enolase, and synaptophysin; a variety of other hormonal markers of neuroendocrine tumors were negative. The radical cystoprostatectomy and bilateral pelvic lymphadenectomy specimen showed a transmurally invasive tumor, without regional lymph node metastases. The patient died 2 months after surgery, and the autopsy revealed disseminated metastases histologically identical to the urinary bladder neoplasm. Awareness of the occurrence of large-cell neuroendocrine carcinoma of the urinary bladder seems to be important because of the possible aggressive outcome associated with this tumor and because of differential diagnostic considerations, which include malignant lymphoma and metastasis from another primary, especially in tumors occurring in a pure form.