Purpose: To review biochemical relapse-free survival (bRFS) rates after either external-beam radiotherapy (RT) or radical prostatectomy (RP) for localized prostate cancer. Patients and Methods: All 1,682 patients had pretreatment prostate-specific antigen (PSA) levels and biopsy Gleason scores (bGS) assigned. No adjuvant therapy was administered after local treatment. RP was the treatment in 1,054 patients (63%) and RT in 628 patients (37%). Median follow-up was 51 months (range, 1 to 134). The median follow-up for RP versus RT patients was 50.5 v 51.0 months. Biochemical relapse was considered detectable PSA levels (> 0.2 ng/mL) in RP patients and three consecutive rising PSA levels in RT patients. The analysis was repeated with a more stringent definition of biochemical control after either RP or RT—namely, reaching and maintaining a PSA level < 0.5 ng/mL—and excluding patients receiving any androgen deprivation (AD). Results: Eight-year bRFS rates for RP versus RT were 72% and 70%, respectively (P .010). Multivariate analysis indicated T stage (P < .001), pretreatment PSA (P < .001), bGS (P < .001), year of therapy (P < .001), and neoadjuvant AD (P .019) to be the only independent predictors of relapse. Age (P .78), race (P .29), prior transurethral resection of prostate (P .81), and treatment modality (P .96) were not independent predictors of treatment failure. Fifty-one percent of RP patients had favorable tumors (T1 to T2A, pretreatment PSA < 10 ng/mL, bGS < 7), compared with only 34% of RT patients (P < .001). Repeat analysis with a stringent definition of biochemical failure and excluding patients receiving AD indicated no impact of treatment modality on outcome. Conclusion: Eight-year biochemical failure rates were identical between RT and RP in any subgroup. Outcome is determined mainly by pretreatment PSA levels, bGS, clinical T stage, and, for RT patients, radiation dose. J Clin Oncol 20:3376-3385. © 2002 by American Society of Clinical Oncology.

OBJECTIVE:To evaluate the long-term potency after radical prostatectomy (RP) with the early use of a vacuum erection device (VED), and reasons for sexual inactivity and long-term attrition and maintenance of sexual activity, as RP is one of the most common treatments for prostate cancer but erectile dysfunction (ED) is a common side-effect.PATIENTS AND METHODS:We identified 141 sexually active patients who underwent RP at Cleveland Clinic Foundation. Patients were offered various non-oral treatment options to prevent ED and were also motivated for early penile rehabilitation. At 5 years 62% remained sexually active, of whom 71% had natural erections sufficient for intercourse without assistance, 8.5% were still using sildenafil, 10% were using combined therapy (sildenafil plus VED). At 5 years 38% (43/113) men were sexually inactive. The reasons included loss of interest in 17 (40%), cardiovascular/neurological diseases in 18 (42%), hormonal therapy in three (7%), loss of partner in three (7%) and two had other surgery. The natural rate of erections for sufficient vaginal penetration without an erection aid were preserved and maintained in the early-prophylaxis group, and almost 60% of them had used a VED as early prophylaxis.CONCLUSION:Despite current phosphodiesterase-5 inhibitor treatments for ED, VED is becoming recognized again as having a primary role in early penile rehabilitation in many patients, specifically those treated for prostate cancer.

65 Background: To examine gastrointestinal (GI) and genitourinary (GU) toxicity profiles of patients treated in 1999 with external beam radiotherapy (RT), prostate interstitial brachytherapy (PI) or radical prostatectomy (RP). Methods: The records of 483 patients treated in 1999 were retrospectively reviewed to evaluate toxicity profiles, with 24% of the patients treated with PI, 40% with RP, and 36% with RT. Late GI and GU morbidity profiles were specifically examined and both were graded according to the RTOG acute and late morbidity scoring criteria. Other factors examined were patient age, BMI, smoking history, and medical comorbidities including presence of diabetes mellitus (DM), peripheral vascular disease, and connective tissue disease. Due to the low event rate for late GU and GI toxicities, a competing risk regression (CRR) analysis was done with death as the competing event. Results: See Table. Median follow-up time was 8.6 years (range 0.2-11.5). On CRR univariate analysis the presence of DM was associated with GU toxicity grade ≥2 (p=0.043, HR 2.35, 95% CI=1.03-5.39). DM remained significant on multivariate analysis (p=0.034, HR 2.44, 95% CI= 1.07-5.59). Since there were no events in the RP group, only the PI and RT patients were included in the CRR analysis for late GI toxicity Grade <=2. On univariate analysis, RT and DM were significantly associated with late GI toxicity. On multivariable analysis, both variables remained significant (RT: p=0.038, HR=4.71, 95%CI=1.09-20.3; DM: p=0.008, HR=3.81, 95%CI=1.42-10.2). Conclusions: Late effects occur with all three treatment modalities. The presence of DM at the time of treatment was significantly associated with worse late GI and GU toxicity. RT was significantly associated with worse late GI toxicity compared to PI and RP. [Table: see text] No significant financial relationships to disclose.

INTRODUCTIONVacuum erection devices (VEDs) are becoming first-line therapies for the treatment of erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, there is limited efficacy of the use of phosphodiesterase type 5 inhibitors in elderly patients, or patients with moderate to severe diabetes, hypertension, and coronary artery disease.AIMThe article aims to study the role of VED in patients following prostate cancer therapy.RESULTSAlternative therapies such as VED have emerged as one of the primary options for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of postradical prostatectomy veno-occlusive dysfunction. This is evident by the preservation of penile length and girth that is seen with early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in the use of VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size prior to implantation of the penile prosthesis.CONCLUSIONVEDs can be one of the options for penile rehabilitation after prostate cancer therapy.

OBJECTIVE:To examine the early use of phosphodiesterase-5 inhibitor (PDE-5i; sildenafil citrate) in preventing subsequent erectile dysfunction (ED) after (monotherapy) prostate brachytherapy (PB, an accepted option for Gleason 6 or low-volume Gleason 7 prostate cancer), as PB is currently being offered more frequently in younger patients, and ED can be a side-effect often within the first 12 months after treatment.PATIENTS AND METHODS:We examined a single-surgeon series of 69 patients who had been treated with PB from 2002 to 2005. All patients had a follow-up of ≥ 1 year; prospectively, and patients had baseline, 6- and 12-month assessments using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF)-6 scores. The 69 patients were divided into early treatment with PDE-5i (31) and not treated with PDE-5i (38), and their SHIM and IIEF-6 scores were compared at baseline, 6 and 12 months. Daily sildenafil (25-50 mg) was given immediately after PB for 12 months. Overall, for the entire group, the mean prostate-specific antigen (PSA) level was 6.8 ng/mL; 78% had Gleason 6 cancer and 20% had Gleason 7 (3 + 4) cancer. The mean age in the early PDE-5i group was 64.8 years, and was 66.0 years in the no-PDE-5i group. The mean radiation dose in the early PDE-5i group was 50.2 Gy, and 43.9 Gy in the other group (P= 0.08).RESULTS:In the no-PDE-5i group, the mean baseline SHIM score of 17.1 decreased rapidly to 9.1 at 6 months (P= 0.01) and stayed at 9.3 at 12 months (P= 0.01). In the early PDE-5i group, the mean baseline SHIM score of 21.8 decreased slightly to 17.6 at 6 months (P= 0.2), and was maintained at 17.9 at 12 months (P= 0.2). Using the Wilcoxon rank-sum test, the 6- and 12-month SHIM scores in the two groups (P < 0.001). The IIEF-6 questionnaire confirmed the SHIM analysis.CONCLUSIONS:After PB patients had a significant decline in SHIM/IIEF-6 scores at 6 and 12 months. Our results indicate a 50% decrease in the quality of their erections. This provides an opportunity to initiate early intervention with PDE-5i or perhaps vacuum constriction devices or intraurethral alprostadil. In this study, the early use of PDE-5i after PB maintained erectile function at both 6 and 12 months.

PURPOSE:We compared prostate cancer detection rates for the 2 most commonly used transrectal ultrasound prostate biopsy probes, end fire and side fire, to determine whether the probe configuration affects detection rates. MATERIALS AND METHODS:We evaluated 2,674 patients who underwent initial prostate biopsy between 2000 and 2008 with respect to prostate specific antigen, biopsy technique and pathological findings. Patients were divided into 1,124 in whom biopsies were performed with an end fire probe and 1,550 in whom biopsies were performed with a side fire probe. RESULTS:There was a significant difference in the overall cancer detection rate in the end vs side fire arms (45.8% vs 38.5%, p <0.001). In the subsets of patients with prostate specific antigen greater than 4 to 10 ng/ml or less and greater than 10 ng/ml a significant difference persisted (46.4% vs 38.9% and 61.7% vs 49.1%, p <0.004 and <0.015, respectively). There was also a significant difference in detection rates between probes in those who underwent 8 to 19 biopsy cores (p <0.009). Biopsies of greater than 20 cores failed to attain statistical significance (p >0.105). We also found that prostate volume, patient age, prostate specific antigen and hypoechoic findings were independent variables for predicting cancer detection on multivariate analysis (p <0.001). CONCLUSIONS:The type of probe significantly affects the overall prostate cancer detection rate, particularly in patients with prostate specific antigen greater than 4 ng/ml and/or nonsaturation (8 to 19 cores) prostate biopsy. This may be because the end fire probe allows better mechanical sampling of the lateral and apical regions of the peripheral zone, where cancer is most likely to reside. We set the stage for a randomized, controlled trial to confirm our observations.

Prostate mono brachytherapy (PMB) is an accepted treatment option for Gleason 6 prostate cancer. In individual cases, patients with Gleason 7 cancer with concerns of erectile dysfunction often elect to undergo PMB. Retrospectively, we analyzed our database with the hypothesis that PMB can be an accepted treatment option for Gleason 7 cancer. We identified 61 patients from the Cleveland Clinic database (1997-2003), that underwent PMB for a Gleason 7 cancer and had a minimum follow-up of 4 years. We compared it to 56 patients with Gleason 6 cancer from the author's personal series in the same time period. We subdivided the Gleason 7 cancers into Gleason 7 (3+4) and Gleason 7 (4+3). In our Gleason 7 group, we found 48 had Gleason 3+4 and 13 had Gleason 4+3 cancer. The mean age of the patients in Gleason 7 (3+4) group was 68.2 years; in Gleason 7 (4+3) – 71 years; in Gleason 6-65 years. The mean baseline PSA of both the groups were comparable; Gleason 6-6.67; overall Gleason 7-6.70. In Gleason 6 group, the mean PSA at 4 years was 0.18 ± 0.20 with a 3.5% biochemical failure rate (ASTRO). In Gleason 7 (3+4) group, the mean PSA at 4 years was 0.16 ± 0.17 with a 6.2% biochemical failure rate. In Gleason 7 (4+3) group, the mean PSA at 4 years was 0.70 ± 0.74 with a 23% biochemical failure rate. There were 3 failures in the Gleason 7 (3+4) group, 3 failures in Gleason 7 (4+3) group and 2 failures in Gleason 6 - all 8 failures occurring between 2 and 3 years. Our intermediate data indicates that prostate mono brachytherapy is an acceptable treatment option for low intermediate risk Gleason 7 cancers. At 4 years, our biochemical cure rate for Gleason 7 (3+4) cancer (94%) was comparable to Gleason 6 (97%). This data should impact positively on our selection criteria for prostate mono brachytherapy, such that low intermediate risk Gleason 7 cancers can be routinely recommended.

OBJECTIVE:To assess the value of nuclear matrix protein-22 (NMP22), compared with urinary cytology, in predicting the recurrence of bladder cancer that is not transitional cell carcinoma (non-TCC).PATIENTS AND METHODS:We tested the sensitivity, specificity and the predictive accuracy of NMP22 in the context of non-TCC bladder cancer recurrence, and compared it to the performance of urinary cytology. The study group comprised 2687 patients with history of non-muscle-invasive bladder cancer from 10 centres across four continents.RESULTS:The mean patient age was 64.8 years and 75.4% were men; of all patients, 513 (19.1%) had positive urinary cytology, 906 (33.7%) had a positive NMP22 test (>or=10 units/mL) and 80 (3.0%) had non-TCC recurrence. Most of these, i.e. 60 (75%), were stage >or=T2. The sensitivity and specificity of urinary cytology were, respectively, 20.0% and 94.8%, vs 77.5% and 81.8% for NMP22 of >or=10 units/mL. The predictive accuracy of urinary cytology was 57.5%, vs 87.1% for NMP22 >or= 10 units/mL. A combined model that included dichotomized NMP22 and urinary cytology was 85.3% accurate.CONCLUSION:The ability of a NMP22 level of >or=10 units/mL to predict non-TCC recurrence was better than that of urinary cytology, suggesting that NMP22 might have a role in the surveillance of patients at risk of non-TCC recurrence.

Prostate mono brachytherapy (PMB) is an accepted option for Gleason 6, low-volume Gleason 7 prostate cancers, and is being offered more frequently in younger patients. Unfortunately, erectile dysfunction can be a side effect from PMB, occurring frequently in the first 12 months following treatment. This study examines the use of early PDE-5 inhibitors (sildenafil citrate) in preventing subsequent erectile dysfunction following prostate brachytherapy. We examined a single surgeon series of 69 patients that had undergone prostate mono brachytherapy from 2002-2005. All patients had a minimum 1-year follow-up. Prospectively, patients had baseline, 6 and 12 month SHIM and IIEF-6 scores recorded. The 69 patients were divided into early sildenafil (31) and non sildenafil groups (38) and their SHIM and IIEF-6 scores were compared at 6 and 12 months. Daily sildenafil (25-50 mg) was given immediately in the perioperative period for a duration of 12 months. Overall, for the entire group, the mean PSA was 6.8; 78% had Gleason 6 cancer; 20% had Gleason 7 (3+4) cancer. The mean age in the early PDE-5 group was 62.8 years; in the non PDE-5 group, 66.0 years. The mean radiation units in the early PDE-5 group was 50.2; in the non PDE-5 group, 43.9U (p = 0.08). In the non PDE-5 group, the mean baseline SHIM score of 17.1 dropped quickly to 9.1 at 6 months and stayed at 9.3 at 12 months. In the early PDE-5 group, the mean baseline SHIM score of 21.8 decreased slightly to 17.6 at 6 months, and was maintained at 17.9 at 12 months (p > 0.01 vs. baseline). Using the Wilcoxon Rank Sum Test, the 6 and 12 month SHIM scores in the early PDE-5 group differed from the non PDE-5 group (p < 0.001). The IIEF-6 questionnaire confirmed the SHIM analysis. Following prostate mono brachytherapy, patients experience a significant decline in SHIM / IIEF-6 scores at 6 and 12 months. Our data indicates a 50% decrease in the quality of their erections. This gives us a window of opportunity to initiate an early intervention program with PDE-5 inhibitors, vacuum constriction devices or intraurethral alprostadil. In this study, the early use of sildenafil citrate following PMB maintained erectile function at both 6 and 12 months.

Aim: To evaluate the long-term effectiveness, side effects and compliance rates of two types of drugs (luteinizing hormone-releasing hormone [LHRH] agonist and antiandrogen) that were used individually to treat patients with localized prostate cancer (T1-2) at our institution. Methods: Ninety-seven patients who were diagnosed in the period from April 1997 to January 2000 as having clinically localized prostate cancer (T1-2) received either LHRH agonist (leuprolide acetate 7.5 mg/month) monotherapy (group 1, n = 62) or antiandrogen monotherapy (group 2, n = 35; 18 received bicalutamide 50 mg q.d., 13 received nilutamide 150 mg t.i.d. and 4 received flutamide 250 mg t.i.d.). The mean age in both groups was 76 years. Results: The mean follow-up time was (50.8 +/- 8.5) months in group 1 and (43.1 +/- 2.2) months in group 2. Prostate-specific antigen (PSA) levels rose in only 1 of the 62 patients (1.6%) in group 1, and in 20 of the 35 patients (57.1%) in group 2. In group 2, 10 of the 20 patients (50%) with increasing PSA levels were treated with LHRH salvage therapy, and eight (80%) responded. Hot flashes (54.8%) and lethargy (41.9%) were the most common side effects in group 1. In contrast, nipple-tenderness (40%) and light-dark adaptation (17.1%) were more often seen in group 2. Only 1 of the 62 patients (1.6%) in group 1 switched to another medication because of adverse side effects; whereas 8 of the 35 patients (22.9%) in group 2 did so. Conclusion: Unlike antiandrogen monotherapy, LHRH agonist monotherapy provided long-term durable control of localized prostate cancer (T1-2). It can also be an effective treatment option for patients whose disease failed to respond to antiandrogen monotherapy. The limitations of our study are the lack of health outcomes analysis and a small sample size.

The reported potency rates after radical prostatectomy (RP) vary from 11–86% and are often reported 12–24 months after surgery. 5-year potency status after RP has not been reported in the literature. Retrospective study. We obtained 1 and 5 year potency data on a prospective RP population of 141 sexually active patients between 1997–1999. Mean age was 65.08 ± 6.68 and mean follow-up; 6.4 ± 1.5 years. The following data was obtained: sexually active or not, natural erections, nerve sparing status (NS), erectaids used, reasons for sexual inactivity (loss of interest, cardiovascular factors, urinary incontinence, loss of spouse, hormonal treatment). TablePotency status at 1 and 5 yearsTypes of ErectaidsAt 1 YrsAt 5 YrsTotal (n = 141)11370 (62)PDE5 inhibitors55 (48.7)28 (40)Combination with Sildenafil (VCD, ICI, MUSE)05 (7), 5 (7), 1 (1.4)MUSE9 (8)0ICI26 (23)10 (14.3)VCD19 (16.8)5 (7.1)Natural Erections4 (3.5)16 (22.9)Reasons for DiscontinuationAt 1 yrAt 5 yrsTotal28 (20)43 (38)Urinary Incontinence15 (53)0Loss of Interest10 (36)17 (39.5)CVS & CNS018 (42)Loss of partner03 (7)Loss of Libido3 (11)3 (6.9) Open table in a new tab 1 yr. Analysis: 113/141(80%) patients were sexually active (including drug therapy and erectaids); 28 (20%) were sexually inactive. The reasons for sexual inactivity included incontinence (15/28, 53%), loss of interest in sex (10, 36%); loss of libido (3/28, 11%; hormonal therapy). Of the 113 patients; 4 (3.5%) had natural erections sufficient for intercourse, 55 (48.7%) were using sildenafil, 26 (23%) intracavernosal injections (ICI), 19 (16.8%) vacuum constriction device (VCD), 9 intraurethral alprostadil (MUSE). 5 yr. Analysis: 70/113 (62%) remained sexually active. Of the 70 patients, 16 (22.9%) had natural erections sufficient for intercourse (15/16 NS), 21/70 (30%) were still using sildenafil, 10 (14.3%) IC injections, 5 (7%) VCD, 11 (15.7%) were using combination therapy, sildenafil with VCD, ICI or MUSE. Additional 7 (10%) patients switched to tadalafil alone. At 5 years 38% (43/113) were sexually inactive. See table for the reasons for discontinuation. At 5 years, sexual activity following radical prostatectomy decreases 50%, most of them due to loss of interest and associated medical co-morbidities. The vast majority (77.8%) of radical prostatectomy patients are sildenafil/erectaid dependent, with only 22.2% having natural erections sufficient for intercourse.

OBJECTIVE:To assess the contemporary inter-institutional accuracy of urinary cytology in predicting the recurrence of transitional cell carcinoma (TCC) of the bladder, in a large multi-institutional cohort from four continents, as cystoscopy and urinary cytology represent the 'gold standards' for surveillance of TCC recurrences, but the ability of cytology to predict recurrence varies. PATIENTS AND METHODS:Ten institutions contributed 2542 patients with a history of superficial TCC, of whom 898 had TCC recurrence. Age- and gender-adjusted logistic regression models were used to evaluate the association between urine cytology and TCC recurrence. The predictive accuracy derived from the logistic regression model was tested using the area under the receiver operating characteristic curve. The resulting predictive accuracy estimates were internally validated with 200 bootstrap re-samples. RESULTS:The mean (range across institutions) age of the patients was 65 (48-69) years and 75 (67-87)% were men. Cytology was positive in 19 (10-38)% of patients; recurrence was identified in 35 (27-54)% of patients. The sensitivity was 38-65% across institutions. Urinary cytology varied significantly in its ability to predict recurrence of bladder cancer. Institution-specific predictive accuracy adjusted for gender and age was 0.627-0.893. Stratifying by grade and stage only partly attenuated the discrepancies between centres. CONCLUSIONS:The variability of urinary cytology results was very appreciable among the 10 centres and ranged from poor (63%) to excellent (89%).

cotransmitters, including vasoactive intestinal polypeptide and prostaglandins that act through the adenylate cyclase pathway and its secondary neurotransmitter, cyclic adenosine monophosphate (cAMP).6,7 Urological Institute, Andrology-Oncology Research Laboratory and the Cleveland Clinic Foundation, Cleveland, Ohio; USA * Department of Pharmacology, King George's Medical College, Lucknow. play a role in the complex physiological response that leads to penile erection. Before an erection can occur, the central cavernosal arteries of the corpora cavernosa must dilate to increase blood flow to the penis. This increased blood flow combined with the production of NO from the nerve endings in the smooth muscles that form the lacunar spaces for the corpora cavernosa-produce lacunar smooth muscle relaxation.3 Once the smooth muscles have relaxed, blood flows rapidly into the lacunar spaces, increasing the volume in the corpora. This process also compresses and elongates the subtunical veins that drain the corpora cavernosa, decreasing venous outflow and increasing intracorporeal pressure. Pressure in the corpora cavernosa is supplemented by the contraction of the perineal muscles, resulting in a high-pressure rigid erection that is satisfactory for sexual activity. On a subcellular level, control of smooth muscle activity depends on intracellular calcium flux. Neurotransmitters and endothelium-derived factors influence the flow of intracellular calcium that balances penile flaccidity and rigidity. The principal substance responsible for smooth muscle relaxation is NO.4 Nitric oxide is produced from the precursor L-arginine through the enzyme nitric oxide synthase (NOS). Nitric oxide subsequently diffuses into smooth muscle cells and activates the secondary neurotransmitter system guanylate cyclase, which converts guanosine triphosphate into cyclic guanosine monophosphate (cGMP). This secondary neurotransmitter activates the intracellular sodium pump system, opening potassium channels and decreasing levels of intracellular potassium, which causes smooth muscles to relax. cGMP is metabolized through enzymatic breakdown by phosphodiesterase type 5 (PDE5), which closes potassium channels, increases levels of intracellular calcium, and facilitates smooth muscle contraction.5 Other neurotransmitters serve as Erectile dysfunction (ED) is the inability to achieve and maintain an erection sufficient for satisfactory sexual activity.1 Researchers have made great strides in understanding the complex neural and vascular pathways that are essential for normal erectile function. Investigations into smooth muscle physiology, endothelial cell function, central nervous control, and neurotransmitters such as nitric oxide (NO) and vasoactive intestinal peptide in the corpus cavernosum have led to the design, development, and use of specific pharmacological agents to recreate the normal physiology of the corpus cavernosum and restore erectile dysfunction in men who were previously termed impotent. Several treatment options are currently available for ED. Intracavernosal injection (IC) of vasoactive drugs, transurethral vasodilators, and vacuum constriction devices (VCDs) are safe, nonsurgical treatments that have variable ranges of efficacy and satisfaction rates. All of these erectaid treatments can potentially work and can have excellent compliance in an individual patient 2. The introduction of the first effective oral agent for ED treatment, sildenafil citrate, has revolutionized the management of this disorder and has significantly increased the number of men coming forward for evaluation and treatment. Sildenafil is effective in most men with erectile dysfunction (ED) in the general population including men with spinal cord injury, diabetes mellitus, and patients who have had nerve-sparing radical prostatectomy. This paper will discuss the physiology of the normal erection and how the aforementioned treatment options can help those with ED. The paper will also review new medications that may soon be available to supplement treatment with sildenafil.

PURPOSE We developed and validated nomograms that accurately predict disease recurrence and progression in patients with Ta, T1, or CIS transitional cell carcinoma (TCC) of the bladder using a large international cohort. METHODS Univariate and multivariate logistic regression models targeted histologically confirmed disease recurrence, and focused on 2,542 patients with bladder TCC from 10 participating centers. Variables consisted of pre-cystoscopy voided urine Nuclear Matrix Protein 22 (NMP22) assay, urine cytology, age and gender. Resulting nomograms were internally validated with bootstrapping. Nomogram performance was explored graphically with Loess smoothing plots. RESULTS Overall 957 patients had recurrent TCC. Tumor grade and stage was available for 898 patients, including 24% grade I, 43% grade II, and 33% grade III; 45% stage Ta, 32% T1 and/or CIS, and 23% T2 or greater. Bootstrap corrected predictive accuracy for any TCC recurrence was 0.842; grade III Ta/T1 or CIS was 0.869; and T2 or higher stage TCC of any grade was 0.858. Virtually perfect performance characteristics were observed for the nomograms predicting any TCC recurrence or grade III Ta/T1 or CIS. The nomogram predicting T2 or higher stage TCC overestimated the observed probability for predicted values greater than 45%. CONCLUSIONS We developed and internally validated nomograms that incorporate urinary NMP22, cytology, age and gender to predict with high accuracy the probability of disease recurrence and progression in patients with Ta, T1, and/or CIS bladder TCC. These nomograms could provide a means for individualizing followup in patients with Ta, T1, CIS bladder TCC.