Stesura Seveso 369Archivio Italiano di Urologia e Andrologia 2022; 94, 3 LETTER TO EDITOR No conflict of interest declared. Submitted 14 June 2022; Accepted 17 June 2022 To the Editor, The exact time to stop bladder cancer patient’s follow-up is not well known and there is not a clear recommendation on if and when stop to follow a patient managed for muscle invasive bladder cancer (MIBC). Major urological guidelines (1, 2) do not provide a precise indication on the timing of follow-up, and there is currently no real consensus on optimal time schedule. However, MIBC is a disease with a high relapse rate of over 50% of patients at 5 years (considering local, distant and urothelial relapses), and very late recurrences have been detected in several patients after 5-years-tumor free periods (3, 4). Furthermore, patients undergoing radical cystectomy require oncological but also functional follow-up, considering that complications related to urinary diversion are detected in 45% of patients during the first five years, reaching 54% after 15 years of follow-up (5). Recently, we detected a very late urethral recurrence in a patient who underwent cystoprostatectomy and Bricker’s ileal conduit urinary diversion in 2002 for MIBC (pT2 G3 N0). The patient, a 73 y/o diabetic man, strong tobacco consumer, had abandoned the follow-up 10 years ago, after as many years of surveillance in which he was free from disease. In 2021 the patient had urethral bleeding and prepuce edema. The urethroscopy found a white, solid mass in the proximal ure- thra, that the biopsy confirmed to be a urothelial carcinoma. Abdominal-penile MRI found a neoplasia likely originated from the urethra and from the corpus spongiosum, invading both corpora cavernosa, and bilateral inguinal lymphade- nomegaly. After six months of chemotherapy the patient underwent penectomy and lymphadenectomy. The definitive his- tological diagnosis was urothelial papillary carcinoma, with areas of squamous differentiation (pT3 G3 pN1). The aim of this letter is not to present in detail the case of this unlucky patient, and therefore many info are voluntarily omitted, but to put the light on the possible need of a life-long follow-up for patients with MIBC who underwent radical cystectomy. As previously stated, there is currently no clear recommendation on the timing of follow-up required in MIBC patients undergoing radical cystectomy. Recently a risk-adapted schedule (6) has been proposed, based on the interaction between recurrence risk and competing health factors that could lead to individualized follow-up recommendations and may increase recurrence detection. However, this model has not yet been validated and has several limitations such as not con- sidering histological variants (7), which are increasing and that might be responsible of greater rate of recurrences. To offer a patient-targeted follow-up, could become essential the use of biomarkers (8-10) currently available or in the experimental phase, capable of identifying the risk of recurrence and prognosis of different patients. This could lead to specific surveillance schedules, tailoring the patient's characteristics and recurrence risk (TNM, rare variants, urethral preservation, etc…). In this light, It is also essential to help the patient to stop smoking (11), in order to possibly reduce the risk of relapses, a factor that is often not investigated or stressed by the urologists. Ultimately, in our opinion, the patient undergoing cystectomy is a patient who should be followed for life by the urolo- gist, both from an oncological, functional and psychological point of view (12, 13). REFERENCES 1. Muscle-invasive and Metastatic Bladder Cancer - FOLLOW-UP - Uroweb. Accessed May 29, 2022. https://uroweb.org/guidelines/muscle-inva- sive-and-metastatic-bladder-cancer/chapter/followup. 2. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline (Amended 2020) - American Urological Association. Accessed May 29, 2022. https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-metastatic-muscle-invasive-guideline. How long should we follow patients managed for muscle-invasive bladder cancer? Lesson learned from a recent clinical practice Aldo Franco De Rose 1, Francesco Vecco 1, 2, Francesca Ambrosini 1, 2, Rafaela Malinaric 1, 2, Guglielmo Mantica 1, Carlo Terrone 1, 2 1 IRCCS Ospedale Policlinico San Martino, Genova, Italy; 2 Università di Genova, (DISC), Genova, Italy. DOI: 10.4081/aiua.2022.3.369 Archivio Italiano di Urologia e Andrologia 2022; 94, 3 A.F. De Rose, F. Vecco, F. Ambrosini, R. Malinaric, G. Mantica, C. Terrone 370 3. Matsumoto K, Kikuchi E, Horiguchi Y, et al. Late recurrence and progression in non-muscle-invasive bladder cancers after 5-year tumor-free periods. Urology. 2010; 75:1385-1390. 4. Yoo SH, Kim H, Kwak C, Kim HH, Jung JH, Ku JH. Late recurrence of bladder cancer following radical cystectomy: characteristics and out- comes. Urol Int. 2019; 103:291-296. 5. Hautmann RE, Volkmer B, Egghart G, et al. Functional outcome and complications following Ileal neobladder reconstruction in male patients without tumor recurrence. More than 35 years of experience from a single center. J Urol. 2021; 205:174-182. 6. Stewart-Merrill SB, Boorjian SA, Thompson RH, et al. Evaluation of current surveillance guidelines following radical cystectomy and propos- al of a novel risk-based approach. Urol Oncol Semin Orig Investig. 2015; 33:339.e1-339.e8. 7. Mantica G, Simonato A, Du Plessis DE, et al. The pathologist’s role in the detection of rare variants of bladder cancer and analysis of the impact on incidence and type detection. Minerva Urol e Nefrol. 2018; 70:594-597. 8. Sawazaki H, Arai Y, Ito Y, et al. Expression of L-type amino acid transporter 1 is a predictive biomarker of intravesical recurrence in patients with non-muscle invasive bladder cancer. Res Reports Urol. 2021; 13:603. 9. Saoud R, Sanford TH, Hewitt SM, Apolo AB, Agarwal PK. Rapidly progressing urothelial carcinoma due to a rare TP53 (p.Arg110Pro) muta- tion: a case report and review of the literature. Res reports Urol. 2021; 13:181-184. 10. Singh R, Singh UP, Agrawal V, Garg M. Epithelial-to-mesenchymal transition based diagnostic and prognostic signature markers in non-mus- cle invasive and muscle invasive bladder cancer patients. Mol Biol Rep. 2022; 49:7541-7556. 11. van Osch FHM, Jochems SHJ, Reulen RC, et al. The association between smoking cessation before and after diagnosis and non-muscle-inva- sive bladder cancer recurrence: a prospective cohort study. Cancer Causes Control. 2018; 29:675. 12. Jensen BT, Lauridsen SV, Jensen JB. Optimal delivery of follow-up care after radical cystectomy for bladder cancer. Res Reports Urol. 2020; 12:471. 13. Borghi C, Manservigi M, Milandri ES, Greco P, Ippolito C, Dell’Atti. The impact of orthotopic reconstruction on female sexuality and quali- ty of life after radical cystectomy for non-malignant bladder conditions. Arch Ital di Urol e Androl. 2021; 93:255-261. Correspondence Aldo Franco De Rose, MD aldofrancoderose@gmail.com Francesco Vecco, MD (Corresponding Author) francesco.vecco@gmail.com IRCCS Ospedale Policlinico San Martino, Genova Francesca Ambrosini, MD f.ambrosini1@gmail.com Rafaela Malinaric, MD rafaela.malinaric@gmail.com Guglielmo Mantica, MD guglielmo.mantica@gmail.com Carlo Terrone, MD carlo.terrone@med.uniupo.it