We are grateful for the additional comments on our article (1). However, such a general review cannot completely meet the need for a comprehensive discussion of all aspects for such a complex tumor disease. It is absolutely correct that, in addition to the factors addressed in our article, there are numerous toxic chemicals which can directly or indirectly cause the induction of bladder carcinoma.

With regard to urine cytology, we refer in particular to the background texts of the relevant German S3 clinical practice guideline. The authors are correct to mention that the sensitivity of urine cytology, in particular, is strongly influenced by the grading of the tumor (high-grade versus low-grade). The reported sensitivity of 20% to 50 % refers to all tumor grades. For high-grade tumors of the bladder or the upper urinary tract, the sensitivity is significantly higher and thus urine cytology is, especially for this subgroup of aggressive tumors, a very important addition to the primary diagnostic assessment with endoscopy and tomography as well as a valuable aftercare tool.

The simple ureterocutaneostomy mentioned by Prof. Otto et al. should, in the absence of absolute contraindications, be a rare exception, even in elderly or comorbid patients. Due to its significantly lower rate of long-term complications in respect to strictures and urinary tract infections, the ileal conduit procedure almost completely replaced ureterocutaneostomy several decades ago. If performed in an experienced center, cystectomy with urinary diversion using a segment of bowel is associated with an acceptable complication risk und few long-term problems (need of permanent ureteral stenting with high risk of occlusion and febrile urinary tract infections).

Finally, we do agree that a rate of erectile function recovery after cystectomy of up to 100% reported in the literature is unrealistic. It should be emphasized that not the surgical technique (open versus robot-assisted approach) but rather high experience and proper perioperative management translate to good surgical outcome. We do thank Prof. Otto et al. for pointing out the possibility of hyperprogression on immunotherapy with checkpoint inhibitors. However, this mechanism is not specific for bladder carcinoma and the discussion of this very special aspect is beyond the scope of our review article.

DOI: 10.3238/arztebl.m2021.0230

Corresponding author

Prof. Dr. med. Jürgen E. Gschwend

Klinik und Poliklinik für Urologie am Universitätsklinikum rechts der Isar der Technischen Universität München, Munich, Germany


Conflict of interest statement

Prof. Gschwend received consultancy fees (advisory board) from Roche, MSD Pharma, BMS, and Merck. He received reimbursement of congress fees and travel expenses from Roche. He received lecture fees from Roche, MSD and Merck.

de Wit M, Retz MM, Rödel C, Gschwend JE: The diagnosis and treatment of patients with bladder carcinoma. Dtsch Arztebl Int 2021; 118: 169–76 VOLLTEXT
1.de Wit M, Retz MM, Rödel C, Gschwend JE: The diagnosis and treatment of patients with bladder carcinoma. Dtsch Arztebl Int 2021; 118: 169–76 VOLLTEXT