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Orthotopic bladder substitute (OBS) has been popularized over the past 2 decades as a diversion following radical cystectomy for invasive bladder cancer. Various reports, mostly single-center experiences, are published on patients with OBS.
This study reviews the literature regarding indications, postoperative care, complications, quality-of-life measures, as well as functional and oncologic outcomes that have been published on patients with OBS.
Evidence acquisition
An English-language literature review of the Medline database (1990 to January 2010) of published data on patients with OBS following radical cystectomy for bladder cancer was undertaken. Articles that included surgery for noncancer etiology were excluded.
Evidence synthesis
Indications and patient selection criteria have significantly widened over the past 2 decades. Comparable oncologic data have been reported between patients with OBS versus other diversions. Secondary urethral tumors seem less common in patients with OBS compared with those with conduits or continent cutaneous diversions. Durable daytime and nocturnal continence is achieved in 85–90% and 60–80%, respectively. Continence is inferior in elderly patients with OBS. Urinary retention remains significant in the female patients, ranging from 25% to 50%. Complications including electrolyte disturbances, altered sensorium and drug metabolism, mucus retention, rupture, urinary tract infections, and upper tract deterioration are reviewed.
Indications for OBS following radical cystectomy in patients with invasive bladder cancer have significantly widened over the past 2 decades. An OBS should be offered to both male and female patients in the absence of contraindications. Good long-term functional and oncologic outcomes can be achieved in patients with OBS treated in high-volume institutions by experienced surgeons with specific knowledge in the field. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.
Keywords: Bladder cancer, Orthotopic bladder substitute, Neobladder, Continence, Functional results, Outcomes, Radical cystectomy.
1. Introduction
Radical cystectomy with lymphadenectomy and urinary diversion is the gold standard for invasive bladder cancer [1], [2], [3], and [4]. The goals are to provide optimal cancer outcomes, prevent renal deterioration, and maintain functional and anatomic restoration as close as possible to the natural preoperative state. A variety of urinary diversions performed to reconstruct the urinary tract includes urinary conduits, continent cutaneous diversions, and orthotopic bladder substitute (OBS). Ileal OBS has gained increasing popularity as a form of urinary diversion in patients undergoing radical cystectomy for bladder cancer in recent years. In the past, the general default was to recommend an ileal conduit as the preferred diversion. Over the years, there has been a paradigm shift to OBS as the default diversion, and the question has become, "Who is not a suitable candidate for an OBS?" This review focuses on various aspects of OBS including indications, postoperative care, complications, and quality-of-life (QoL) assessment as well as oncologic and functional outcomes.
2. Evidence acquisition
A literature review of the Medline database (primarily focused from 1990 to January 2010) was undertaken to find relevant papers on OBS following radical cystectomy with restrictions to humans and English-language publications. Articles that included surgery for noncancer etiology were excluded. Search terms included bladder cancer, urinary diversion, orthotopic bladder substitute, neobladder, ileum, urinary reconstruction, radical cystectomy, urethral recurrence, cancer outcome, continence, hypercontinence, functional results, and complications.
3. Evidence synthesis
Most publications were based on retrospective single-institutional experiences with nonstandardized reporting of complications and varying duration of follow-up. Randomized prospective studies evaluating urinary diversions are sparse. As such, most of the data presented is of level 3 or 4 evidence. Due to these limitations, this review provides suggestions based on everyday clinical practice in addition to evidence-based medical recommendations.
3.1. Selection criteria for bladder cancer patients
As the understanding of bladder cancer biology and physiologic changes post-OBS increases, the contraindications for OBS has significantly narrowed. An absolute contraindication to OBS is overt involvement of disease within the urethra distal to the prostate. Additional contraindication for OBS or any form of continent diversion is severely compromised renal function (serum creatinine levels >150
3.2. Bowel segment considerations
The three important properties for OBS include configuration, accommodation, and compliance. A good capacity OBS under low pressure (highly compliant) without significant high-pressure reflux is the desired outcome. Detubularized and folded segments provide these characteristics using shorter length of bowel needed compared with nondetubularized segments [10]. Ileum is the preferred bowel segment because it has less contractility and better compliance compared with colon and cecum [11] and [12]. Reservoirs constructed with colonic segments have higher storage pressures compared with ileum segments and may be associated with lower continence rates in patients with OBS [13] and [14]. Finally, as a result of mucosal atrophy over the long term, ileal segments have less reabsorption of urinary wastes and electrolytes in patients with OBS compared with colonic segments [15].
3.3. Specific postoperative management of orthotopic bladder substitutes
Objectives of postoperative care following radical cystectomy are to minimize complications because rates can be significantly high when using standardized reporting methodology [16] and [17], educate patients, and provide cost-effective care. Specifics regarding postoperative management following OBS are well reviewed by Varol and Studer [18]. Briefly, we recommend two single J stents that are exteriorized through the OBS. If there is suspected blockage, the ureteral catheters can be irrigated with 2
3.4. Metabolic disturbances
3.4.1. Electrolyte abnormalities
Metabolic acidosis is more commonly seen in patients with compromised renal function. It is also associated more commonly with ileal or colonic OBS than with ileal conduit diversions. This is due to the longer contact of urine with the bowel mucosa. An initial salt-loss syndrome and acidosis as a result of ammonium reabsorption are the most frequently observed complications but may be prevented if patients are supplemented with sodium chloride and sodium bicarbonate [20]. The clinical significance of minor acidosis remains unknown. However, if severe, symptoms of fatigue, lethargy, weakness, anorexia, and vomiting can develop along with hypokalemia and hypocalcemia. Treatment is commonly effective with the administration of fluid (intravenous Ringer lactate) and alkalinization therapy with oral sodium bicarbonate (2–6
Hypokalemia is more common with colonic OBS than ileal OBS because the ileum reabsorbs some of the potassium and thus is capable of blunting potassium loss by the kidney [22]. Because colon reservoirs have a tendency to lose potassium, potassium citrate is often most appropriate for colonic reservoirs. Severe hypocalcemia and/or hypomagnesemia (due to nutritional depletion and excessive renal wasting) do occur but are infrequent with OBS.
3.4.2. Altered sensorium and drug metabolism
Magnesium deficiency, drug intoxication, or abnormalities in ammonium metabolism are causes of altered mental status specific to patients with OBS. Hyperammonemic encephalopathy in patients with OBS has been reported, particularly in those with cirrhosis or altered liver function. Patients who have hyperammoniogenic coma with clinically normal liver function may have a significant infection with urease-producing bacteria. Treatment of the encephalopathy includes drainage of the OBS with a Foley catheter and oral neomycin to reduce the ammonia load. Abnormal drug metabolism can occur with drugs that are secreted unchanged in the urine and absorbed by the intestinal tract. Toxicity from chemotherapeutic agents such as methotrexate may occur in patients with OBS [23]. To minimize risk of toxicity, patients with OBS should be well hydrated and the reservoir preferably drained during treatment by frequent voiding or placement of a temporary indwelling catheter. Other drugs that can be absorbed from the intestinal tract include phenytoin, theophylline, and antibiotics.
3.4.3. Vitamin B12 deficiency
Absorption of vitamin B12 occurs primarily in the terminal ileum. Deficiency in vitamin B12 has been reported in varying degrees in patients with OBS constructed with ileum or ileocecal segment, and if deficiency persists, irreversible neurologic and hematologic sequelae may occur. Incidence and prevalence of vitamin B12 deficiency in patients with OBS remains unknown, although some report up to a third of patients may develop vitamin B12 deficiency over long-term follow-up [24]. Vitamin B12 loss seems to be more frequent either in patients whom >60
3.4.4. Osteomalacia
Osteomalacia occurs when mineralized bone is reduced and the osteoid component becomes excessive. Over the long term, patients with OBS may develop osteomalacia due to persistent acidosis, vitamin D resistance, exchange of bone calcium against protons, and stimulation of osteoclasts. With normal renal function, severe bone defects are uncommon after OBS; the risk is higher with colonic OBS because metabolic acidosis is more frequent and calcium reuptake is less efficient than with ileal OBS. Symptoms include lethargy, pain in weight-bearing joints, and proximal myopathy. Serum calcium and phosphate are usually reduced in patients with osteomalacia, and alkaline phosphatase is elevated [26]. Treatment involved correction of acidosis along with calcium and active vitamin D supplementation.
3.5. Urinary tract infection
Unlike ileal conduits, urine cultures from OBS are typically sterile. Mixed cultures generally do not require treatment as long as the patient is asymptomatic. However, patients with Proteus or Pseudomonas in the urine should be treated regardless of symptoms because there is a risk for deterioration of the upper tracts in this setting. One should ensure adequate emptying of the reservoir because bacterial colonization is strongly correlated with postvoid residual urine in patients with OBS. Although the clinical significance of bacteriuria in asymptomatic patients with OBS is controversial, its presence has been associated with worsening incontinence [27]. Others have also reported that patients with OBS have a significant increased risk of bacteriuria (around 50%); half of these patients will develop a urinary tract infection (UTI), and 18% will develop septic episodes over a 5-yr period [28]. In asymptomatic and continent patients with OBS who adequately empty their reservoir and develop recurrent bacteriuria despite antibiotic therapy, many investigators do not recommend routine prophylactic antibiotics to reduce risk of drug-resistant bacteria and drug-related adverse effects.
3.6. Mucus production
In the early postoperative period while the indwelling catheter is still in place, it is recommended to irrigate regularly to avoid mucus buildup and blockage [18]. Mucus accumulation occurs more frequently in patients with incomplete emptying of the reservoir and those performing CIC. Increased mucus production may be an early sign of UTI or irritation of the OBS. Early and late mucus retention develops in 0.6–2% and 3% of patients, respectively [29] and [30]. In the rare situation when significant mucus retention develops, patients are recommended to irrigate periodically with sterile water via a catheter and evacuate mucus from the reservoir as well as a trial of medical therapy (N-acetylcysteine or urea). Importantly, the cause of residual urine must be identified and treated.
3.7. Rupture
Rupture can occur due to acute (catheter trauma, mucus retention) or chronic overdistention of the OBS [31] and [32]. To decrease risk of rupture due to chronic overdistention, one should emphasize to the patient with OBS not to retain urine for long periods and void regularly every 3–4
3.8. Upper tract deterioration
Renal function deterioration in patients with OBS can be caused by several specific factors related to OBS including obstruction (more commonly due to stenosis at the ureteroileal anastomosis or inability to evacuate the reservoir completely), transmission of high-pressure reservoirs to the upper tract, recurrent infections, and stone formation. Other factors that can also cause renal function compromise in general (not specific to OBS) include diabetes, hypertension, and medications. Few long-term studies have evaluated renal function after OBS, and the assessment of renal function in most studies is limited because it relied on suboptimal end points such as serum creatinine and/or radiologic studies. One prospective study followed a cohort of 74 patients with long-term follow-up (mean: 84 mo) treated with OBS and refluxing anastomosis at the afferent limb and demonstrated that only 1% of the renal units developed loss of cortical thickness if kidneys were normal preoperatively [33]. In this study, renal deterioration was seen only in patients with pre- or postoperative ureteral obstruction.
High-pressure reflux may lead to renal damage over long-term follow-up. However, the need for antireflux procedures for low-pressure detubularized OBS is not the same as with ureterosigmoidostomy, continent cutaneous diversion, or a conduit. Long-term randomized studies evaluating the role of antireflux procedures in patients with OBS are sparse. One study randomized patients who received an ileal OBS with a refluxing end-to-side ureteroileal anastomosis at the isoperistaltic limb versus an antirefluxing nipple valve [34]. After a median follow-up of approximately 5 yr, there was no difference in serum creatinine, incidence of infected urine, and functional reservoir capacity between the two groups. It has been demonstrated that the afferent limb in the refluxing group functions as a dynamic antireflux system that causes minimal ureteral reflux under normal voiding conditions in the absence of an overfilled reservoir. Anastomotic stenosis with upper tract deterioration was significantly higher in patients with antirefluxing nipple valves compared with those with refluxing anastomosis (13.5% vs 3%) [34]. Another randomized study confirmed these findings where patients with nonrefluxing anastomosis had a higher incidence of stenosis compared with those with refluxing anastomosis (16.7% vs 3.3%) [35]. Other studies, albeit nonrandomized, have shown no difference in the rates of pyelonephritis, upper tract stone formation, or serum creatinine in patients with refluxing versus nonrefluxing anastomoses; however, the incidence of ureteroileal stenosis remains higher in the nonrefluxing anastomoses compared with a refluxing one (13% vs 1.7%) [36]. Currently, an ongoing randomized trial at the University of Southern California (USC) is comparing the Studer pouch and the T-pouch (it includes an extraserosal afferent limb that prevents reflux from the pouch to the kidneys). Until then, a simple end-to-side freely refluxing anastomosis to an afferent limb of a low-pressure OBS, in combination with residual-free regular voiding of sterile urine and close follow-up to treat any outlet obstruction of the upper urinary tract or the OBS, is the optimal strategy for lowest overall complications and minimizing renal deterioration.
3.9. Continence
Objective evaluation of continence with OBS varies across series due to different methodology including subjective and objective definition of degrees of continence determined at different time points from surgery. Multiple factors influence continence including patient age and mental status, an intact and innervated urethral sphincter, urethral length, low-pressure/large-capacity reservoir (>300
3.9.1. Daytime continence
Recovery of continence during the day is achieved at an earlier time compared with recovery of nocturnal continence. Analysis of various studies (some reviewed in Hautmann et al. [38]) demonstrated rates of good or excellent daytime continence at 85–90%, defined as totally dry or use of one pad per day after 12 mo from OBS [11], [29], [30], [39], [40], [41], [42], [43], [44], [45], and [46]. Multicenter experiences have not observed significant deterioration of daytime continence over long-term follow-up [47]. Hautmann reported that decreased functional urethral length is associated with higher rates of stress incontinence [48]. Decreased urethral sensitivity at the male membranous urethra has also been shown to be associated with higher rates of incontinence [49]. Older patients may have higher incontinence rates due to decreased tone of the urethral sphincter with advanced age, which may explain the mild increase in daytime incontinence that occurs 4–5 yr after OBS [50] and [51]. Takenaka et al demonstrated daytime continence rates of 75% in octogenarians following OBS [52]; others reported continence rates of 56% in patients >75 yr of age [53]. Bowel configuration can also influence continence rates in patients following OBS. In one study, elongated ileal OBS had lower early continence rates compared with spherical OBS (41% vs 69% at 3–6 mo); however, the continence rates were the same by 1 yr following surgery (89% vs 87%) [54]. Nerve-sparing cystectomy is significantly associated with better continence rates [55]. Whether this is due to the actual nerves spared or simply a more meticulous dissection around the prostatic apex with less damage to the external sphincter mechanism and membranous urethra remains to be determined. Lastly, there may be an association between gender and daytime continence rates. Most reports of the functional outcomes such as continence are derived from OBS in male patients. However, there are recent data on daytime continence in women following OBS. In a study from the Mayo Clinic on 59 women following OBS, the daytime continence rate defined as no pads per day was 90% [56]. In contrast, the USC experience reported daytime continence rates in women following OBS to be 77% [57].
3.9.2. Nocturnal continence
Recovery of nocturnal continence is slower and may take up to 12–24 mo following surgery. Many patients wear a pad at night. Analysis of various studies demonstrated that most series report nocturnal incontinence rates of 20–40% [11], [29], [30], [39], [40], [41], [42], [43], [44], [45], and [58]. To optimize nocturnal continence, patients are recommended to avoid sleeping pills and alcohol in the evening, to void before going to sleep, and to set up an alarm to void at least once during the night. One study demonstrated that urinary infection is a cause of incontinence where continence resumes after antibiotic therapy [27]. Others have noted nocturnal incontinence rates of 50% in 100 patients following OBS and a minimum follow-up of 1 yr. Univariate analysis showed significantly higher pressure, positive urine cultures, and larger postvoid residuals with decreased maximal urethral pressure, maximum flow rate, and compliance in OBS patients with enuresis [59]. However, on multivariate analysis, only postvoid residual volumes, frequency, and maximal amplitude of uninhibited contractions remained significantly associated with nocturnal incontinence. Up to 25% of patients reported an improved nocturnal continence with the use of imipramine hydrochloride 25
Some studies reported nocturnal continence rates to be inferior in females compared with men. Although studies on nocturnal continence in the female population following OBS are less extensive, rates of 57% and 66% have been reported [56] and [57]. Similar to daytime continence, higher age also correlated with higher nocturnal incontinence rates (up to 60% in octogenarians) [52]; however, this factor was not consistent across all studies. Lastly, bowel segments may influence nocturnal continence rates. In a recent randomized trial comparing 71 patients who underwent ileal OBS versus ileocolonic OBS, the nocturnal continence rates were superior with ileal OBS compared with ileocolonic OBS (76.3% vs 48.5%; p
3.9.3. Clean intermittent catheterization
In patients with OBS, voiding is initiated by relaxing the pelvic floor while increasing intra-abdominal pressure. Optimum OBS emptying is achieved in the sitting position. Most patients with OBS void spontaneously with adequate emptying of the reservoir. Dysfunctional voiding that requires CIC can occur in approximately 10% of the male population with an OBS, ranging between 4% and 33% depending on various reports and duration of follow-up [11], [39], [46], [63], and [64]. It is crucial to exclude the presence of a urethral stricture when evaluating patients with voiding dysfunction necessitating CIC. In addition to dysfunctional voiding and stricture of the ileourethral anastomosis, other causes of urinary retention include kinking of the OBS outlet, infraneovesical obstruction due to local recurrence (8.7%), obstructive mucosal prolapse (0.9–7%), cystolithiasis (0.2%), prostatic adenoma (1.7%), and distal urethral strictures (2–3.5%) [25] and [65]. If a funnel-shaped outlet is avoided and deobstructive surgery is appropriately implemented, excellent long-term results with spontaneous voiding can be observed, and CIC can be avoided in 96% of patients at 10 yr [5] and [25]. Urinary retention requiring CIC is more common in women, as first described by Hautmann et al. [66], with long-term prevalence rates of 25–50% reported in other series [57], [65], and [67]. It is unclear why the rates of urinary retention are significantly higher in women compared with men. Some investigators believe that this increase is due to changes in the urethral innervations and inability to open the urethra or to relax the pelvic floor. As a consequence of excessive straining, angulation and obstruction of the neobladder-urethral junction and formation of a "pouchocele" in women is observed. A recommendation that may potentially (but is not necessarily proven to) decrease risk of urinary retention includes placement of omentum posterior to the reservoir, suspension of the vaginal fornices to Cooper ligament, suspension of the vaginal apex to the sacrum, avoidance of excess pouch size (by selecting bowel segment of 40
3.10. Oncologic outcomes
3.10.1. Secondary urethral tumors
In patients with OBS, early symptoms of secondary urethral tumors may include hematuria (microscopic or gross) and changes in urinary stream. Later symptoms can include urethral bleeding and induration of the periurethral tissue. For patients undergoing the recommended surveillance of the urethra with periodic washes or voided cytology, a secondary urethral tumor can be detected by an abnormal urinary cytology only.
18.104.22.168. Men
Overall, in patients with primary and recurrent bladder cancer, the incidence of urethral tumors is approximately 6% [75]. The incidence of urethral recurrence after radical cystectomy ranges from 0% to 18%, with a meta-analysis in 2002 reporting an incidence of 8.1% [76]. Patients with OBS seem to have a lower risk of secondary urethral tumors compared with those with heterotopic urinary diversions [77] and [78]. Stein el al reported a 5% risk of secondary urethral tumors with OBS compared with 9% with cutaneous diversions; whether these findings are due to the proximity of the ileum in exerting a protective effect on the retained urethra or due to a patient selection bias remains controversial [79]. Prostatic urethral involvement (superficial and/or stromal invasion) is significantly associated with increased risk of secondary urethral tumors. In the largest reported series of 768 patients by Stein et al, secondary urethral tumors in patients without prostatic urethral involvement, superficial prostatic urethral involvement (mucosal or ductal), and stromal involvement was 6%, 12%, and 18%, respectively, after a median follow-up of 13 yr [79]. Although factors such as multifocal disease and CIS are reported to be associated with an increased risk of concurrent prostatic urethral involvement or secondary urethral tumors [9], studies from USC have demonstrated that they do not appear to significantly increase risk of secondary urethral tumors following radical cystectomy; however these patients reported have not been prospectively followed [77] and [80]. Selection criteria in the USC series include a negative intraoperative frozen-section analysis of the distal urethral margins at cystectomy. Because the false-negative rates of frozen sections can be as high as 30–50%, other institutions perform routine preoperative paracollicular biopsies to select patients against OBS if CIS is present.
22.214.171.124. Women
Because OBS was first applied to male patients and the incidence of bladder cancer is much lower in women, there is a more extensive experience and longer follow-up in male compared with female patients. Urethral tumor on presentation in women who underwent radical cystectomy for bladder cancer is lower than in men with an incidence of 2–7% [81] and [82]. In women, tumors at the bladder neck or involvement of the anterior vaginal wall are factors significantly associated with concomitant disease within the urethra [82] and [83]. Most studies show that almost all female patients with an uninvolved bladder neck also had an uninvolved urethra; similarly, all female patients with urethral involvement also had concomitant bladder neck involvement. As such, routine preoperative bladder neck biopsies are recommended to rule out the presence of cancer or CIS and help counsel patients. However, because 50% of women with bladder neck and/or anterior vaginal wall involvement do not demonstrate tumor within the urethra, these patients can still be eligible for OBS if they are willing to accept the significant risk of developing secondary urethral tumors. Importantly, there are some case reports of skip lesions where urethral involvement was present in the absence of bladder neck involvement; as such, full-thickness intraoperative frozen section of the distal urethral margin is recommended in all patients who are undergoing an OBS.
3.10.2. Pelvic recurrence
Radical cystectomy with bilateral lymphadenectomy provides excellent local/pelvic control of bladder cancer. In a large series of 1054 patients treated with radical cystectomy, the local recurrence rate was 7% after a median follow-up of 10 yr [1]. Even in women without extensive posterior involvement who were selected to undergo OBS after preservation of the entire vagina, local recurrences were seen in only 5% of the patients [84]. Local recurrence rates remain low but slightly higher in patients with non-organ-confined node-negative disease and node-positive disease compared with organ-confined node-negative disease (13%, 13%, and 6%, respectively) [1]. Similar findings were also observed in a large European series of patients treated with radical cystectomy where local recurrence rates of 13–16% were observed in patients with non-organ-confined disease [2] and [3]. As such, patients with non-organ-confined disease may still benefit from the advantages of an OBS, particularly because 60% and 30% of patients with extravesical or node-positive disease are alive without evidence of disease at 10 yr after cystectomy. Furthermore, even with local recurrence, most patients (>90%) maintain good OBS function [25] and [85]. Importantly, the quality of the cystectomy is not compromised in patients receiving an OBS. After adjusting for pathologic stage, several studies demonstrated no difference in cancer-specific survival in patients (male and female) receiving ileal conduit and/or continent cutaneous diversions versus OBS following radical cystectomy [57] and [86]. OBS appears safe and feasible even in patients with positive nodes and does not affect the ability to receive salvage treatment [87]. However, in the rare situation where patients are found to have intraoperatively gross palpable adenopathy, it is unclear whether they will benefit from the advantages of an OBS because their prognosis remains guarded with limited life expectancy and they commonly die before they attain optimal continence recovery.
3.11. Quality of life
OBS is technically more challenging with slightly longer operative times than ileal conduits. Because longer bowel segments are needed, the risk of bowel dysfunction (diarrhea, vitamin B12 malabsorption) may be higher with OBS than ileal conduit. Early studies comparing ileal conduits with continent cutaneous diversions have shown that patients are satisfied regardless of the type of diversion and adapt well biopsychosocially as long as an adequate and realistic preoperative education is instituted about their type of diversion [88] and [89]. In a retrospective study, Bjerre et al compared health-related QoL of 38 patients with OBS to 29 with ileal conduits after a median follow-up of 1 yr [90]. Although urinary leakage occurred more frequently in patients with OBS, urinary leakage affected conduit patients more severely, and they scored higher on a leakage distress scale. Sexual and nonsexual physical contacts decreased in most conduit patients but only in the minority of OBS patients. In a recent study, 57 patients who underwent an ileal conduit or ileal OBS were assessed preoperatively with a Karnofsky performance score and followed with a health-related QoL questionnaire [91]. In a similar age-group population, there was no significant difference in most QoL indexes, but body image issues persisted in the conduit group. OBS patients had significantly better physical function and a more active lifestyle. Several other reports have attempted to examine the QoL of patients with various types of diversions and showed inconsistent results among different types of diversions [92], [93], [94], [95], [96], and [97].
After careful analysis of all the QoL studies, it becomes evident there is a lack of good data evaluating QoL in patients with OBS versus other diversions. Most QoL studies used inappropriate questionnaires. Although some are validated, they were not designed to evaluate specific urologic aspects but rather QoL of patients during chemotherapy (eg, European Organization for Research and Treatment of Cancer C-30, SF-36). Most urologists perform only/mostly one type of diversion. There is a strong bias because patients are subjected preoperatively for selection of a specific diversion and hence patients are prepared for the disadvantages and advantages associated with the different diversions. As such, there is a real risk that patient-led preferences are inappropriately labeled against the OBS. We firmly believe that the QoL of patients with a well-functioning OBS is significantly better than other forms of diversions. However, in agreement with a systematic review in 2005 [98], randomized prospective trials using well-validated disease-specific health-related QoL outcome instruments are warranted to render definitive conclusions regarding QoL measures with different type of diversions.
4. Conclusions
Indications for OBS following radical cystectomy in patients with invasive bladder cancer have significantly widened over the past 2 decades. An OBS should be offered to both male and female patients in the absence of contraindications. Good long-term functional and oncologic outcomes can be achieved in patients with OBS treated in high-volume institutions by experienced surgeons with specific knowledge in the field. Preoperative patient education, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.
Study concept and design: Kassouf, Hautmann, Bochner, Lerner, Colombo, Zlotta, Studer
Acquisition of data: Kassouf.
Analysis and interpretation of data: Kassouf.
Drafting of the manuscript: Kassouf.
Critical revision of the manuscript for important intellectual content: Kassouf, Hautmann, Bochner, Lerner, Colombo, Zlotta, Studer.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Kassouf.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
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a Division of Urology, McGill University Health Centre, Montreal, Canada
b Division of Urology, University of Ulm, Ulm, Germany
c Division of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
d Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
e Department of Urology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy
f Division of Urology, University of Toronto, Toronto, Canada
g Division of Urology, University of Bern, Bern, Switzerland
Corresponding author. Division of Urology, Montreal General Hospital, 1650 Cedar Ave. L8–315, Montreal, Quebec, H3G 1A4, Canada. Tel. +1 514 934 8246; Fax: +1 514 934 8297.
Please visit www.eu-acme.org/europeanurology to read and answer questions on-line. The EU-ACME credits will then be attributed automatically.
Article information
DOI: 10.1016/j.eururo.2010.05.023
© 2010 European Association of Urology, Published by Elsevier B.V.


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This year's National Sculpture Prize exhibition is the largest and most diverse to date – featuring the work of 39 artists from around Australia. Artists include some of Australia's leading sculptors and the exhibition surveys the range of contemporary sculptural practice.
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Bringing together over 90 works, from the colonial period to the present Moist is a rare glimpse into the Gallery's collection of Australian watercolours. While the title refers to the liquid nature of watercolour, the word 'moist' elicits images of an atmospheric, physical or emotional state of being.
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First 2000 tertiary students free
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text:
Pros: clarity, space, quality, build, isolation
Cons: treble extension, presentation is very tip dependant
>>(first impressions)
>>as tyl herstens said - "Ahhh! Someone slipped liquid gold into my ears! The genies at Shure did some
real magic here."
>>just wonderful ...handsome bass , rich and forward mids , in-offensive treble
Impressions after 6 months :-
I thought of pimping this review and adding on to the above after a full 6 months of listening .
I hated the Shure Olives at first, so started using the flex tips that came with it for most of this period except recently when i switched back on to the olives and came to know what I've been missing.
With the flex tips any one can easily point at the disorganized presentation with a 'here and there' soundstage that is loose, flabby and not so convincing in height.
Let me start with the paradox that these IEMS portray.
They have more of a dynamic sound to my ears and show lotsa timbre and texture, which essentially takes away its 'armature' nature. They are on the meatier side of things, which 'sounds wrong' in some of the fast music i listen to occasionally . I tried my hand at almost everything to get a fast sound out of them but none worked.
Another thing that these were not showing were some of the texture in treble, which in head-fi terms is a roll-off. I EQ'd my source for treble to pop out but FR charts proved me wrong there and the treble EQ gives it a piercing sound with some of the electronica that the shures handle very well.
So I decided to take a look at some faster IEMs out there and found a great deal on the CK100 pro, that's when a great head-fier pointed me to the option of after-market cables, hell he even made me a custom one, a 6N OFHC SPC.
I noticed better seperation and better treble, not instantly but you could say I sank down to it. The bass might be a bit tighter with the custom cable as well, but this is something I still have to verify.
However the flex tips were still limiting them from providing any coherency, so I went back to the olives.
Now if you can't get out of a problem, you might as well go further in. (implying my search for improving the shures at what they are good at)
So i tried the olives again, and this improved the texture even further, yes even the treble had some
body with the olives and the custom-cable.
They can be only worn over the ears.(Below is an on the ear picture of them with stock cables)
Evaluation of the sound and Conclusions:
The sub-bass of these are very much there, all the way down low, provide great texture but at the lowest of lows can sound abstract.
The mid-bass is great as well, but they don't really hit you like my DT-990 Pros do.
The mid-bass is more like a water balloon that someone threw at you, but it didn't break on impact(with your FACE) and neither did you close your eyes.
The mids are the magic. Amazingly open and very forward mids that might get annoying to some. But as much as it wowed me at first, it has still remained a great pleasure and can provide one too many eargasms. The forward mids really provide superlative clarity that still stands as a reference to my ears.
With the flex tips, I even found a lot of sibilance in the mids, this goes away obviously with the olives, comply foams etc. an example here for its mids is 'lullaby for cain' by sinead o'connor that with the 535s actually sounds like it was sang to scare a baby to death(beautiful vocals with lots of raw emotions - what did you think?)
The treble with the stock is 'very' inoffensive and sound only extended to make details audible and provide great resolution .This is the place where higher pitch toned instruments lack air and you can find deficiencies .In other words, most of the instruments like flute, trumpet, clarinet, cymbals of drums, oboe etc sound thin and bodyless once they go to the higher registers of the instrument pitch. It might be unsatisfying to many, atleast to me it is.
the solution > custom cable starting from the 6N ofhc SPC available for 60 $ all the way to the OCC 7N pure silver dream cable for 300 $, provide great compliment to the overall sound(see link below). I wouldn't say the treble just improved to sheer awesomeness or anything. It was much more strong and slightly more extended from its original presence.
The shures have a very inorganic presentation with no rawness to it imho(mind you its just the presentation and not really the sound which is supremely realistic), the music sounds forward and mesmerizing and the details sound slightly in the distance. I know the music I listen to from back to front, sideways to centre, so the 'detail' i listen to is more or less part of the rythm now. this i deem to be the characteristics of the shure magic and does not really work with the other iems I've tried.
Like a dad riding a bicycle who is helping his kid balance on a bicycle at the same time.
P.S>What most IEMS represent today are great transparency, a technical nature of revealing details and brilliant transients.
The shures might not be the best for any of the above sonic properties and signature , but the quality of sound they put out is one of its kind.
they are a good all rounder and provide a near full view of the music without sacrificing too much of any part of the sonic spectrum.(with SPC to my ears)
AFTER P.S>What I mean to say is that these are an amazing product, but more or less an acquired taste(easiest one in that way) and very expensive. They are very sensitive and provide me with deafening volumes at around 70 percent of my i-pod volume bar.
The build quality is just superb, one of my fat assed friends sat on it for hours while I was asleep and NO-THING at all happened to them, super tough build( made for audiophile construction workers out of their hard hat material) !! The microphonics of the stock cable is near to NO-THING.
The isolation is just stupendously superbly divine. A few months back, I roamed for around 3 hours in the city with the shures on, and don't even remember hearing a private bus honk reminiscent of ship horns(very present in my part of the world). Comfort again is good, but not really great. They don't really disappear into the ears, you always know they are there and cutting you off from this world in 2 ways :
1. you have them on and walk around your house, don't here the phone ringing (probably your boss who wants to fire you)
2. you have them on and walk on the road, take your DAP to change the music, forgetting you are on the middle of the stupid road and get hit by a kidnap van.
Hope you enjoyed this.
Thank you for reading.


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Teen Talks to 911 on Phone During Break-in
911 tapes reveal the shocking moments after an Omaha, Nebraska girl watched men break into her home. The 17-year-old girl was home alone when two men broke through the front door window and came inside. She hid in the closet. But the terrifying experience can also serve as a lesson and a chance to talk to you kids about being home alone.
"Someone just broke into my house," the girl said to a 911 operator.
"I just turned my head to look through the doorway and I saw someone looking in," said the girl.
She didn't know the person at the door so she didn't answer. Instead she called her mother, who didn't answer. Then she heard the sound of glass falling and ran to hide in her closet.
"I came in between the clothes and this is where I called 911," said the girl.
She stayed on the line for awhile but wasn't able to talk because the robber was in her bedroom.
"I was trying to be as quiet as I could. I wasn't sure I was going to make it to be honest," said the girl.
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Azumi 1 & 2
how about you guys.
Azumi 1 & 2
how about you guys.
Oh yeah Battle Royale rocked, not so much the second one though..
Train Man: Densha Otoko, such a sweet story,
Why don't more people read these mangas?
Are there two part of Battle Royale movie? Coz I'm planning on downloading that movie.
It was weird and kind of twisted, but interesting enough. Suicide Circle/Club.
It might be oldschool but My favorite movies from the land of the rising sun are Sanjuro, Yomjimbo, Seven Samurai, and The Hidden Fortress. Yes I'm a big fan of Akira Korosawa.
if u guys like to watch japper movies, they've got some neat shows...top of my head, hana yori dango....love story/comedy ohssss and gokusen....think GTO but a female teacher.
well tada kimi wo aishiteru is the recent japper movie i saw that really made an impact to me....one of those movies that motivates you to "grab it and dont let go" kind of movies. i've also seen anata wo wasurenai....on second thought maybe not....is it about the overprotective brother? if yes then yea i have....i was so sad after watching that movie T____T


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Rebels Jules Flat Sandal
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Item # 278574
Take on the warm months in the Rebels Jules. This gladiator inspired sandal will pair with anything in your wardrobe for an effortless look!
- Faux leather upper
- Lace-up ankle cuff
- Heel zipper
- ½" stacked wedge heel
- Synthetic sole
- Imported
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Nike Tiempo Natural IV FG Soccer Cleats - Womens
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Item # 265684
Whether its football or soccer to you, the ability to win, run, maneuver and get to the goal will depend on your cleats. The women's Nike® Tiempo Natural IV Firm-Ground Soccer Cleats are sure to get you there.
- Full grain leather upper
- Lightly padded collar
- Recycled-EVA high-density sockliner for comfort and a low-to-the-ground feel
- Lightweight TPU plate with conical and bladed studs for perfect traction and ball control
- Forefoot flex-grooves for a natural range of motion
- Oblong heel studs maximize traction during heel strike
- Imported
- View more Women's Nike Shoes
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I'm not sure about having requests here, so if I'm not allowed to, I apologize to the admins/mods. Feel free to remove it if it breaks the rules.
This is for a request of a fanfic or an AMV of a couple from Hikaru no Go-Waya Yoshitaka and Shindou Hikaru. If you're willing to do it, please PM me so we can work the details out. Please post the link to the finished work in this thread. Thank you.~


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Students at Castle Dale Elementary attended some very different classes on the morning of Oct. 24. From 9-11:45 a.m., the students had the opportunity to choose four out of 20 different mini workshops offered for an alternative to Halloween and in celebration of Red Ribbon Week.
Students spent 40 minutes in each session and seemed to enjoy the variety of experiences. There were several outdoor sports available as well as crafts and instructional sessions.


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Ask what special features your airline offers for families. Some companies offer children's meals, bassinets, gate check for strollers, or early boarding privileges.
If you can afford to do so, buy a seat for your child and bring along his carseat. Your baby is used to being buckled into his carseat, and the familiarity may make it easier for him to sit still and even sleep. This only works though when your child is able to fit comfortably in the tight seat compartments. A toddler with long legs will be scrunched between his seat and the seat in front of him. The added benefit of bringing a car seat when you can, is the safety feature of having your child in a protective seat on the airplane. Make sure your carseat bears a sticker that says it's FAA approved for air travel, so that it's not turned away at the gate. You'll need that seat anyway to get to and from the airport at home and at your destination. (Carseat rentals are typically expensive, and availability is often limited.)
Visit your baby's pediatrician a week or two before your trip to be sure your little one isn't harboring an ear infection or other illness. If possible, avoid exposing your child to other children the week before the flight so he's less likely to catch one of those many kid-carried bugs.
If you will be visiting relatives at your destination, make a family photo album and "introduce" your baby to these new people via their pictures prior to the actual meeting.
If your baby will be taking any medication on the day of the trip (such as a decongestant or pain reliever), be sure to test it out before the day of travel to gauge any side effects.
Decide if you'll need a stroller at your destination. If you don't think you'll need a conventional one, at least consider bringing a lightweight portable type for use in airports; this will give you a free hand as you tend to tasks such as luggage check-in and pickup, while keeping your child safe and close by. If you opt to take your regular stroller, you can usually check it at the gate or right at the door of the airplane.
Alternatively, a sling or soft-pack carrier can be very helpful if your child still likes to be carried and is light enough for you to carry this way for long walks through the airport.
Dress yourself and your child in comfortable layers of clothing. Airplanes are often cramped and hot, but sometimes too cold.
Use these checklists (and make lists of your own) to ensure that you don't forget anything.
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Today is February 27, 2017
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December 10, 2013
Emery Sports
December 10, 2013
Emery Sports
Emery boys and girls basketball week
After winning the first game of the week in dramatic fashion, the wheels came off just a little for the Emery High Spartan basketball team as they lost twice at the 2A/3A Boys Preview tournament at the Sevier Valley Center in Richfield on Friday and ...
HeadlineGreen River basketball teams begin season
Both of the Green River High basketball teams are off and running in the 2013-14 season. Last week the Lady Pirates played three games and won two of those games. They defeated Tabiona at home on Saturday night 39-32; lost to Kanab 56-41 the night be...
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Posted on June 21, 2012
Often over-looked genealogical resources include "vertical files" or "clipping files" kept by many libraries and historical societies. These files usually contain items such as pamphlets, newspaper clippings, hand-written notes, photocopies of pages from family bibles or diaries, newsletters and the like. The contents of each file may range from a single sheet or two to several folders. There may be only a drawer or two in a file cabinet or a bank of file cabinets. Generally these items don't appear in the catalog, but may be in a special list or you may need to speak to the reference staff. Each institution handles these items in a different manner.
At the Newberry, our vertical Family Research Files take up over 15 large file drawers. We have another 38 vertical file Family Collections that are each stored in their own archival box. Since the Newberry is a closed-stacks library, researchers are not able to browse through these materials, but need to request the folder/box they are interested in. Lists of the vertical Family Research Files and Family Collections are available online and in the library.
Here are examples of a few treasures included in the Family Research Files:
Fish Family
- Photo of house built by Samuel Fish (pre-1700) in Groton, CT
- A 1910 letter between cousins discussing their ancestors during the Revolutionary War
- An application for DAR membership
- Transcript of a will executed in 1913
- Wedding invitation
Dorsey Family
- Large hand drawn, annotated pedigree charts
- Typed family history including the descendants of Robert Fuller (MA), Benjamin Clark (RI, CT) and Peter Wright (RI, VT)
Floyd Family
- "Certificate of Qualification to Practice Medicine" for PCA Du Bois
- Floyd - Dubois Family photo album
Latah, Washington File
- Booklet from the dedication ceremony of the new Zion Church, Evangelical United Brethren, containing the history of the congregation
An example of a vertical file Family Collection would be:
Reid and Manierre Family
Papers, 1700's-1900's
Six Boxes
Abstract: Contains a thirteen folder study entitled "Ancestral Trails." First few folders are more of a family scrapbook than genealogical research. The first twelve untitled folders were complied by Julie Manierre Mann and include notes, pedigree charts, family groups sheets, certificates, news clippings, photographs, letters, music production programs, postcards, and telegrams. The last folder is "The Memoirs of Honorable George Manierre."
Please note that these Family Collections are only those collections that are relatively small and have not been included in the Newberry Modern Manuscript Collection. (More on this collection in another post.)
So take a break from the usual sources and look around for some hidden treasures - check with local libraries and historical societies. And don't forget to consult the Newberry listings!


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Another facet of our business ... Printing - ink on paper
We look small, but looks can deceive. We take gigantic pride in our commercial printing business. We consistently exceed the expectations of our clients in quality, turnaround, trouble-shooting and technical support. Ask for a list of our satisfied clients. How do we do it? Detail, detail. We listen, especially to the small stuff. And we make sure we get it right. Let's talk about your printing needs. While we're at it, we could brainstorm about where you want to be this time next year, or in five years, or ten.
Call us (717) 944-4628 or email us at firstname.lastname@example.com and we'll discuss your needs, goals, dreams.
Our equipment inventory includes Goss Community Press with Community folder, Osaka saddle/stitcher with three-knifer trimmer and cover feeder, Krause Smart-n-Easy computer-to-plate system, Kansa multi-station inserter, Kirk-Rudy mailing system, full Preps and Harelquin RIP page imposition systems, InkIt! ink optimization system.
Listen to the heart beat of community journalism!
Can you smell the ink?


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Los Angeles Lakers
Orlando Magic
Originally Posted by f19ure
No, not really.
In case you failed to realize, as the title of the thread would suggest, the Finals thread was designed to make early predictions on the outcome of the event (who would win it and so forth and why? Blah blah blah blah blah...), mine is a reflection on the entire season, leading up to last night's big moment. Your reaction to the events that occurred throughout the year (LeBron being ousted by Orlando in the Conference Finals for example)? And your reaction to last night (hence the title, ...Banner 15)? What you predict will happen during the summer (draft, summer-leagues, trades, etc...)? And what you predict will happen next season as a result of what happened this year?
Can't really break it down anymore than that. I realize the title of my thread was a bit misleading (but the one that would have been, I guess, clearer, wouldn't have been as catchy). Besides, I explained what I expected out of starting that thread pretty thoroughly.
It doesn't matter. The NBA doesn't get enough attention on this forum to warrant two threads discussing it, especially not one designed for the off season, or the regular season. The only time people bother to discuss is there is the playoffs, and more precisely, the finals. There is no necessity for two threads. You want to discuss what will happen in the next year? Do it here.
♥ Ravona
Ever wonder why one of your particularly bad posts has been deleted? Feel free to contact me!
Originally Posted by Asce
You want to discuss what will happen in the next year? Do it here.
Sure. RAPTORS WILL WIN IT NEXT YEAR!
Mangashare's Xbox 360 tournament!
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By GARY ARRINGTONSports writer
Emery continued struggling in volleyball as they lost two more region matches last week.
On Tuesday, Emery hosted the second ranked Richfield Wildcats and lost in straight sets and then on Thursday Emery traveled to Manti and lost another heartbreaker.
Against Manti, Emery won the first games 25-22 and 25-17 as they played pretty well in both games. Manti then prevented the shutout by winning the third game 25-17 and then Manti won in two very close games to win the match.
The final two game's scores were 24-26 and 14-16 as Emery was right there in both games but could not grab the win.
Against Richfield, Emery lost the first game 26-18, the second game 25-19 and then the final game 25-10 as Richfield continued their domination over region 12 volleyball so far this season.
Richfield leads the region with a 4-0 record. Juab and North Sanpete both have 2-1 records followed by Delta with a 2-2 record and Manti at 1-3. Richfield on the season has a record of 14-2.
The Deseret News rankings this season are Morgan first followed by Richfield with Hurricane third, Juan Diego fourth and Wasatch fifth.
Emery plays Delta this Tuesday night in the Spartan Center with varsity action starting around 6:30 p.m.


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The other day BtDigg was drawn to my attention due to the fact that it was the first time I've ever seen a torrent search engine that relied entirely on DHT (Distributed Hash Tables) for torrents. This means there is no central tracker to remove that would cause the files to be unavailable.
This is a good move in some respects as the main focus of the anti-piracy groups has been shutting down trackers. When they did this it effectively killed hundreds to thousands of torrents in one single swath. However, the downside of DHT is the fact that it must be a public torrent.
Currently torrent communities are split into two main groups, Private and Public trackers. Private trackers being selective about their members and many enforcing ratio's to ensure good download speeds; and public trackers allowing everyone and anyone to download torrents. The push for private trackers is that they appear to be more secure against shutdown and legal action as many of them are difficult or impossible to get into.
The addition to DHT to the Public Tracker side however means that since the has is a simple base 32 encode of a SHA-1 hash, the same content could be available from 15 public trackers. Using Peer Exchange and DHT you could be downloading from 15 separate pools of peers that would otherwise been unaccessible with out the advent of DHT and peer exchange.
There have been several filesharing platforms before that have used similar distributed hashing algorithms however, many of them have been restricted to specific applications. With the magnet/torrent DHT model it is available to be applied to any software as it's an open standard.
Do you think that the future of filesharing rests with torrents? Will we go more public in the future or private? Or shall a whole new tech replace bittorrent as the decentralized filesharing medium.


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Contacts and Astigmatism
How many times have we heard individuals bemoan being forced to wear glasses? One of the most common reasons you'll undoubted hear is "I can't wear contacts because I have astigmatism." Well, truth be told, the idea that you can't wear lenses because of this condition is a myth that far too many people buy into.
Astigmatism is a vision condition that causes vision to blur due to an irregularly shaped cornea, lens of the eye, or even the cover of the eye. Astigmatism is a very common disorder. In fact, most people have some form of astigmatism (however slight it may be); the good news is that astigmatism can now be fully corrected with contact lenses!
To find which contact lenses are optimal for you it is always best to consult with your eye care professional, so they can give advice tailored to you; but it is good to be informed of the options. An eye doctor is the only person who will be able to tell how much astigmatism you have—which is critical in deciding which specific description is for you. For more information on the different contact lens styles, check out our post How to choose the right contact lenses for your lifestyle. There are a whole slew of contact lens brands and variations to choose from—and some are specifically designed for astigmatism.
The first step in addressing astigmatism is to find out to what degree you are affected; generally astigmatism is measured in diopters. If a doctor determines that there is not much astigmatism, you may not need special contacts and can wear regular contacts. If a doctor determines that you need special contacts for astigmatism, there are fewer lens options designed for significant amounts of astigmatism (unfortunately, there is no standard definition of "significant amount of astigmatism" it is a doctor's judgment call.)
– Astigmatism of .75 diopters is about the lowest that any toric lens is designed to correct.
o A toric lens is a soft contact lens specifically designed to compensate for the irregularities of astigmatism; as well as correct any vision problems such as nearsightedness and far sightedness. If you have less than .75 diopters of astigmatism, say .6 diopters, a toric lens might not provide additional benefit over a normal soft contact lens.
o Toric lenses are generally more expensive and may feel a bit different than normal lenses. The doctor should be able to advise if the vision correction benefits would be equal between normal and toric lenses. It may be worth trying samples of each for a week to see which works better for you.
If a doctor determines that toric lenses are the right lenses for you…what brand should you go with? Well, most newer designs work very well—so brand names should not make much difference. However, some brands make their lenses in a wider range of options. The following contact lenses are some of the most popular lenses for astigmatism:
– Acuvue Oasys for Astigmatism
o Made by Johnson and Johnson. These contacts are designed to keep moist while wearing (prevent dry eyes), have good breathability, and provide a good fit. These contacts are replaced every 2 weeks if worn daily and removed/cleaned at night; or can be worn 6 days in a row and then replaced.
o Made by Cibavision. These contacts are designed for maximum oxygen permeability, consistent fit, and comfort. These are monthly disposable lenses that are meant to be removed and cleaned with solution each night.
o Made by Coopervision. These contacts are designed for all day comfort by allowing large amounts of oxygen to the eye, and reducing dry eyes with a special Aquaform Technology. These contacts can be worn 7 days straight and replaced, or as daily wear lenses removed/cleaned each night and replaced after a month.
If you have astigmatism, know that you have options—including many contact lens options! The days of glasses being your only form of vision correction are over. With this article you should be able to have an informed discussion with your eye care professional and find the best pair of contacts for you. Always remember, you can try out as many sample pair of contact lenses as you want—the eye doctor should understand and want to find the most comfortable and well performing lenses for you. Let us know about your experience with contact lenses for astigmatism in the comments section.
Comments are closed.


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Herve Leger Oribel Leather & Suede Platform Bootie
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Item # 265645
Synonymous with glamour and sensuality, Herve Leger by Max Azria captures the allure of a modern powerful woman. With a trendy design, the Oribel is the epitome of casual, yet edgy style.
- Leather & suede upper
- Back zipper
- Almond peep toe
- Fully lined in leather
- 1½" stacked platform, 5½" heel
- Rubber lug sole
- Made in Italy
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Ideally located on University Avenue, between Queen and Dundas Streets, University Centre is minutes away from both the St. Patrick and Queen Street subway stations. This Class 'A' office complex is comprised of two buildings, a 22-storey office tower, totaling 523,000 square feet and a 9-storey building totaling 170,000 square feet. An impressive granite and marble lobby with 24-hour on-site security connects the two buildings. Fitness Club The Fitness Club at University Centre offers tenants and their employees a wide variety of health and fitness services. Our goal is to provide the optimum level of beneficial exercise and enjoyment without compromising the health and safety of the members. The 10,000 square foot facility includes aerobic equipment, free weights and a variety of fitness programs. Fitness personnel provide equipment instruction, fitness testing, aerobic classes, and strength training. Men's and women's day-use lockers, fully equipped change rooms and towel service are also provided. For a complete information package or to join the Fitness Club, please call (416) 868-6831. Parking For monthly cardholders, parking is available 365 days a year, 24-hours a day in our 4-level parking garage. Handicapped spaces are located on P2 and P3. Motorcycles must park on P4 and are subject to same hourly/monthly rates as cars.University Centre may periodically offer hourly parking for temporary use, subject to space availability. The parking kiosk is open from 7:00 a.m. to 5:00 p.m., Monday to Friday, except on Building Holidays. All monthly cardholders must use their security card when entering and exiting the parking facility. Bicycle Parking A bicycle rack is located in the outdoor parking lot for tenants and their staff. For more information, please contact the Property Management Office.
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