The Journal of Urology
Volume 179, Issue 5, Supplement , Pages S33-S34, May 2008

Commentary on Prostate and Urothelial Carcinoma in Cystoprostatectomy Specimens

Department of Urology, The University of Texas Southwestern Medical Center, Dallas, Texas

Article Outline

 

There has been a growing emphasis on improving quality of life (QOL) in patients undergoing cystectomy for bladder cancer. While increased use of neobladders and nerve sparing cystectomy has resulted in some benefits from a QOL standpoint, there is still much room to improve continence and potency in men undergoing cystectomy. An area of development has been in studies evaluating total or partial prostate sparing cystectomy with the goal of preserving potency and continence.1, 2, 3, 4, 5, 6, 7 However, there is a major concern that these types of procedures may result in worse oncologic outcomes.8 As such, studies evaluating the likelihood of cancer in the prostate, prostatic urethra and apex have been critical to identify the best candidates for prostate sparing approaches.

In the preceding article Revelo et al describe their study of the incidence and location of prostate cancer and prostatic urothelial carcinoma using whole mounted prostates from 121 consecutive cystoprostatectomy specimens. Of the specimens 50 (41%) had unsuspected prostate cancer, including 24 (48%) that were clinically significant. Of the prostate cancers 60% involved the apex, including 19 of the 24 (79%) significant tumors and 11 of 26 (42%) deemed clinically insignificant.

Of the 121 specimens 58 (48%) had urothelial carcinoma involving the prostatic stroma, noninvasive urothelial carcinoma or urothelial carcinoma in situ (CIS) in the prostatic urethra or periurethral ducts, and 19 (33%) had apical involvement. Overall only 32 of 121 patients (26%) had no prostate cancer or prostate urothelial carcinoma/CIS and 45 (37%) had no clinically significant prostate cancer or prostate urothelial carcinoma/CIS in the prostate specimen. However, 70% of the patients had no apical involvement by clinically significant prostate cancer or prostate urothelial carcinoma/CIS.

Using similar methodology, Pettus et al reviewed the records of 235 consecutive patients who underwent radical cystoprostatectomy with whole mount sections of the prostate.9 They identified 113 (48%) and 77 (33%) men with prostate cancer and prostate urothelial carcinoma, respectively. Of the cases of prostate cancer 48 (42%) were considered clinically significant. Of the 77 cases of prostatic urothelial carcinoma 28 (36%) had in situ disease only, while 49 (64%) had prostatic stromal invasion. Overall, 158 (67%) of the patients had either prostate cancer or prostate urothelial carcinoma.

Due to the high risk of prostate cancer and prostate urothelial carcinoma, it is clear that selection of appropriate patients is vital to maintaining good oncologic outcomes if one pursues a prostate sparing or prostate apical sparing approach. Revelo et al noted that patients with prostatic apical involvement by invasive or in situ urothelial carcinoma uniformly had involvement of more proximal portions of the prostate. Pettus et al reported that bladder tumor location in the trigone/bladder neck and bladder CIS were strongly associated with prostate urothelial carcinoma in the final specimen.9 Similarly, Nixon et al reviewed 192 consecutive radical cystectomy specimens and found that CIS and tumor multifocality were independent predictors of prostatic urethral involvement.10 However, in their absence prostatic urethral involvement was rare.

There are multiple approaches to prostate sparing cystectomy but most of the reports have included a relatively small number of patients and different selection criteria. In one of the largest series of cystectomy with prostate sparing Vallancien et al evaluated outcomes of 100 patients with a mean followup of 38 months.1 Criteria for this approach include a normal digital rectal examination, prostate specific antigen and transrectal ultrasound of the prostate with prostate biopsies to exclude prostate cancer if any abnormalities are noted. Cystectomy with prostate sparing should not be performed if there is urothelial cancer at the bladder neck/trigone or CIS. Surgery consists of transurethral resection of the prostate with analysis of frozen section of the prostatic urethra, transitional prostate and confirmation of the absence of prostate or bladder cancer on frozen sections of the surgical capsule specimens. Most of the prostate sparing procedures include similar steps but not all involve transurethral resection of the prostate. Furthermore, the definition of prostate apical sparing is not clear as to the amount of tissue to be spared.

There is growing recognition that early cystectomy may be the best treatment for patients with bladder cancer even before muscle invasion (T1 grade 3, high risk histological variants).11 Providing improvements in QOL may reduce patient resistance to undergo cystectomy and result in improved survival. While younger men are more apt to want to have a prostate sparing procedure to preserve potency and continence, they are also more likely to live long enough to have prostate cancer. It will be important to define the optimal selection criteria for performing prostate sparing procedures and the optimal surgical technique (total prostate sparing, prostate apical sparing, seminal sparing cystectomy). Furthermore, it will be critical to make sure that QOL concerns do not outweigh oncologic outcomes since the room for error in urothelial cancer is much smaller than it is for prostate cancer.

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References 

  1. Vallancien G, Abou El, Fettouh H, Cathelineau X, Baumert H, Fromont G, et al. Cystectomy with prostate sparing for bladder cancer in 100 patients: 10-year experience. J Urol. 2002;168:2413
  2. Davila HH, Weber T, Burday D, Thurman S, Carrion R, Salup R, et al. Total or partial prostate sparing cystectomy for invasive bladder cancer: long-term implications on erectile function. BJU Int. 2007;100:1026
  3. Botto H, Sebe P, Molinie V, Herve JM, Yonneau L, Lebret T. Prostatic capsule- and seminal-sparing cystectomy for bladder carcinoma: initial results for selected patients. BJU Int. 2004;94:1021
  4. Colombo R, Bertini R, Salonia A, Naspro R, Ghezzi M, Mazzoccoli B, et al. Overall clinical outcomes after nerve and seminal sparing radical cystectomy for the treatment of organ confined bladder cancer. J Urol. 2004;171:1819
  5. Nieuwenhuijzen JA, Meinhardt W, Horenblas S. Clinical outcomes after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy) in 44 patients. J Urol. 2005;173:1314
  6. Muto G, Bardari F, D’Urso L, Giona C. Seminal sparing cystectomy and ileocapsuloplasty: long-term followup results. J Urol. 2004;172:76
  7. Martis G, D’Elia G, Diana M, Ombres M, Mastrangeli B. Prostatic capsule- and nerve-sparing cystectomy in organ-confined bladder cancer: preliminary results. World J Surg. 2005;29:1277
  8. Hautmann RE, Stein JP. Neobladder with prostatic capsule and seminal-sparing cystectomy for bladder cancer: a step in the wrong direction. Urol Clin North Am. 2005;32:177
  9. Pettus JA, Al-Ahmadie H, Barocas DA, Koppie TM, Herr H, Donat SM, et al. Risk assessment of prostatic pathology in patients undergoing radical cystoprostatectomy. Eur Urol. 2008;53:370
  10. Nixon RG, Chang SS, Lafleur BJ, Smith JA, Cookson MS. Carcinoma in situ and tumor multifocality predict the risk of prostatic urethral involvement at radical cystectomy in men with transitional cell carcinoma of the bladder. J Urol. 2002;167:502
  11. Stein JP. Indications for early cystectomy. Semin Urol Oncol. 2000;18:289

PII: S0022-5347(08)00551-X

doi:10.1016/j.juro.2008.03.009

The Journal of Urology
Volume 179, Issue 5, Supplement , Pages S33-S34, May 2008

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