Commentary on Clinical Outcomes of Sexuality Preserving Cystectomy and Neobladder
Article Outline
The preceding article by Nieuwenhuijzen et al adds to the growing number of reports on prostate and seminal vesical sparing during radical cystectomy for bladder cancer in men. The 3 goals of such modifications over traditional radical cystoprostatectomy are to 1) maintain oncologic control, 2) increase functional outcomes for urinary continence and erectile function, and 3) preserve fertility among younger patients. The topic remains controversial.1, 2, 3
The first obligation is to obtain optimal control of the bladder cancer for which treatment was indicated initially. The oncologic issues are exclusion of transitional cell carcinoma (TCC) in the prostatic urethra or invasion into the prostate, avoidance of tumor spillage when the bladder neck is divided and exclusion of prostate cancer. TCC of the prostate is reported in 17% to 48% of cystectomies.1 An even higher prevalence of prostate cancer is reported in men who undergo cystectomy for bladder cancer.1, 2, 3 Local and/or distant patterns of urothelial tumor recurrence may be altered by the surgical technique. Urinary continence after standard radical cystoprostatectomy and neobladder is good to excellent in most patients. Erectile function also may be preserved in some men.
In the study by Nieuwenhuijzen et al patients were evaluated with serum prostate specific antigen measurements and prostate sextant biopsies, and all had negative biopsies of the bladder neck and prostatic urethra. Patients were excluded from study if the bladder tumor was near the bladder neck. Today a larger number of prostate biopsies would be performed to exclude prostate cancer. Urinary continence was excellent and consistent with other reports for standard radical cystoprostatectomy and neobladder. However, clean intermittent catheterization was required in 28% of the patients. This rate is higher than most neobladder series and suggests either obstruction by the remaining prostate tissue or narrowing at the anastomosis of the neobladder to the bladder neck/prostate remnant. The results for preservation of erectile function were good and exceed those for standard nerve sparing cystoprostatectomy.
Before one can analyze the oncologic outcome in the current series, it must be noted that 12 of the 43 patients received either neoadjuvant or adjuvant methotrexate, vinblastine, doxorubicin and cisplatin chemotherapy for clinically positive nodes or locally advanced disease. The potential impact of this uncontrolled use of chemotherapy clouds the ability to interpret the oncologic safety of the surgical technique. Despite the frequent use of chemotherapy, disease specific mortality was seen in 30% of patients at a mean followup of 42 months. Pelvic relapse was seen in 6.9% of patients, one of whom had stage pT1N0 disease. Pelvic relapse is associated with a high fatality rate and should rarely if ever be seen in organ confined disease.
Concern remains for an increased risk of pelvic tumor spillage with this technique. The development of subsequent carcinoma in situ (CIS) of the prostatic urethra in 1 patient is not an indictment of the prostate sparing as CIS also may occur in the remainder of the urethra after standard cystoprostatectomy. The development of prostate cancer in 1 patient indicates the need to monitor for prostate cancer after prostate sparing cystectomy as well as the inevitable need to assess risks and benefits of treating this common malignancy in many of these patients.
Invasive bladder cancer is a lethal and unforgiving disease. The authors have shown that prostate sparing cystectomy is feasible and provides good functional outcomes. Preservation of erectile function is more achievable with their technique than with careful nerve sparing cystoprostatectomy. Urinary continence is equivalent with either approach. The oncologic safety of prostate sparing cystectomy remains an open question. Reports of larger series and longer followup are needed. For all of these reasons prostate sparing cystectomy would seem best restricted to a narrow subset of young patients with bladder cancer and no increased risk of prostate cancer, who are highly motivated for maximal attempt at retaining potency and/or fertility and who acknowledge the potential increased oncologic risks.
References
- . Neobladder with prostatic capsule and seminal-sparing cystectomy for bladder cancer: a step in the wrong direction. Urol Clin North Am. 2005;32:177
- . Clinical indications and outcomes with nerve-sparing cystectomy in patients with bladder cancer. Urol Clin North Am. 2005;32:165
- Evaluation of the prostate peripheral zone/capsule in patients undergoing radical cystoprostatectomy: defining risk with prostate capsule sparing cystectomy. Urol Oncol. 2007;25:460
PII: S0022-5347(08)00557-0
doi:10.1016/j.juro.2008.03.015
© 2008 American Urological Association. Published by Elsevier Inc. All rights reserved.