Neobladder with Prostatic Capsule and Seminal-sparing Cystectomy for Bladder Cancer: A Step in the Wrong Direction

Prevalence of incidental prostate cancer in patients undergoing radical cystoprostatectomy: data from China and other Asian countries

The purpose of this study is to investigate the frequency of prostate cancer (Pca) discovered incidentally in radical cystoprostatectomy specimens in Asia and to determine the feasibility of prostate-sparing cystectomy (PSC) for Asian patients. Ninety-two male bladder cancer patients who underwent radical cystoprostatectomy at our center between January 2003 and January 2008 were included in this study. The mean age of patients was 67.1 years (range: 32-75 years). Prostate-specific antigen (PSA) levels and digital rectal examination (DRE) results before surgery were obtained retrospectively. Prostates of all patients were embedded and sectioned at 5-mm intervals. The same pathologist examined the prostatic tissues from radical cystoprostatectomy specimens. Finally, a structured literature review was performed using MEDLINE and PUBMED to estimate the occurrence of incidental Pca in Asia. Of the 92 patients, 3 (3.3%) were found to have Pca; in one out of three (33.3%) patients the disease was clinically significant due to a Gleason grade 4 carcinoma. Eight articles were included in our review. The overall incidence of Pca discovered incidentally in radical cystoprostatectomy specimens in Asia was 9.9% (64/642). When age was restricted to < 60 years, only 7 out of 222 (3.2%) patients were found to have synchronous Pca, and none of the cases was clinically significant. The occurrence of Pca in radical cystoprostatectomy specimens in Asia is much lower than that in Western countries. PSC might be feasible for Asian patients under a strict preoperative selection.

Risk Assessment of Prostatic Pathology in Patients Undergoing Radical Cystoprostatectomy

OBJECTIVES

To determine the incidence and location of prostate adenocarcinoma (PCa) and prostatic urothelial carcinoma (PUC) for patients undergoing radical cystoprostatectomy (RCP) for bladder cancer and to ascertain what preoperative information may be useful in predicting PUC or PCa in patients who may be candidates for prostate-sparing cystectomy.

METHODS

Between 2001 and 2004, 235 consecutive patients underwent RCP and had whole-mount sections of the prostate. We reviewed our prospective radical cystectomy database for preoperative clinicopathological information associated with each patient. The bladder and whole-mount prostate sections were re-reviewed to determine the location and depth of the bladder tumor as well as the presence of any associated PCa and PUC.

RESULTS

We identified 113 of 235 (48%) and 77 of 235 (33%) men with PCa and PUC, respectively. Among patients with PCa, 33 (29%) had Gleason score of > or = 7, 25 (22%) had PCa tumor volume > 0.5 cc, and 15 (13%) had extracapsular extension. On multivariable analysis, only increasing age was significantly associated with PCa (odds ratio=1.3, p=0.046). Of the 77 with PUC, 28 (36%) had in situ disease only, while 49 (64%) had prostatic stromal invasion. Bladder tumor location in the trigone/bladder neck (p<0.001) and bladder carcinoma in situ (p<0.001) was strongly associated with PUC in the final specimen. Overall, 158 (67%) had either PCa or PUC in the prostate.

CONCLUSIONS

PCa and/or PUC is present in a majority of RCP specimens. Current preoperative staging and tumor characteristics are not adequate for determining who can safely be selected for prostate-sparing cystectomy.

Radical cystectomy and lymphadenectomy for invasive bladder cancer: towards the evolution of an optimal surgical standard

The surgical management of invasive bladder cancer has undergone a significant evolution in technique since its initial introduction. Changes in the extent of surgery have largely reflected a better understanding of the natural history of bladder cancer and the recognized pathways of progression. Incorporation of contemporary surgical techniques that target the perivesical soft tissues, regional lymph nodes, and adjacent organs appear to enhance oncologic outcomes. A growing body of evidence indicates that the quality of radical cystectomy (RC) directly affects patient outcome. Recently, quality of life and functional considerations have led to surgical modifications such as nerve-, prostate-, vaginal wall-, and urethra-sparing approaches. While some modifications in appropriate candidates appear not to decrease cancer control, further studies will be needed to establish their role and safety. This ongoing evolution in the technique of RC and pelvic lymph node dissection (PLND) may help define a new surgical standard that provides optimal benefit in patients with invasive bladder cancer.

Urothelial carcinoma in the prostatic urethra and prostate: current controversies

We reviewed the literature on urothelial carcinoma in the prostatic urethra and prostate. We concluded that the incidence of urothelial carcinoma in the prostatic urethra and prostate is probably underestimated. This fact warrants thorough follow-up of patients with high-risk bladder cancers and also whole-mount examination of the prostate after cystectomy to recognize the true incidence and extent of such tumor involvement. Resectoscope loop biopsy is the method of choice to detect urothelial carcinoma in the prostatic urethra/prostate and such biopsies should include the area around the verumontanum to ensure optimal sensitivity. Carcinoma in situ in the prostatic urethra should be treated with intravesical Bacillus Calmette-Guérin and a transurethral resection of the prostate prior to that treatment might increase the contact of Bacillus Calmette-Guérin with the prostatic urethra, improve staging and in itself treat the prostatic involvement. Conservative treatment of carcinoma in situ in the prostatic ducts is an option, although radical surgery is probably best for treating extensive intraductal involvement, since data on the former strategy are inconclusive. Patients with stromal invasion should undergo radical surgery. It is necessary to take the route of prostatic involvement into account when estimating prognosis in each individual patient, since contiguous growth into the prostate is associated with worse prognosis. Prospective studies using a whole-mount technique to investigate the prostate are needed to clarify both the role of different routes of prostate invasion and the prognostic significance of different degrees of prostate invasion. At cystectomy, when urothelial carcinoma is present in the prostatic urethra and/or prostate, it is necessary to balance the risk of urethral recurrence and decreased sexual function against opinion and expectations expressed by the patient during preoperative counseling regarding urinary diversion and primary urethrectomy.

Surgical benchmarks for the treatment of invasive bladder cancer

Radical cystectomy is the gold standard for treatment of localized invasive bladder cancer in the United States. In recent years, there has been increasing focus on the importance of surgical technique as a factor that may influence the clinical and oncologic outcome of the operation, beyond the classically recognized patient and tumor-related factors. There is still insufficient high-quality evidence to support the absolute standardization of the surgical technique or the establishment of firm benchmarks by which the individual surgeon can measure performance. However, there is considerable evidence suggesting that 3 aspects of surgical technique have an impact on outcome: (1) Positive surgical margins nearly always result in ultimate cancer death. The rate of positive margins varies with surgeon experience as well as with cancer-specific variables. (2) The extent of lymphadenectomy has a significant impact on recurrence rates of the cancer, regardless of whether the lymph nodes are pathologically positive or not. (3) Higher volume surgeons have lower operative mortality and fewer positive surgical margins than low-volume surgeons. Higher volume hospitals also have lower operative mortalities and shorter hospital stays for patients who have undergone radical cystectomy. In this review, the authors evaluate the evidence supporting each of these statements and suggest potential areas of standardization of surgical technique that could translate into improved patient outcomes.

Clinically significant prostate cancer found incidentally in radical cystoprostatectomy specimens

OBJECTIVE

To review the incidence, histopathological features and clinical outcomes of patients with incidental prostate cancer found in radical cystoprostatectomy (RCP) specimens excised for bladder cancer, to determine if these cancers affected the follow-up strategy and if prostate-sparing cystectomy would be appropriate for these patients.

PATIENTS AND METHODS

We retrospectively reviewed the charts of men who had a RCP for transitional cell carcinoma (TCC) of the bladder, at our institution between 1987 and 2003. Patients with a preoperative diagnosis or clinical suspicion of prostate cancer were excluded from further analysis. We identified those men with incidental prostate cancer in the RCP specimens. The patients' demographic, histopathological and clinical outcome data were collected.

RESULTS

In all, 217 men had RCP for TCC between 1987 and 2003; 13 were excluded from the study due to a preoperative diagnosis or clinical suspicion of prostate cancer, and 58 (28%) were found to have incidental prostate cancer. The mean (range) follow-up was 47 (6-157) months. Of these prostate cancers, 20% were of Gleason score > or = 7 and two patients developed local and metastatic prostate cancer recurrences.

CONCLUSION

Incidental prostate cancer is a relatively common finding in RCP specimens, with a significant proportion having the characteristics of clinically relevant prostate cancer. The follow-up for prostate cancer should be incorporated with that for TCC and adapted according to the grade and stage of the prostate cancer. Preserving the prostate in an attempt to decrease the morbidity after RCP carries a high risk of significant prostate cancer in the residual prostatic tissue, suggesting that prostate-sparing cystectomy should only be reserved for a highly selected group of patients.

Should prostate cancer status be determined in patients undergoing radical cystoprostatectomy?

INTRODUCTION

We estimate the frequency of prostate cancers detected incidentally in radical cystoprostatectomy specimens and discuss whether the prostate cancer status should be determined in patients undergoing radical cystoprostatectomy.

MATERIALS AND METHODS

A total of 97 radical cystoprostatectomies without evidence of prostate cancer on digital rectal examination were performed for transitional cell carcinomas of the bladder between January 2001 and May 2004. The mean patient age at the time of surgery was 66.9 +/- 9.52 (range 49-75) years.

RESULTS

The overall incidence of prostate cancer detected in radical cystoprostatectomy specimens was 21.6% (21/97 specimens). The mean tumor volume was found to be 0.93 +/- 0.81 ml. The tumor volume was >0.5 ml in 12 cases (57.1%). The surgical margin was negative in all cases, and the disease was organ confined in 20 patients (95.2%). Capsular invasion was evident in 2 patients (9.5%), 1 of whom had lymph-node-positive disease.

CONCLUSIONS

Despite the high prevalence of incidental prostate carcinomas among patients with bladder cancer undergoing cystoprostatectomy, the vast majority of the cancers are organ confined. However, the prostate cancer status should be determined on the basis of digital rectal examination and prostate-specific antigen in patients undergoing radical cystoprostatectomy - especially if prostate-sparing cystectomy is planned.

Nerve-sparing laparoscopic radical cystectomy: Technique and initial outcomes

OBJECTIVES

To report the technique and early outcomes of nerve-sparing laparoscopic radical cystectomy with continent orthotopic ileal neobladder in selected male and female patients with bladder cancer.

METHODS

Since 2000, 52 patients have undergone laparoscopic radical cystectomy at our institution, with nerve-sparing laparoscopic radical cystectomy performed in 5 patients. In the nerve-sparing technique, transection of the lateral vascular pedicle and the posterior dissection proceeds closer to the bladder, at some distance from the rectum. Hem-o-lock clips were used for hemostasis, avoiding the need for any energy source near the neurovascular bundle (NVB). In the male, the identification and complete release of the NVB before division of the urethra minimizes damage to the NVB along the prostatic apex. In the female, preservation of the uterus, fallopian tubes, ovaries, and vagina, maintenance of the endopelvic fascia, and minimal mobilization distal to the urethra facilitates nerve sparing.

RESULTS

The median operative time was 10 hours, blood loss was 400 mL, and the length of stay was 5 days. No patient required blood transfusion, and one had a postoperative complication. All patients were free of recurrence at a median follow-up of 30 months. At 12 months, nocturnal and daytime continence was preserved in 100% and 75% of patients, respectively. Sexual function was preserved in the female patient and 2 of the 4 male patients.

CONCLUSIONS

With careful attention to the anatomic location of the NVBs and a precise operative technique, nerve-sparing laparoscopic radical cystectomy can be performed in appropriately selected male and female patients with organ-confined bladder cancer.

Management of BCG Failures in Superficial Bladder Cancer: A Review

OBJECTIVE

Review management of bacillus Calmette-Guérin (BCG) failures in superficial bladder cancer.

METHOD

Search of published literature and meeting abstracts.

RESULTS

Patients in whom BCG fails are not a uniform group. Failure cannot be predicted but high-risk patients can be identified. In case of failure and progression the outcome is bad. Conservative but investigative alternatives are BCG/interferon-alpha, intravesical hyperthermia/chemotherapy, or photodynamic therapy. Standard treatment in failing patients remains cystoprostatectomy.

CONCLUSION

BCG failures need careful and individualized therapy in experienced hands.