Transurethral prostate biopsy before radical cystectomy remains clinically relevant for decision-making on urethrectomy in patients with bladder cancer

Prostatic urethra recurrence after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC)

Urinary bladder cancer is frequently multifocal and has a high incidence of recurrence. Although the prostatic urethra is a frequent site of tumor relapse in patients with non-muscle-invasive bladder cancer treated with TURBT, such tumors are often underdiagnosed. Here we present two cases having urethral recurrence after TURBT.

Incidence, risk factors and outcomes of urethral recurrence after radical cystectomy for bladder cancer: A systematic review and meta-analysis

We aimed to conduct a systematic review and meta-analysis assessing the incidence and risk factors of urethral recurrence (UR) as well as summarizing data on survival outcomes in patients with UR after radical cystectomy (RC) for bladder cancer. The MEDLINE and EMBASE databases were searched in February 2021 for studies of patients with UR after RC. Incidence and risk factors of UR were the primary endpoints. The secondary endpoint was survival outcomes in patients who experienced UR. Twenty-one studies, comprising 9,435 patients, were included in the quantitative synthesis. Orthotopic neobladder (ONB) diversion was associated with a decreased probability of UR compared to non-ONB (pooled OR: 0.44, 95% CI: 0.31-0.61, P < 0.001) and male patients had a significantly higher risk of UR compared to female patients (pooled OR: 3.16, 95% CI: 1.83-5.47, P < 0.001). Among risk factors, prostatic urethral or prostatic stromal involvement (pooled HR: 5.44, 95% CI: 3.58-8.26, P < 0.001; pooled HR: 5.90, 95% CI: 1.82-19.17, P = 0.003, respectively) and tumor multifocality (pooled HR: 2.97, 95% CI: 2.05-4.29, P < 0.001) were associated with worse urethral recurrence-free survival. Neither tumor stage (P = 0.63) nor CIS (P = 0.72) were associated with worse urethral recurrence-free survival. Patients with UR had a 5-year CSS that varied from 47% to 63% and an OS - from 40% to 74%; UR did not appear to be related to worse survival outcomes. Male patients treated with non-ONB diversion as well as patients with prostatic involvement and tumor multifocality seem to be at the highest risk of UR after RC. Risk-adjusted standardized surveillance protocols should be developed into clinical practice after RC.

Risk factors, follow-up, and treatment of urethral recurrence following radical cystectomy and urinary diversion for bladder cancer: a meta-analysis of 9498 patients

Purpose

Patients frequently undergo radical cystectomy and urinary diversion for treatment of bladder cancer. However, they remain at risk of urethral recurrence (UR). Studies have determined various risk factors leading to urethral recurrence. However, no publications have weighed the predictive values of these factors.

Materials and Methods

Studies published between 1971 and 2016 were retrieved from PubMed, EMBASE and MEDLINE. We used STATA software (Version 12.0) to estimate the pooled risk ratio.

Results

Twenty-five publications with 9498 patients were included. Overall, male patients, especially those with concomitant carcinoma in situ, superficial or intravesical bladder cancer, non-orthotopic diversion, prostatic involvement, bladder neck involvement, positive urethral margins or multifocal bladder cancer were at higher risk of urethral recurrence. The overall risks of recurrence, reported as risk ratios, varied widely. Among all 25 studies, 118 (60.2%) cases in 9 studies were diagnosed through routine follow-up. Another 82 (40.8%) patients in 11 studies first reported symptomatic abnormalities. Prognoses were worse for patients with symptomatic recurrence. Urethral cytology was the most common diagnostic method. Treatment after UR was reported for 272 cases in 14 publications, and 190 patients underwent urethrectomy and 52 underwent urethra-sparing treatments. Outcomes after UR were described in 12 studies reporting 180 cases, and 41 patients were alive through the end of follow-up and 65 patients died of bladder cancer.

Conclusions

UR following radical cystectomy for bladder cancer was closely related to risk factors. Precautions, strict follow-up protocols and rational therapies were critical to patients with high risks of urethral recurrences.

The role of prostatic urethral biopsies as a staging tool for bladder cancer

Objective:

To determine the incidence of prostatic urethral involvement in our patient population and how prostatic urethral biopsy correlates with final cystectomy pathology.

Patients and methods:

We conducted a retrospective review of prostatic urethral biopsies (PUB) performed between February 2008 and April 2012 in a single centre. PUB pathology was correlated with cystectomy pathology.

Results:

PUB was undergone by 172 patients with a median age of 70 years (range: 37–84 years): There were 35 (20%) patients having a positive PUB and 137 (80%) who were negative. Of the 94 patients who underwent cystectomy, we found that when the entire prostatic urethra was sectioned, 20 (21%) patients had cancer in the prostatic urethra. Cancer was found in 17 (77%) of 22 patients with a positive PUB and in three (4%) out of the 72 with a negative PUB (positive predictive value (PPV) 77%, negative predictive value (NPV) 96%, sensitivity 85% and specificity 93%). In all 94 patients, the prostatic apical margin was negative.

Conclusion:

Disease in the prostatic urethra affected 20% of patients, consistent with published data. Prostatic urethral apical margins were all negative. Intra-operative frozen section would have missed cancer in the 20 patients with prostatic urethral cancer, whereas PUB identified 17 (85%) of the 20 patients. These data confirm the value of using PUB before cystectomy, in our UK population.

Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy

CONTEXT

Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs).

OBJECTIVE

To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC.

EVIDENCE ACQUISITION

A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors.

EVIDENCE SYNTHESIS

Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective.

CONCLUSIONS

SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment.

PATIENT SUMMARY

Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.