Prostate Sparing Cystectomy for Bladder Cancer: 20-Year Single Center Experience

Loss of ORP3 induces aneuploidy and promotes bladder cancer cell invasion through deregulated microtubule and actin dynamics

We have recently shown that loss of ORP3 leads to aneuploidy induction and promotes tumor formation. However, the specific mechanisms by which ORP3 contributes to ploidy-control and cancer initiation and progression is still unknown. Here, we report that ORP3 is highly expressed in ureter and bladder epithelium while its expression is downregulated in invasive bladder cancer cell lines and during tumor progression, both in human and in mouse bladder cancer. Moreover, we observed an increase in the incidence of N-butyl-N-(4-hydroxybutyl)-nitrosamine (BBN)-induced invasive bladder carcinoma in the tissue-specific Orp3 knockout mice. Experimental data demonstrate that ORP3 protein interacts with γ-tubulin at the centrosomes and with components of actin cytoskeleton. Altering the expression of ORP3 induces aneuploidy and genomic instability in telomerase-immortalized urothelial cells with a stable karyotype and influences the migration and invasive capacity of bladder cancer cell lines. These findings demonstrate a crucial role of ORP3 in ploidy-control and indicate that ORP3 is a bona fide tumor suppressor protein. Of note, the presented data indicate that ORP3 affects both cell invasion and migration as well as genome stability through interactions with cytoskeletal components, providing a molecular link between aneuploidy and cell invasion and migration, two crucial characteristics of metastatic cells.

Oncological and functional outcomes of organ-preserving cystectomy versus standard radical cystectomy: A systematic review and meta-analysis

Introduction

Radical cystectomy (RC) is historically considered the gold standard treatment for muscle invasive and high-risk non-muscle invasive bladder cancer. However, this technique leaves the majority of patients of both sexes with poor sexual and urinary function. Organ-sparing cystectomy (OSC) techniques are emerging as an alternative to the standard procedure to preserve these functions, without compromising the oncological outcomes. We present a systematic review and meta-analysis of the published literature.

Methods

MEDLINE, Embase and Web of Science were systematically searched for eligible studies on 6 April 2021. Primary outcomes studied were both oncological outcomes, specifically overall recurrence, and functional outcomes, specifically sexual function, and daytime and nighttime continence. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. The PROSPERO registration reference number was CRD42018118897.

Results

From 13 894 identified abstracts, 19 studies (1886 male and 305 female patients) were eligible for inclusion in this review. These studies included patients who underwent either whole prostate, prostate capsule, seminal vesicle, nerve, uterus, ovary, vagina and fallopian tube sparing techniques. Four studies included only female patients.Thirteen studies reported oncological outcomes, and overall recurrence rate was similar between the two groups (five studies; OR 0.73; 95% CI 0.38-1.40, p = 0.34). Thirteen studies reported on male sexual function. In men, OSC had significantly greater odds of retaining potency (five studies; OR 9.05; 95% CI 5.07-16.16, p < 0.00001). Fourteen studies (13 on males and 1 female) reported urinary outcomes. In men, OSC demonstrated greater odds of daytime (seven studies; OR 2.61; 95% CI 1.74 to 3.92, p < 0.00001) and nighttime continence (seven studies; OR 2.62; 95% CI 1.76 to 3.89, p < 0.00001).

Conclusion

In carefully selected patients, OSC allows the potential to provide better sexual and urinary function without compromising oncological outcomes. There remains, however, a paucity of OSC studies in females. Further studies are required to make recommendations based on robust clinical evidence.

Cystectomy for Benign Indications

PURPOSE OF REVIEW

This article evaluates the historical influences, current use, surgical techniques, and recent evidence on outcomes for cystectomy performed for benign indications.

RECENT FINDINGS

At the population level, cystectomy for benign indications has similar perioperative morbidity to radical cystectomy for cancer. Postoperative patient satisfaction is high and functional outcomes appear good, including sexual function. Patient regret about diversion choice is low provided decisions are well informed. Cystectomy is important both as a primary procedure for benign disease and as an adjunct to primary urinary diversion. Early morbidity remains high but long-term results are encouraging. Further studies are needed to guide patient decision-making, to help inform diversion choice, and to understand the long-term impact of surgery and diversion choice on quality of life.

Extraperitoneal Laparoscopic Radical Cystectomy With Preservation of Fertility for the Treatment of Ewing Sarcoma: The First Report of a Reliable Surgical Method

OBJECTIVE

To improve the complications of traditional laparoscopic radical cystectomy (LRC), a novel technique of extraperitoneal laparoscopic radical cystectomy (ELRC) with preservation of fertility was described.

MATERIALS AND METHODS

Selected patients with bladder cancer were treated with the ELRC technique. The seminal vesicles and the vas deferens were preserved. Patient's perioperative conditions, tumor prognosis, and follow-up data were analyzed retrospectively.

RESULTS

We successfully completed ELRC surgery in dozens of patients. The orthotopic ileal neobladder was placed in the extraperitoneal area, completely preserving the peritoneum. The postoperative complications caused by postoperative peritoneal loss were reduced. Moreover, the perioperative period was strictly managed with the concept of enhanced recovery after surgery (ERAS). We described the operation process in detail through a typical case of a child. All patients were free of complication at short-term follow-up, and reported satisfied sexual function with normal erections.

CONCLUSION

The ELRC technique has benefits in terms of decreased ileus, reoperation rates, hospital stay, ease of management of urinary leaks, and improves the patient quality of life. ELRC is also an oncologically safe approach with excellent significant functional outcomes in carefully selected transitional cell carcinoma (TCC) or non-TCC patients who expect to maintain sexual function and fertility, especially for young patients. In addition, more patient groups and longer follow-ups are needed to further understand the safety and practicality of the ELRC technology.

Erectile dysfunction post radical cystectomy. The role of early rehabilitation with pharmacotherapy in nerve sparing and non-nerve sparing group: A randomized, clinical trial

OBJECTIVES

No clinical studies testing erectile function (EF) post radical cystectomy (RC) were done. Our objective was to assess the effect of early pharmacologic therapy after RC using intracorporeal injection (ICI), phosphodiesterase inhibitor (PDE5i) and PDE5i+ICI.

MATERIALS AND METHODS

In our randomized, double-blinded study, we prospectively enrolled 160 potent male patients with invasive bladder cancer. Patients were operated by RC using the nerve-sparing (NS) or non-nerve sparing (NNS) technique. They were treated since 1 month postoperatively by different regimens (PDE5i vs. ICI vs. ICI+PDE5i). Patients were evaluated using the international index of erectile function questionnaire and were followed up regularly at 1, 3, 6, and 12 months using the same parameters.

RESULTS

One month after therapy, the mean of EF domain improved in both NS and NNS group. In the NNS group, in patients treated with ICI alone and ICI+PDE5i, the EF domain at 12 months moved to the moderate and to the mild category respectively. In patients treated by the NS approach, the mean value remained in the mild category with or without therapy.

CONCLUSIONS

Early pharmacotherapy since one-month post RC using ICI and a combination of ICI+PDE5i can improve the erectile function of patients operated with a NNS approach.

Early Oncological and Functional Outcomes of Prostate Capsule Sparing Cystectomy Compared with Standard Radical Cystectomy

Introduction and Objectives

A comparative study of standard radical cystectomy and prostate capsule sparing radical cystectomy regarding functional and oncological outcomes.

Materials and Methods

A randomized study of 96 patients with transitional cell carcinoma of the bladder (December 2014 - June 2016) was done. We excluded cases with preoperative T4 staging, lymphadenopathy, prostatic specific antigen > 4 ng/dl, and cases with positive biopsies from the bladder neck, trigone, and/or prostatic urethra. Patients were divided into 2 groups, Group 1: standard radical cystectomy with orthotopic diversion (n = 51), Group 2: prostate capsule sparing cystectomy with orthotopic diversion (n = 45). Preoperative transrectal ultrasound and prostatic biopsies were done in Group 2 to exclude prostate cancer. We compared the urinary continence and erectile function in both groups after 6 months, 1, and 2 years.

Results

There was no significant difference between the groups regarding preoperative demographic data, tumor stage, grade, site by cystoscopy, and biopsy. Intraoperative monitoring showed no significant differences regarding blood loss, surgical complications, or operative time (2.5 ± 0.48 vs. 2.4 ± 0.45 h). There was a significantly higher percentage of continence and potency in Group 2 than in Group 1. Sixteen cases (35.6%) in Group 2 but only 4 cases (7.8%) in Group 1 developed large post-voiding residual urine and needed intermittent self-catheterization cleaning (p = 0.001). The tumor recurrence rate was not significantly different between the groups after 2 years (p = 0.3).

Conclusion

Prostate capsule sparing cystectomy is a good option in selected cases with better continence and potency and without compromising oncological outcomes after 2 years.

Prostate cancer incidentally discovered at the time of radical cystoprostatectomy does not decrease overall survival: Results from a large Chinese medical center

Purpose

To investigate the incidence and pathologic characteristics of prostate cancer (PCa) incidentally discovered at the time of radical cystectomy and its impact on overall survival.

Materials and Methods

A single center retrospective study of 762 male patients who underwent radical cystoprostatectomy from Jan 1994 to Dec 2012.

Results

Of all included patients, 132 (17.3%) were found to have PCa. Patients with incidental PCa had a significantly higher mean age (69.2 vs. 62.2 years, P=0.015). Among the 132 patients with PCa, prostate specific antigen (PSA) analysis was available in 76 patients (57.6%), with a median value of 1.06ng/mL, and 61 (80.3%) patients had a PSA value below 4ng/mL. Four hundred and thirty-six patients (57.1%) were successfully followed, with a median duration of 46.5 months. The overall 5-year survival rate was 62.1%, and the 5-year cancer–specific survival rate was 72%. PCa recurrence was defined by two consecutive PSA values of >0.2 ng/mL and rising, and no PCa recurrence occurred. According to a univariate analyses, incidental PCa was not associated with cancer-specific survival (P=0.192) or overall survival (P=0.493). According to univariate analyses, the overall survival of patients with PCa was not associated with prostate cancer staging, PSA value, or Gleason score (All P values>0.05).

Conclusions

Prostate cancer incidentally discovered at the time of radical cystectomy does not decrease overall survival. Patients with incidental PCa were older than those without. The PSA value before operation is not helpful for predicting incidental prostate cancers.

Comparisons of Quality of Life and Functional and Oncological Outcomes after Orthotopic Neobladder Reconstruction: Prostate-Sparing Cystectomy versus Conventional Radical Cystoprostatectomy

OBJECTIVES

To compare health-related quality of life and oncological and functional outcomes on erectile function, continence, and voiding function among bladder patients who underwent orthotopic neobladder reconstruction after prostate-sparing cystectomy (PSC) and conventional radical cystoprostatectomy (CRC).

METHODS

This is a retrospective cohort study from a single surgeon. During 2007 to 2015, we identified 25 of 186 male patients receiving radical cystectomies due to bladder cancer who underwent orthotopic neobladder reconstruction, 14 patients with PSC and the other 11 patients with CRC. International Index of Erectile Function-5 (IIEF-5), International Prostate Symptom Score (IPSS), European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire-Core 30-item questionnaire (EORTC-QLQ-C30), and self-catheterizations were used to evaluate functional outcomes in the baseline and 1 year after operation.

RESULTS

There were better physical and social functioning scales, less fatigue symptoms, better IIEF (16 versus 3.7, p = 0.01), and less self-catheterization rate (33% versus 89%  p = 0.006) in the PSC group. The oncologic outcomes were the same between two groups.

CONCLUSIONS

For selected patients with bladder cancer who underwent neobladder reconstruction, prostate-sparing cystectomy provided better sexuality preservation, less daily self-catheterization, and better physical function and social function scales without compromising overall survival.

Oncological and functional outcomes of sexual function-preserving cystectomy compared with standard radical cystectomy in men: A systematic review

INTRODUCTION

Different sexual function-preserving surgical techniques aimed at improving voiding and sexual function in patients undergoing radical cystectomy for bladder cancer have been described. The objective of this systematic review is to determine the effect of sexual function-preserving cystectomy (SPC) on functional and oncological outcomes.

MATERIALS AND METHODS

Relevant databases were searched covering the time frame 2000 to 2015. All publications presenting data on any type of SPC reporting oncological or functional outcomes with a minimum follow-up of 1 year were identified. Comparative studies including a minimum of 30 patients and single-arm case series with a minimum of 50 patients were selected. No language restrictions were applied.

RESULTS

In a total of 8,517 identified abstracts, 12 studies were eligible for inclusion. SPC described included prostate-, capsule-, seminal vesicle, and nerve-sparing techniques. Local recurrence ranged from 1.2% to 61.1% (vs. 16.0%-55.0% in the control group) and metastatic disease from 0% to 33.3% (vs. 33.0%). No differences were found in comparative studies reporting oncological outcomes. Postoperative potency was significantly better in the SPC groups in 6 studies comparing sexual function-preserving cystectomy vs. radical cystectomy (P<0.05). No major effect on continence was found. Overall, there was moderate to high risk of bias and confounding.

CONCLUSIONS

The evidence base for prostate-, capsule-, or nerve-sparing cystectomy suggests that these procedures may yield better sexual outcomes than standard cystectomy, without compromising oncological outcomes. However, the overall quality of the evidence was moderate, and hence if offered, patients must be carefully selected, counseled, and closely monitored.

Advances in surgical management of muscle invasive bladder cancer

INTRODUCTION

Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC).

METHODS

A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review.

RESULTS

Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients.

CONCLUSION

There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here.

Radical cystectomy: do we need standardization?

INTRODUCTION

The first series of radical cystectomy with a definition of surgical landmarks was published in 1949 and was characterized by a high perioperative mortality and a 5-year survival rate around 50%. Decades later, nevertheless many surgical progresses were made and the perioperative mortality dropped to 2,5%, this had not lead to an improvement of long term survival rates, also because a standardization of the procedure is still missing. Areas covered: Radical cystectomy is performed with different surgical techniques obmitting a standardization. The comparability of many studies is therefore difficult or havely compromised. A paragon with other diciplines was made emphazing that there high surgical quality is defined, measured and controlled. A systematic literature search was made selecting finally 76 article adressing this issue. Expert commentary: Surgical guidelines in uro-oncology are vague and a definition of surgical quality is missing. A view outside of the box could be very helpful. This is a plea for a change.

Robotic-assisted Laparoscopic Bilateral Nerve Sparing and Apex Preserving Cystoprostatectomy in Young Men With Bladder Cancer

OBJECTIVE

To describe our technique and outcomes of robotic-assisted nerve-sparing cystoprostatectomy with prostatic apex preservation and orthotopic ileal conduit urinary diversion in young men undergoing robotic-assisted radical cystectomy (RARC) for the management of urothelial carcinoma.

MATERIALS AND METHODS

Young men (<40 years old) with the diagnosis of urothelial carcinoma undergoing RARC with orthotopic neobaldder formation were eligible for our technique of nerve-sparing cystoprostatectomy with prostatic apex preservation at the time of orthotopic ileal conduit urinary diversion. During the apical prostatic dissection step of the RARC, the plane of dissection is directed under the dorsal vein complex and through anterior prostatic fibromuscular stroma. This plane is further carried through the prostatic urethra, transecting the most caudal aspect of prostatic peripheral zone posteriorly, to create a long urethra and a posterior urethral plate formed by peripheral zone of the prostate, which serves as a robust, long stump for the subsequent vesicourethral anastomosis.

RESULTS

From January 2013 to January 2014, 3 men were treated with RARC and intracorporeal neobladder urinary diversion based on the described technique. There were no intraoperative complications. Two patients experienced grade II complications postoperatively. Pathologic assessment demonstrated negative surgical margins in all 3 cases. With mean follow-up time of 28.2 months, 2 out of 3 patients are free from disease recurrence. All patients report daytime urinary continence with no pad usage and potency without the need for phosphodiesterase-5 inhibitors.

CONCLUSION

RARC with bilateral nerve and apical preservation can be performed safely in appropriately selected young patients with excellent functional and acceptable short-term oncologic results.

Laparoscopic radical cystectomy with prostate capsule sparing. Initial experience

INTRODUCTION

In 2008, our department introduced a modified technique of laparoscopic radical cystectomy in which the prostatic capsule is spared in selected patients with bladder cancer. The different series published are mostly using the standard open procedure. The aim of this study is to describe this technique using the laparoscopic approach and present our preliminary results.

MATERIAL AND METHODS

This study includes 20 patients selected by clinical analysis and imaging criteria operated using laparoscopic radical cystectomy with prostate capsule sparing at our department in the period between 2008 and 2012.

RESULTS

Patient mean age was 58 years. Mean operative time was 390 minutes. Median follow-up was 36 months. No patient had bladder cancer recurrence. Only one patient died of disease progression, as the pathological findings was a pT3 pN1 Mx. Mean PSA before surgery: 1.3 ng/ml (03-2), mean PSA after surgery 1.0 ng/ml (0.08-1.7). No patients had prostate cancer recurrence. Satisfactory daytime and night-time continence was achieved. 90% of patients have sexual function preserved.

CONCLUSIONS

Prostate-sparing radical cystectomy remains one of the most controversial topics in urology today. The laparoscopic approach could be an alternative to conventional radical cystoprostatectomy in well selected patients, done in experienced institutions in order to find better functional results, with a low disease progression and recurrence rate.

Robot-assisted intracorporeal pyramid neobladder

OBJECTIVE

To describe a robot-assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.

PATIENTS AND METHODS

In all, 20 patients (19 male and one female) with a mean (sd; range) age of 57.2 (12.4; 31.0-78.2) years underwent robot-assisted radical cystectomy (RARC). Most cases were ≤pT1 (17 patients) and the remaining three patients had muscle-invasive bladder cancer (MIBC) at RARC histopathology. Although half of the patients (10) actually had MIBC at transurethral resection histopathology. All patients underwent RARC, bilateral pelvic lymphadenectomy, and intracorporeal neobladder formation using a pyramid detubularised folding pouch configuration.

RESULTS

The median estimated blood loss was 250 mL and operating time was 5.5 h. The mean (sd) number of lymph nodes removed was 16.5 (7.8) and median hospital stay was 10 days. Early postoperative complications included urinary tract infection (UTI) (four patients), ileus (four), diarrhoea and vomiting (three), postoperative collection (two), and blocked stent (one). Late postoperative complications included UTI (seven patients), neobladder stone (two), voiding Hem-o-Loc (two), neobladder leak (two), diarrhoea and vomiting (one), uretero-ileal stricture (one), vitamin B12 deficiency (one), and port-site hernia (one). There was no evidence of hydronephrosis in 18 patients with a median follow-up of 21.5 months. At 24 months, recurrence-free survival was 86% and overall survival was 100%. In all, 19 patients and 13 patients reported 6-month day time and night time continence, respectively.

CONCLUSIONS

The pyramid neobladder is technically feasible using a robotic platform and provides satisfactory functional outcomes at median of 21.5 months.

Usefulness of transurethral biopsy for staging the prostatic urethra before radical cystectomy

PURPOSE

We determined the likelihood that transurethral resection biopsy of the prostatic urethra adjacent to the verumontanum would detect prostatic involvement of urothelial carcinoma in patients with bladder carcinoma.

MATERIALS AND METHODS

We compared precystectomy transurethral resection biopsy specimens of the prostatic urethra with those of the matched radical cystoprostatectomy in 272 patients with urothelial carcinoma of the bladder. All prostates were evaluated by whole mount step sections.

RESULTS

Prostatic involvement by urothelial carcinoma was detected by transurethral resection biopsy or radical cystoprostatectomy in 101 patients (37.1%). Transurethral resection biopsy detected urothelial carcinoma in 72 cases with 71.3% sensitivity and 100% specificity. The overall accuracy of transurethral resection biopsy to detect urothelial carcinoma of the prostate was 89% (positive and negative predictive values 100% and 86%, respectively). Invasive prostatic urothelial carcinoma arising from the prostatic urethra was detected by transurethral resection biopsy in 21 of 26 patients (81%) while prostatic carcinoma in situ was detected in 39 of 52 (75%). Transurethral resection biopsy detected prostatic invasive urothelial carcinoma resulting from transmural invasion of a bladder tumor in 4 of 15 patients.

CONCLUSIONS

Prostatic involvement by urothelial carcinoma of the bladder was found in 37.1% of patients. Transurethral resection biopsy missed most tumors resulting from transmural invasion of the bladder primary lesion. Carcinoma in situ and invasive urothelial carcinoma arising from the prostatic urethra were detected in most cases. Transurethral resection biopsy of the prostatic urethra can complement staging and support clinical decision making with respect to neoadjuvant chemotherapy and planning for an orthotopic neobladder.

Sexual dysfunction after cystectomy and urinary diversion

Erectile dysfunction (ED) in men and sexual dysfunction in men and women are common after cystectomy and urinary diversion. Research has focused on both qualifying the prevalence of ED following cystectomy and identifying surgical approaches to limit sexual dysfunction after surgery, but most studies have been limited by small patient populations, an absence of control groups, and a lack of adjustment for confounding factors. Similarly, quality of life (QoL) research studies have also emerged in the context of bladder cancer and cystectomy, and increase our understanding of sexual outcomes associated with cystectomy. A number of instruments for collection of patient-reported outcomes among patients with bladder cancer treated with cystectomy are available for the assessment of condition-specific and procedure-specific QoL. However, other factors that negatively affect sexual function after removal of the bladder, such as psychological issues, age, and health-related competing risks for ED, body image, partner response, and change in life course and sexual priorities, have received less attention. Nevertheless, ED and sexual dysfunction are important complications of cystectomy and urinary diversion. Although changes in the approach to surgery, such as nerve-sparing cystectomy, might improve outcomes, evaluation and management of the source factors of ED and sexual dysfunction are necessary to optimize recovery of function.

Incidental prostate cancer at the time of cystectomy: the incidence and clinicopathological features in Chinese patients

OBJECTIVES

To evaluate the incidence and the clinicopathological features of incidental prostate cancer detected in radical cystoprostatectomy (RCP) specimens in Chinese men and to estimate the oncological risk of prostate apex-sparing surgery for such patients.

METHODS

The clinical data and pathological feature of 504 patients who underwent RCP for bladder cancer from January 1999 to March 2013 were retrospectively reviewed. Whole mount serial section of the RCP specimens were cut transversely at 3-4 mm intervals and examined in same pathological institution.

RESULTS

Thirty-four out of 504 patients (6.8%) had incidental prostate cancer with a mean age of 70.3 years. 12 cases (35.2%) were diagnosed as significant disease. 4 cases were found to have apex involvement of adenocarcinoma of the prostate while in 5 cases the prostate stroma invasion by urothelial carcinoma were identified (one involved prostate apex). The mean follow-up time was 46.4±33.8 months. Biochemical recurrence occurred in 3 patients but no prostate cancer-related death during the follow-up. There was no statistical significance in cancer specific survival between the clinically significant and insignificant cancer group.

CONCLUSIONS

The prevalence of incidental prostate cancer in RCP specimens in Chinese patients was remarkably lower than in western people. Most of the incidental prostate cancer was clinically insignificant and patient's prognosis was mainly related to the bladder cancer. Sparing the prostate apex was potentially associated with a 1.0% risk of leaving significant cancer of the prostate or urothelial carcinoma.