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

Functional and oncologic outcomes of prostate capsule-sparing radical cystectomy: A systematic review and meta-analysis

Radical cystectomy (RC) is the gold standard treatment for patients with organ-confined bladder cancer. However, despite the success of this treatment, many men who undergo orthotopic neobladder substitution develop significant erectile dysfunction and urinary symptoms, including daytime and nighttime urinary incontinence. Prostate-capsule-sparing radical cystectomy (PCS-RC) with orthotopic neobladder (ONB) has been described in the literature as a surgical technique to improve functional outcomes in appropriately selected patients. We performed a systematic review and meta-analysis of manuscripts on PCS-RC with ONB published after 2000. We included retrospective and prospective studies with more than 25 patients and compared PCS-RC with nerve-sparing or conventional RC. Studies in which the entire prostate was spared (including the transitional zone) were excluded. Comparative studies were analyzed to assess rates of daytime continence, nighttime continence, and satisfactory erectile function in patients undergoing PCS-RC compared with those undergoing conventional RC. Fourteen reports were included in the final review. Our data identify high rates of daytime (83%-97%) and nighttime continence (60%-80%) in patients undergoing PCS-RC with ONB. In comparative studies, meta-analysis results demonstrate no difference in daytime continence (RR:1.12; 95% CI: 0.72-1.73) in those undergoing PCS-RC compared to those undergoing conventional RC. Similarly, nighttime continence was similar between the 2 groups (RR:1.85; 95% CI: 0.57-6.00. Erectile function was improved in those undergoing PCS-RC (RR 5.35; 95% CI: 1.82-15.74) in the PCS-RC series. Bladder cancer margin positivity and recurrence rates were similar to those reported in the literature with conventional RC with an average weighted follow-up of 52.2 months. While several studies utilized different prostate cancer (CaP) screening techniques, the rates of CaP were low (incidence 0.02; 95% CI:0.01-0.04), and oncologic outcomes were similar to standard RC. PCS-RC is associated with improved nighttime continence and erectile function compared to conventional RC techniques. Further work is needed to standardize CaP screening before surgery, but the data suggest low rates of CaP with similar oncologic outcomes when compared to RC.

The Rate of Prostatic Involvement in Men Treated With Radical Cystectomy for Muscle Invasive Bladder Cancer

PURPOSE

Radical cystoprostatectomy (RC) is one standard treatment for muscle-invasive bladder cancer (MIBC) in male patients. Another therapeutic option is trimodal therapy. Including the prostate in the trimodal therapy radiation therapy volume is based on MIBC surgical series showing prostatic stromal (PS) involvement. Our aim was to establish the rate of pathologic PS involvement by preoperative T stage in men treated with RC for MIBC.

METHODS AND MATERIALS

We conducted a retrospective review of men with MIBC treated with RC between 2006 and 2019. Electronic medical records were reviewed, and preoperative clinical staging data were collected. χ² test was done to test for a statistically significant difference in the rate of prostatic involvement between clinical tumor (cT) stages. Preoperatively identified carcinoma in situ, lymph node involvement, tumor location, and urethral involvement were also analyzed to see if they conferred a higher risk of PS involvement. Multivariate analysis using multiple logistic regression was performed.

RESULTS

We identified 283 men with bladder cancer treated with RC. Patients with non-MIBC or incomplete medical data were excluded (n = 72). We analyzed 211 patients, and 46 (22%) had pathologic PS involvement. PS involvement by preoperative T stage was cT2 = 18%, cT3 = 23%, and cT4 = 48%. Twenty-nine (12%) patients had clinical lymph node involvement, of whom 19 (76%) had PS involvement. Thirty-four (16%) had urethral involvement, of whom 17 (50%) had PS involvement. Sixteen percent and 17% of percent of clinical T2 and T3 patients had bladder neck/trigone tumors, of whom 57% and 50% had prostatic involvement. Clinical T2 and T3 were not statistically different with regards to PS involvement (P = .385). Preoperative urethral involvement, lymph node involvement, cT4, and bladder neck/trigone location were statistically significant predictors of pathologic PS involvement (all P < .05). On multivariate analysis, only clinical urethral involvement was significant (P < .0001).

CONCLUSIONS

The high rate of pathologic PS involvement seen in cT2 patients and the lack of ability of cT stage to predict PS involvement support routinely treating the prostate in trimodal therapy. Patients with preoperatively identified bladder neck/trigone tumors, urethral involvement, positive lymph nodes, or prostatic involvement are a subset at even higher risk of having pathologic PS involvement.

Nerve-Sparing Laparoscopic Cystoprostatectomy Based on Inferior Hypogastric Plexus Dissection: Our Initial Experience

INTRODUCTION

The aim of this study was to implement our technique for the initial dissection of the inferior hypogastric plexus and protection of the autonomic nerve supply to the corpora cavernosa in laparoscopic radical cystoprostatectomy with an orthotopic ileal neobladder and report the initial outcomes.

METHODS

Eleven normally potent patients with preoperative cT2N0 bladder cancer who underwent bilateral nerve-sparing laparoscopic cystoprostatectomy performed by the same surgeon were selected from May 2018 to September 2020. In this procedure, the anterior part of the inferior hypogastric plexus was dissected first between the prehypogastric nerve fascia and rectal proper fascia medial to the distal ureter. Then the Denonvilliers' fascia and the nerves around the prostate were preserved according to current intrafascial principles. The preliminary operative, oncologic, and functional results are presented.

RESULTS

The median follow-up duration was 18 months. We observed early and late complications in 5 patients, but none exceeded grade III. Of the 11 patients, ten gained daytime continence (90.9%), and 8 (72.7%) showed nocturnal continence at the last follow-up. Regarding postoperative potency, 10 of the 11 patients (90.9%) remained potent with or without oral medications, excluding one who had partial tumescence but did not follow our recommendations regarding medication use. No local recurrence or positive surgical margins were noted.

CONCLUSION

In addition to emphasizing our cavernosal nerve-sparing procedure, this report on the precise dissection and protection of the inferior hypogastric plexus could be of clinical significance, providing potentially ideal short-term functional results.

Orthotopic bladder substitution: Surgical aspects and optimization of outcomes

Objectives

Orthotopic bladder substitution (OBS) is a management option for urinary diversion in men and women undergoing cystectomy. The aim of the procedure is to provide a functional continent urinary reservoir of adequate capacity, compliance and low pressure. We have provided a narrative review of the existing literature and highlighted areas where improvement and standardization can be recommended.

Methods

Literature search included database search for publications from January 1970 to November 2020, using keywords including OBS, bladder reconstruction, neobladder, radical cystectomy, robotic cystectomy, intracorporeal neobladder, surgical technique, patient selection and outcomes.

Results

Due to various factors including indications, operative technique and risk of complications, OBS is an enormous undertaking and commitment for patients, surgeons and health professionals involved in the care pathway. The main considerations for patient selection, the technical elements of the procedure and the rationale behind these are discussed. Previously considered to be a choice for a select few, the inclusion criteria have expanded over the last decade. Similarly, surgical techniques including the choice and configuration of bowel segments, construction of anastomosis and nerve or organ sparing procedures have evolved over the years. Minimally invasive laparoscopic and robotic assisted surgery has added further perspectives to the existing literature on OBS. Understanding the principles of operative techniques and assessing the best evidence to influence patient management is crucial as it has a major impact on clinical outcomes. Peri‐ and post‐operative care, focused on the prevention of complications and morbidity, affects long‐term functional and oncological outcomes, which ultimately dictates the quality of life.

Conclusions

This concise overview of OBS literature highlights the importance of pre‐operative, peri‐operative, and post‐operative aspects with regards to the optimization of patient care. To achieve the best results, meticulous attention should be paid in all these areas, surgical and multi‐disciplinary. Patient education and counseling, with shared decision making are central to the success of the procedure.

Modified completely intrafascial radical cysprostatectomy for bladder cancer: a single-center, blinded, controlled study

BACKGROUND

We have proposed a modified, completely intrafascial radical cysprostatectomy (RC) to treat bladder cancer patients with the aim of preserving the patients' post-surgical urinary control and erectile function. This study aimed to evaluate the oncological and functional outcomes of this innovation relatively to that with the conventional technique.

METHODS

A retrospective, single-center, blinded, and controlled study was conducted using the medical data of patients since the past 5 years from the hospital database. A total of 44 patients were included, including 20 who received complete intrafascial cysprostatectomy and 24 who received conventional interfascial surgeries. The patients' continent and sexual information of 1-year follow-up after the surgery were extracted. The oncological and functional outcomes of the 2 groups were compared and analyzed.

RESULTS

The demographics parameters of the 2 groups showed no significant difference. The results of follow-up of the oncological outcomes did not reveal any significant difference between the completely intrafascial group and the conventional interfascial group in terms of the positive surgical margins, local recurrences, and distant metastasis. Patients following neobladder diversion in the intrafascial group showed a faster recovery of the urinary control, with a 76.9% (10/13) daytime continent rate at 3-month, as well as 46.2% (6/13) and 58.3% (7/12) nighttime continent rates at 3-month and 6-month, respectively. Regarding the sexual functions, our results revealed significant advantages in favor of completely intrafascial technique on the post-surgical International Index of Erectile Function (IIEF)-5 score at 3-, 9-, and 12-month follow-up relative to that with the conventional interfascial process. Thus, the IIEF score of patients in the intrafascial group was 11.4 ± 3.5 at 3-month, 14.1 ± 3.6 at 9-month, and 15.2 ± 3.8 at 12-month follow-up after the cystectomy, which was significantly greater than that of the patients in the control group.

CONCLUSIONS

Our novel data illustrated that the modified completely intrafascial technique could result in a better sexual function and faster continence recovery for patients following RC, without any compromise in the cancer control. Thus, this technique could be considered as an alternative extirpative technique for bladder cancer treatment in a clinical setting.

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.

Bladder Cancer Survivorship

PURPOSE OF REVIEW

Bladder cancer (BC) is the second most common genitourinary malignancy, with a growing population of survivors globally. Over the past two decades, there has been a growing awareness of not only the oncologic, but also the quality of life ramifications of a BC diagnosis, treatment, and surveillance. In the current review, the literature surrounding the many domains that encompass bladder cancer survivorship is summarized and analyzed.

RECENT FINDINGS

There have been ongoing efforts to decrease perioperative morbidity, particularly in patients undergoing radical cystectomy, with mixed results. There is a growing emphasis on the short and long-term health-related quality of life (HR-QoL) impacts of bladder cancer spanning the domains of physical and mental QoL related to urinary function, sexual function, and financial and psychological burden, with validated measures specific to BC patients. There continue to be disparities in oncologic outcomes by race and gender. The impact of BC is prolonged and there is an unmet need for long term support and survivorship resources to address this. There is a growing global population of bladder cancer patients, and their needs are complex and vary by stage, treatment, and certain demographic features. Outcome-centered perioperative strategies show potential to diminish treatment morbidity, and validated BC specific HR-QoL tools have helped to define the impact and burden of BC, but there continue to be large areas of unmet need that warrant greater study and intervention.

Role and Indications of Organ-Sparing "Radical" Cystectomy: The Importance of Careful Patient Selection and Counseling

Organ-sparing cystectomy remains an operation for a highly selected patient population that can offer similar oncologic outcomes but improved sexual function in men and women. Occult prostate cancer in men may occur even with screening but the majority is of clinical insignificance. Paramount to patient selection are oncologic concerns, but preoperative sexual function, age, performance status, and postoperative expectations must also be evaluated during patient selection. Improved diagnostic and surveillance tools may facilitate and improve patient selection in the future.

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.

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.

Standard cystectomy fits all: truth or myth?

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) followed by urinary diversion is the treatment of choice for muscle-invasive bladder cancer (BC) and non-invasive BC refractory to transurethral resection of the bladder (TUR-B) and/or intravesical instillation therapies. Since the morbidity and possible mortality of this surgery are relevant, care must be taken in the preoperative selection of patients for the various organ-sparing procedures (e.g., bladder-sparing, nerve sparing, seminal vesicle sparing) and various types of urinary diversion. The patient's performance status and comorbidities, along with individual tumor characteristics, determine possible surgical steps during RC. This individualized approach to RC in each patient can maximize oncological safety and minimize avoidable side effects, rendering 'standard' cystectomy a surgery of the past.

Prostate capsule sparing versus nerve sparing radical cystectomy for bladder cancer: results of a randomized, controlled trial

PURPOSE

Prostate capsule sparing and nerve sparing cystectomies are alternative procedures for bladder cancer that may decrease morbidity while achieving cancer control. However, to our knowledge the comparative effectiveness of these approaches has not been established. We evaluated functional and oncologic outcomes in patients undergoing these procedures.

MATERIALS AND METHODS

We performed a single institution trial in patients with bladder cancer in whom transurethral prostatic urethral biopsy and transrectal prostate biopsy were negative. Men were randomized to prostate capsule sparing or nerve sparing cystectomy with neobladder creation and stratified by Sexual Health Inventory for Men score (greater than 21 vs 21 or less). Our primary end point was 12-month overall urinary function as measured by Bladder Cancer Index. Secondary end points included sexual function, cancer control and complications.

RESULTS

A total of 40 patients were enrolled in the study with 20 patients in each arm. Urinary function at 12 months decreased by 13 and 28 points in the prostate capsule and nerve sparing groups, respectively (p = 0.10). Sexual function followed a similar pattern (p = 0.06). There was no difference in recurrence-free, metastasis-free or overall survival (each p >0.05). The rate of incidentally detected prostate cancer was similar (p = 0.15).

CONCLUSIONS

Our study provides a randomized comparison of prostate capsule sparing and nerve sparing cystectomy techniques. We found no difference in functional or oncologic outcomes between the 2 approaches, although our study was underpowered due to a lack of patient accrual.

Synchronous primary malignancies of the male urogenital tract

The finding of prostate cancer after a cystoprostatectomy for a bladder tumour can occur in up to 70% of cases. The incidence of prostate cancer in patients with a bladder tumour is 18 times higher than in the general population; moreover, the incidence of bladder cancer in patients with prostate cancer is 19 times higher than in the general population. This association can be explained by the common embryological origin of these organs, with molecular similarities. Other similarities between these two cancers are noted. They are multifocal and may be secondary to urinary stasis. However, this association does not seem responsible for an increased risk of progression of both diseases. The prognosis is related to the extension of each cancer. The stage and grade of bladder cancer are, in terms of prognosis, greater than those of prostate cancer. Most often, this is insignificant prostate cancer. Despite this, the prostate-specific antigen test should be administered to monitor patients after cystoprostatectomy.

Prostate-sparing cystectomy: has Pandora’s box been opened?

En bloc removal of the prostate has traditionally been an integral component of radical cystectomy for men with bladder cancer owing to a high incidence of occult prostatic malignancy. However, the risk of functional morbidity following this procedure is considerable and can delay patient acceptance of cystectomy, which can adversely affect the long-term prognosis. Recently, some investigators have advocated prostate-sparing cystectomy (PSCx) to improve postoperative continence and potency rates, and this may also improve timely patient acceptance of cystectomy. Several of these PSCx series describe excellent functional results postoperatively and PSCx may also facilitate a laparoscopic approach, offering further dividends. However, valid concerns regarding the oncologic efficacy of this procedure still predominate and protocols for patient selection, technique and postoperative surveillance are not well defined. The concept of PSCx is arguably one of the most controversial topics in the field of bladder cancer today.

The incidence of prostate cancer and urothelial cancer in the prostate in cystoprostatectomy specimens in a tertiary care Canadian centre

INTRODUCTION

Radical cystoprostatectomy remains the gold standard treatment for muscle invasive bladder cancer. However, given the treatment related complications of compromised potency and continence with this procedure, prostate/sexuality sparing cystectomy in orthotopic neobladder candidates has emerged in an effort to minimize these quality of life concerns. Recent evidence suggests only a marginal functional benefit from these technical refinements. We sought to determine the incidence of occult prostate cancer and urothelial cancer of the prostate in cystoprostatectomy specimens conducted for muscle invasive bladder cancer.

METHODS

We retrospectively reviewed 83 male patients who underwent radical cystoprostatectomy for muscle invasive bladder cancer between April 2004 and March 2007. The median age of our study group was 71 years. Pathologic findings of prostate/urothelial cancer in the prostate were identified. Clinically significant prostate cancer was defined as Gleason score >6, tumour volume >0.5cc, extracapsular extension or perineural invasion.

RESULTS

Our review yielded a 30% (±10%, 0.95 CI) rate of prostate cancer, with 19% (± 8.5%, 0.95 CI) of total specimens being positive for clinically significant prostate cancer. Urothelial cancer in the prostate was identified in 16% (±8.5%, 0.95 CI) of patients, with an overlap with prostate cancer in 2 patients. The overall rate of an underlying cancer within the prostate of our cystoprostatectomy specimens was about 46% (±10.7%, 0.95 CI).

CONCLUSION

These findings suggest that the oncological risk of leaving behind residual cancer may not justify the practice of prostate-sparing cystectomies.

[Radical cystectomy - pro laparoscopic]

Although the technical feasibility of laparoscopic radical cystectomy (LRC) has been proven and the procedure has been accepted in the EAU guidelines 2011 as a valid alternative, its actual position has to be determined. On the one hand the advantages of LRC (less blood loss, lower transfusion rates, shorter analgesia time) have been proven in retrospective studies; however, the technical difficulties of purely laparoscopic urinary diversion result in very long operating times and in cases of a laparoscopic-assisted creation of a neobladder, the question of the advantage of this approach remains doubtful. Despite case reports of port metastases and peritoneal carcinosis following laparoscopic and robot-assisted radical cystectomy, there is no difference in terms of oncological long-term data (up to 10 years) between laparoscopy and open surgery performed at centres of excellence. Evidently, the curative options for the patients do not depend on the type of surgery (open versus minimally invasive) but on the efficacy of adjuvant treatment strategies (polychemotherapy). Currently it is believed that LRC should be considered for patients with low risk of progression (pT1-2). The final position of laparoscopic radical cystectomy can only be evaluated in a multicentric randomized controlled trial.

Sexuality in adult cancer survivors: challenges and intervention

Sexual dysfunction is one of the most common and distressing consequences of cancer treatment. Although some treatment-related sexual adverse effects are short-term, many survivors face long-term effects such as treatment-induced menopause, altered gonadal function, and significant surgical disfigurement. Profound sexual dysfunction has been shown to have a significant negative effect on quality of life. Although these problems have been well documented and there are a range of intervention strategies that can help patients cope with treatment-related sexual problems, many survivors do not feel prepared for potential sexual changes and often do not receive adequate support to manage sexual dysfunction. Numerous barriers contribute to this underprovided aspect of survivorship care, including lack of provider training and access to readily available resources. In addition, psychological, relational, and cultural factors significantly influence sexuality but are often not taken into consideration in research and clinical practice. By taking an integrative approach and providing survivors with appropriate screening, information, and support, sexual dysfunction and accompanying distress can be significantly alleviated. In this article, we aim to provide a concise review of the most common sexual problems experienced by survivors and highlight some of the most promising evidence-based practices for assessment and intervention. We also address limitations encountered in research and practice and explore future directions, including suggestions for adopting an integrative treatment model to address sexual dysfunction in a cancer survivorship treatment setting.

Update on the management of invasive bladder cancer 2012

Muscle-invasive bladder cancer is a deadly disease for which a number of new approaches have become available to improve prognosis. A recent review emphasized the importance of timely indication of surgery and highlighted current views regarding the adequate extent of the surgery and the importance of lymph node dissection. Furthermore, treatment using neoadjuvant and adjuvant systemic chemotherapy has become more prominent, while cystectomy and diversion should be conducted only in experienced centers. Optimal methods of urinary diversion and the use of robot-assisted laparoscopic cystectomy require further study.

Incidentally found prostate cancer and influence on overall survival after radical cystoprostatectomy

Objectives. To determine incidentally found prostate cancer frequency and impact on overall survival after RCP. Patients and Methods. The records of 81 men who underwent cystoprostatectomy from January 2000 to December 2009 were reviewed. The vital status of the study group was assessed as on September 1, 2009, by passive followup, using data from the population registry. Results. The 81 men underwent RCP. The incidental prostate cancer was found in the specimens of 27 (33.3%) patients. 13 (48.1%) of 27 prostate cancer cases were clinically significant. For 3 patients (11.1%) an extraprostatic extension was found. For 2 patients (7.4%)—positive margins, for 1 patient (3.7%)—Gleason sum 8, and for the rest 7 patients bigger than 0.5 cm³ volume tumor, and Gleason sum 7 was found. The mean follow-up time was 39.2 ± 33.8 months (varies from 0.8 to 131.2 months). The patients with bladder cancer and incidentally found prostate cancer lived shorter (28.1 ± 27.5 and 45.5 ± 35.40 months). Higher overall survival (P = 0.03) was found in the patient group with bladder cancer without incidentally diagnosed prostate cancer. Conclusion. There are indications that in this small study prostate cancer has influenced on patients' survival with bladder cancer after radical cystoprostatectomy.

Prostate capsule sparing radical cystectomy: oncologic safety and clinical outcome

OBJECTIVES

Prostate capsule sparing radical cystectomy (PSRC) is a modification of the traditional surgical approach to radical cystectomy and neobladder, which offers the prospect of improved preservation of erectile function and continence.

METHODS

This is a review of the literature regarding the oncologic and quality of life outcomes of this approach for transitional cell carcinoma of the bladder, and a comparison of these results to conventional cystoprostatectomy and neobladder.

RESULTS

There are a limited number of studies addressing prostate capsule or prostate sparing cystectomy. All are retrospective, non-comparative and not uniform in terms of patient selection and technique. Long-term follow-up is lacking. The incidence of synchronous and or metachronous prostate cancer and TCC of the prostatic urethra is lower than that found in conventional cystoprostatectomy. This is likely due to pre-operative patient selection, restricting the procedure to those with no evidence of prostatic involvement by either disease. The local recurrence rate is 5%, comparable to standard cystoprostatectomy. Recurrence free and overall survival rates are comparable.

Defining patient selection for prostate-sparing cystectomy in squamous cell carcinoma of the urinary bladder associated with bilharziasis: an overview of 236 patients

OBJECTIVE

To determine possible risk factors associated with prostate invasion in patients with squamous cell carcinoma (SCC) of the urinary bladder associated with bilharziasis.

METHODS

After obtaining approval from the medical ethics committee, we reviewed the clinical and pathologic data from 236 male patients in our department between January 2006 and October 2010 who were treated with radical cystoprostatectomy and proved to have SCC associated with bilharziasis. We reviewed the clinical and histopathologic data regarding prostate infiltration from SCC of the urinary bladder associated with bilharziasis.

RESULTS

Two-hundred thirty-six patients were included in this study. Prostate infiltration was present in 14 patients (5.9%). Tumor located in the bladder neck (P = .000001), tumors >5 cm (P = .009), and advanced clinical tumor stage (P = .000001) were associated with highly statistically significant increased risk of prostate invasion from SCC of the urinary bladder. Different patients' ages, high tumor grade, and regional lymph nodes' metastasis were not associated with increased risk of prostate invasion from SCC of the urinary bladder.

CONCLUSION

Prostate infiltration from SCC of the urinary bladder (which is associated with bilharziasis) is not uncommon. Tumor >5 cm, bladder neck tumor, and high clinical tumor stages should be considered at least relative contraindications for prostate-sparing cystectomy.

Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long-term oncological, functional, and quality of life results

PURPOSE

The present contribution analyses long-term data regarding oncological, functional, and quality of life aspects of patients subjected to cystectomy due to malignancy with subsequent orthotopic bladder substitution.

METHODS

A literature search was conducted to review literature published from 1887 until today. Oncological aspects, special considerations on female patients, quality of life, geriatric patients, and impact of minimally invasive surgery were also addressed and discussed.

RESULTS

After more than three decades, orthotopic bladder substitution subsequent to radical cystectomy has stood the test of time by providing adequate long-term survival and low local recurrence rates. Compared to radical cystectomy, neither radiation nor chemotherapy, nor a combination of both, offer similar long-term results. Orthotopic bladder substitution does not compromise oncological outcome and can be performed with excellent results regarding functional and quality of life issues. Chronological age is generally not a contraindication for cystectomy.

CONCLUSION

Orthotopic bladder substitution should be the diversion of choice both in men and in women, whenever possible. For orthotopic urinary diversion, a careful patient selection considering tumor extent, patient motivation, preoperative sphincter function, other local and systemic adverse confounding factors, and overall life expectancy must be taken into account. Minimally invasive techniques are promising concepts for the future, awaiting confirmation in larger patient cohorts.

Long-term outcomes of radical cystectomy with preservation of prostatic capsule

OBJECTIVE

We report our results of orthotopic ileal neobladder after radical cystectomy with prostatic adenomectomy with regard to urinary continence, sexual outcome and disease control.

METHODS

Between March 2003 and July 2004, 22 men with bladder transitional cell carcinoma (mean age 65.0) were analyzed. They underwent radical cystectomy with prostatic adenomectomy with preservation of the prostatic capsule, seminal vesicles and orthotopic ileal neobladder. Urinary continence was assessed after 2 days, 2 months, 6 months and 1 year. Preservation of sexual function was defined as the ability to have sexual intercourse and was assessed after 2-, 6-, and 12-months postoperatively. Overall survival and cancer-specific survival were assessed.

RESULTS

Median postoperative follow-up was 60 months. Daytime and nighttime urinary continence after 48 h was 47 and 14%, respectively. After 2, 6 and 12 months, these rates were 74 and 16%, 85 and 26%, and 94 and 31%, respectively. Sexual intercourse was achieved in 69% of patients. Overall survival rate was 68%, and cancer-specific survival rate was 73%. Overall survival rates according to pathologic stage for pT0, pT1, pT2 and pT3 were 100, 60, 71 and 57%, and cancer-specific survival were 100, 80, 71 and 57%, respectively.

CONCLUSIONS

Urinary continence and sexual function achieved by radical cystectomy with prostatic adenomectomy with orthotopic ileal neobladder seem to be similar to those achieved by the conventional technique with satisfactory oncologic results.

Management of muscle-invasive bladder cancer: an update

The aim of this Review is to critically assess the currently used methods for the treatment of muscle-invasive bladder cancer. Radical cystectomy seems to be the gold standard for the treatment of bladder cancer, and the optimum extent of lymph-node dissection has now been identified. An early cystectomy should be carried out once a diagnosis of muscle invasion is established. Preoperative radiation is no longer popular, but could be due a reassessment in view of technical advances. Results of neoadjuvant and adjuvant chemotherapy trials are subject to criticism. Most trials are retrospective, used different chemotherapy protocols and did not have uniform end point assessment. Bladder-preservation strategies can offer cures for a selection of subpopulations, but these patient groups have yet to be clearly defined. Developments in molecular biology are exciting, and their potential application is pending translational research. To be meaningful and useful, future trials that involve additional or alternative modalities should be prospective, randomized and adequately powered.

Risk factors for urothelial carcinoma of the prostate in patients undergoing radical cystoprostatectomy for bladder cancer

OBJECTIVE

To examine the risk factors for urothelial carcinoma (UC) involvement of the prostate in patients undergoing radical cystoprostatectomy (RCP) for bladder cancer, as such involvement has both prognostic and therapeutic implications.

PATIENTS AND METHODS

We examined 308 consecutive men from 1998 to 2005 who had RCP for UC of the bladder, with whole-mount processing of their prostate. Prostatic involvement was categorized by site of origin (the bladder or the prostatic urethra) and, in the case of prostatic urethral origin, by depth of invasion, i.e. dysplasia/carcinoma in situ (CIS), involving the prostatic urethra, prostatic ductal invasion or prostatic stromal invasion. The impact of pathological characteristics was evaluated.

RESULTS

In all, 121 (39.3%) patients had some form of urothelial involvement of the prostate, of whom 59 (48.8%) had dysplasia/CIS of the prostatic urethra, 20 (16.5%) had ductal involvement and 32 (26.4%) had stromal involvement. Multivariate analysis showed that bladder CIS (odds ratio 2.0, 95% confidence interval, 1.2-3.6, P = 0.012) and trigonal involvement of bladder tumours (2.0, 1.1-3.7, P = 0.028) were independent risk factors for urothelial involvement of the prostate.

CONCLUSION

There was prostatic involvement with UC in nearly 40% of patients undergoing RCP. In this study CIS and trigonal involvement were independent predictors of risk, but were not adequate enough to accurately identify most patients who have UC within their prostate; further prospective studies are needed to more accurately predict risk factors and depth of invasion.

Intravesical hyperthermia and mitomycin-C for carcinoma in situ of the urinary bladder: experience of the European Synergo working party

Objectives

To study the results of chemotherapy combined with intravesical hyperthermia in patients with mainly BCG-failing carcinoma in situ (CIS).

Methods

Patients with histologically confirmed CIS were included retrospectively. Outpatient thermochemotherapy treatment was done with mitomycin-C (MMC) and the Synergo^® system SB-TS 101 (temperature range between 41 and 44°C), weekly for 6–8 weeks, followed by 4–6 sessions every 6–8 weeks.

Results

Fifty-one patients were treated between 1997 and 2005 from 15 European centers. Thirty-four were pre-treated with BCG. Mean age was 69.9 years. Twenty-four patients had concomitant papillary tumors. The mean number of hyperthermia/MMC treatments per patient was 10.0. Of the 49 evaluable patients 45 had a biopsy and cytology proven complete response. In two patients CIS disappeared, but they had persistent papillary tumors. Follow-up of 45 complete responders showed 22 recurrences after a mean of 27 months (median 22): T2 (4), T1 (4), T1/CIS (1), CIS (5), Ta/CIS (2), Ta (5) and Tx (1). Side effects (bladder complaints) were generally mild and transient.

Conclusions

In patients with primary or BCG-failing CIS, treatment with intravesical hyperthermia and MMC appears a safe and effective treatment. The initial complete response rate is 92%, which remains approximately 50% after 2 years.