MANAGEMENT OF THE PATIENT WITH BLADDER CANCER

Application of The Paris System in neobladder washing cytology: Comparison between the original diagnosis and correlation with histopathology

BACKGROUND

In urinary diversion after radical cystectomy, the incidence of recurrent urothelial carcinoma (UC) in upper urinary tract or urethra are reported in 2%-17% of the patients. Urine cytology plays a pivotal role in detecting the recurrence of UC. However, cytologic diagnosis in urinary diversion including neobladder is often challenging due to significant degenerative changes and necro-inflammatory background. Since the proposal of The Paris System (TPS) for reporting cytology, the utility of TPS in urinary diversion specimen has not been studied yet. The objective of this study is to evaluate the diagnostic usefulness of TPS compared with the original diagnosis and correlate with the matched histopathological results.

METHODS

Urinary diversion cytology specimens with concurrent or subsequent biopsy or resection at EUMC in recent 16 years (from January 2002 to December 2018) are retrospectively reviewed and reclassified according to TPS criteria. The TPS categories and the original diagnoses were compared and correlated with follow-up histology.

RESULTS

Concurrent or subsequent biopsy or resection within a 6-month period was available in 45 cases from 28 patients. When applying TPS, the rate of atypical and suspicious categories decreased by 13.4% and 11.1%. Using TPS increased the value of sensitivity, NPV, and accuracy to 93.75%, 93.75%, and 90.91%, respectively.

CONCLUSION

Application of TPS reduced the rate of indeterminate diagnoses and moreover, improved the sensitivity and accuracy of urinary diversion cytology. Therefore, we believe that diversion urine cytology diagnosis according to TPS is useful to screen patients for detection of recurrence in routine clinical practice.

Assessing the prognostic impact of prostatic urethra involvement and developing a nomogram for T1 stage bladder cancer

PURPOSE

To investigate prognostic values of prostatic urethra involvement (PUI) and construct a prognostic model that estimates the probability of cancer-specific survival for T1 bladder cancer patients.

METHOD AND MATERIALS

We investigated the national Surveillance, Epidemiology, and End Results (SEER) database (2004-2015) to get patients diagnosed with T1 bladder cancer. An external validation cohort was obtained from the First Affiliated Hospital of Nanchang University. The Kaplan-Meier method with the log-rank test was applied to assess cancer-specific survival (CSS) and overall survival (OS). Moreover, the propensity score matching (PSM) and multivariable Cox proportional hazard model were performed. All patients were randomly divided into the development cohort and validation group at the ratio of 7:3. The performance of the model was internally validated by calibration curves and the concordance index (C-index).

RESULTS

The PUI group had a lower survival rate of both CSS and overall survival OS before and after PSM when compared to non-involved patients (All P < 0.05). Multivariate analysis revealed a poor prognosis in the PUI group for cancer-specific mortality (CSM) and all-cause mortality (ACM) analyses before and after PSM (All P < 0.05). Seven variables, including age, surgery, radiotherapy, tumour size, PUI, and marital status, were incorporated in the final nomogram. The C-index in the development cohort was 0.715 (0.711-0.719), while it was 0.672 (0.667-0.677) in the validation group. Calibration plots for 3- and 5-year cancer-specific survival showed good concordance in the development and validation cohorts.

CONCLUSIONS

PUI was an independent risk factor of ACM and CSM in T1 bladder cancer patients. In addition, a highly discriminative and precise nomogram that predicted the individualized probability of cancer-specific survival for patients with T1 bladder cancer was constructed.

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.

Risk factors and oncological outcomes of urethral recurrence in male patients with muscle invasive bladder cancer after radical cystectomy combined with urinary diversion: a propensity score-matched case control study

BACKGROUND

Radical cystectomy (RC) is the primary treatment strategy for muscle invasive bladder cancer (MIBC). However, it carries a high risk of urethral recurrence (UR) in male patients. The risk factors and oncological outcomes of UR remain unclear. We aimed to identify the risk factors and oncological outcomes of UR in male patients with MIBC after RC combined with urinary diversion.

METHODS

After propensity score matching, we evaluated 137 male patients with MIBC who underwent RC combined with urinary diversion at our center between January 1, 2007 and December 31, 2015. Patient demographics, comorbidity, and perioperative data were recorded. Univariate and multivariate Cox proportional hazards regression were used to estimate the hazard ratio and 95% confidence intervals. Cancer-specific survival (CSS) and overall survival (OS) were measured using the Kaplan-Meier curve with log-rank test. P < 0.05 was considered statistically significant.

RESULTS

Of the 310 patients, 30 (9.7%) patients underwent UR. In the matched group, the independent risk factors of UR were history of TURB (HR = 3.069, P = 0.018), tumor stage (T3 vs. T2, HR = 3.997, P = 0.014; T4 vs. T2, HR = 2.962, P = 0.015), and tumor multifocality (HR = 2.854, P = 0.011). The CSS and OS of patients with UR were equivalent to the patients without UR (P = 0.295, P = 0.616).

CONCLUSION

This propensity score-matched case-control study showed that UR is not rare in male patients with MIBC after RC combined with urinary diversion. We identified three independent risk factors of UR: history of TURB, tumor stage, and tumor mutifocality. The oncological outcomes were equivalent between patients with and without UR. These findings could help improve treatment strategies and follow-up schedules.

Anterior urethra sparing cystoprostatectomy for bladder cancer: a 10-year, single center experience

Purpose

Decision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. To determine whether anterior urethra sparing cystoprostatectomy for bladder cancer is an oncologically-safe procedure, we evaluated the long-term oncologic clinical outcome.

Patients and methods

A total of 51 male patients with cTa-4N0-2M0 bladder cancer were treated with anterior urethra sparing cystoprostatectomy and simultaneous urinary diversion between 2000 and 2013, and underwent follow up for 4 months or more. We assessed differences in the perioperative outcomes, oncologic outcomes and recurrence rates according to the urinary diversion.

Results

The median patient age and follow-up period were 66 years and 35 months, respectively. The 5- and 10-year recurrence free survival (RFS) rates in ileal conduit (IC) group vs. orthotopic neobladder reconstruction (NB) group were 45.0 and 20.3% vs. 39.3 and 19.6%, respectively. Likewise, the 5- and 10-year disease specific survival (DSS) were 52.7 and 32.1% vs. 39.3 and 29.5%, respectively. Multivariate analysis revealed two independent prognostic factors for RFS and DSS, including age at surgery and lymph node status. Local recurrence in the remnant anterior urethra occurred in only 1 patient (2.0%) at 57 months after surgery.

Conclusions

Our long-term data show that anterior urethra sparing cystoprostatectomy is an oncologically-safe procedure regardless of the type of urinary diversion in a subset of carefully selected patients with bladder cancer without evidence of urothelial carcinoma in the urethra/bladder neck and urethral surgical margin.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-015-1200-7) contains supplementary material, which is available to authorized users.

Transitional cell carcinoma in orthotopic ileal neobladder

Urothelial carcinoma developing in orthotopic ileal neobladder is an extremely rare entity. Fewer than 10 cases have been reported in the literature describing urothelial carcinoma recurrence in orthotopic ileal neobladder. We report a case of transitional cell carcinoma recurrence in orthotopic ileal neobladder after 11 years of surgery.

[Prostatic involvement by urothelial carcinoma in patients with bladder cancer and their implications in the clinical practice]

OBJECTIVES

Urothelial carcinoma (UC) is a multifocal disease that may develop in any location of the urinary tract, including the prostate. We analyze the types of prostate involvement due to UC, their diagnosis, risk factors and the clinical implications of this entity.

MATERIAL AND METHODS

Analysis of original, review articles and publications related to prostate involvement due to UC. The study included works published in the period of 1985-2011, most of which were obtained from the search in PubMed.

RESULTS

Prostate involvement due to UC has been observed frequently in both non-muscle invasive bladder cancer (NMIBC) series and prolonged follow-up (39%) as in radical cystectomy series (15-48%). Prostatic involvement may occur in the mucosa and ducts (superficial involvement) or prostate stroma (invasive involvement), a fact that has prognostic and therapeutic implications. Stromal involvement may have both a bladder and intraurethral origin. Carcinoma in situ, multifocality, bladder neck/trigone cancer, and previous history of tumor recurrence are the factors that have been m ore consistently associated to prostate involvement due to UC. The incidence of prostatic involvement by UC in patients with NMIBC increases over time when risk factors exist. In these cases, a prostatic urethral biopsy should be performed during the follow-up. Conservative treatment with transurethral resection and BCG is possible in case of superficial involvement of the prostatic urethra, assuming its risk of progression. Patients subjects to cystectomy and with prostate involvement due to UC have a greater risk of urethral recurrence. The elevated incidence of prostatic adenocarcinoma and prostatic involvement by UC in cystectomy specimens makes it necessary to be very selective when indicating prostate-sparing cystectomy. Chemotherapy may be an option in an attempt to improve survival of patients with prostatic stromal involvement.

CONCLUSIONS

Prostatic involvement by UC is not uncommon and it has important implications in the management of patients with NMIBC and in those who have an indication for or have undergone radical cystectomy.

Focal urethral stricturing following intraurethral mitomycin-C gel and the use of a penile clamp

We present a case of a 51-year-old gentleman, previously diagnosed with high-grade superficial transitional cell carcinoma of the bladder and treated with intravesical mitomycin C and BCG, who developed serial recurrences in the prostatic urethra. This was resected and treated further with intraurethral mitomycin-C gel. He subsequently developed an almost impassable distal penile urethral stricture, corresponding to the site of penile clamp application which we hypothesise is secondary to a combination of the mitomycin-C gel and penile clamp pressure.

[Diagnosis and treatment of urethral recurrence after radical cystectomy in the male]

CONTEXT

From 4%-6% of males subjected to radical cystectomy due to urothelial carcinoma will have urethral recurrence (UR) during the follow-up.

OBJECTIVE

To analyze the diagnosis, treatment and course of the patients with UR following a cystectomy.

ACQUIRING OF EVIDENCE

Analysis of original articles and reviews related with the diagnosis, treatment and course of patients subjected to radical cystectomy and who develop UR. The articles were obtained from a search in PubMed.

SYNTHESIS OF EVIDENCE

Most of the UR appear during the first 3 years of the cystectomy. Approximately 50% of the URs of contemporary series were diagnosed through urethral cytology, the patient being asymptomatic. The urethrectomy is the treatment of choice in patients with UR and cutaneous diversion. In patients with orthotopic bladder replacement (OBR): 1) the treatment of the intraurethral BCG can be useful in patients with carcinoma in situ (CIS), 2) papillary type conservative treatment in UR has contradictory results, 3) when the uretrectomy is necessary, the ileal duct or conversion of the OBR in a continent urinary derivation can be used.

CONCLUSIONS

Urethral cytology is a test having high sensitivity and can contribute to the diagnosis of UR in the earliest stages. In patients with OBR, the diagnosis of a UR is a therapeutic challenge. The bladder tumor, urethral recurrence and presence of an upper urinary tract tumor in 25% of the cases may be a cause of death in these patients.

[Management of the male urethra before and after cystectomy: from the prophylactic urethrectomy to the intraoperative frozen section biopsy of the urethral margin]

CONTEXT

Decision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial.

OBJECTIVE

To analyze the changes produced in the management of the urethra from the beginning of the cystectomy up to the present moment.

EVIDENCE ACQUISITION

Analysis of original articles and reviews obtained through a search in PubMed, related with the risk factors of urethral recurrence (UR) and with the management of the urethra in patients subjected to radical cystectomy.

EVIDENCE SYNTHESIS

At first, many authors recommended urethrectomy simultaneously with cystectomy. The identification of risk factors of the bladder tumor related with the appearance of UR limited the indication of prophylactic urethrectomy in patients with multifocal disease and with prostate tumor involvement. The development of orthotopic bladder substitutes (OBS) complicated the situation. The involvement the prostatic urethral tumor was maintained as the principal risk factor for UR, which then gave importance to its pre-cystectomy staging. Series of OBS observed a lower incidence of UR regarding patients with skin derivations, even in cases with prostatic urethral involvement. Prostatic urethral involvement stopped being a contraindication for OBS when the frozen section biopsy of the urethral margin was negative.

CONCLUSIONS

Currently, most authors agree that the intraoperative frozen section biopsy of the urethral margin will determine whether an OBS or urethrectomy should be performed. In spite of this, we have very few series in which this approach has been systematically used and with sufficient follow-up.

Complications of radical cysto-urethrectomy using modified Clavien grading system: prepubic versus perineal urethrectomy

OBJECTIVES

• To assess the impact of both prepubic and perineal urethrectomy on the complication rate and grade when cysto-urethrectomy is planned. • To review the perioperative complications of radical cysto-urethrectomy and grade them according to the modified Clavien classification system.

PATIENTS AND METHODS

• A total of 186 radical cysto-urethrectomies were performed between 1984 and 2008 • Patients' charts were retrospectively reviewed, focusing on operation duration, hospital stay and complications arising. • According to this new classification, perioperative complications were stratified into five grades.

RESULTS

• Prepubic urethrectomy was done in 71 patients (group I) while perineal urethrectomy was done in 115 patients (group II). • The mean operation duration was significantly lower in group I than in group II (173.8 and 208.9 min in groups I and II, respectively; P= 0.003). • There were a total of 46 perioperative complications in 186 (24.7%) patients, 21 (29.5%) in the prepubic group and 25 (21.1%) in the perineal group. • There were 19 (90.5%) and 18 (72%) low-grade (G1-3) complications in the prepubic and perineal groups, respectively, and two (9.5%) and seven (28%) high-grade (G4-5) complications in the prepubic and perineal groups, respectively (P= 0.033). • The mean hospital stay was significantly lower in group I than in group II (14.5 and 17.6 days in groups I and II, respectively; P= 0.047).

CONCLUSION

• The prepubic approach has a lower incidence of serious complications with shorter operation duration and shorter hospital stay.

Urethral Recurrence of Invasive Carcinoma following BCG Treatment for Bladder Ca in Situ

CIS is a flat, high-grade, non-invasive microscopic urothelial carcinoma. It is considered a precursor of invasive bladder cancer. CIS is classified as primary, secondary or concurrent, when occurred as isolated CIS without cuncurrent papillary tumors, or detected during the follow-up of patients with a previous papillary tumor, or finally in the presence of bladder neoplasm. BCG is widely established as the treatment of choice for CIS with a success rate of approximately 70%. BCG reduces the risk of progression of CIS into invasive carcinoma in 30 to 50% of cases. Direct and prolonged contact between the urothelium and BCG is a prerequisite for successful therapy. Discovery of CIS in the prostatic or membranous urethra represents an ominous sign. CIS may be present only in the epithelial lining of the prostatic urethra or in the ducts, or in the worst case it may be found in the prostatic tissue stroma. Urethral involvement by CIS is at high risk of tumor progression and development of metastases due to reduced thickness of lamina propria and absence of muscolaris mucosa. 83 patients, enrolled from 1/1996 to 12/2005 at our urological department with CIS: primary (focal and multifocal) in 25, secondary in 7 and cuncurrent in 51 (associated with T1bG3 cancer in 37 cases), and urethral CIS in 5 and conservatively treated by TUR and intravescical instillations of BCG, 4 developed after words only invasive cancer of the urethra in the absence of bladder involvement. In 2 cases cancer arised from the prostatic fossa after TURP, in 1 from membranous urethra and in the last from prostatic ducts. Among the 4 patients, 3 were treated by cystoprostatourethrectomy and Platinum-based chemotherapy, 1 refused surgical treatment. Two patients died for disseminated disease. 1 patient is alive at 60–month's follow-up. In the last patient cancer relapsed at 36–month's follow-up. We conclude that prostatic/urethral involvement during follow-up after successful intravesical treatment with BCG in CIS represents a high risk of developing invasive and incontrolled cancer. A careful watch is recommended in these patients.

Urethrectomy following cystectomy for bladder cancer in men: practice patterns and impact on survival

PURPOSE

The benefit of urethrectomy in patients with bladder cancer who are undergoing cystectomy is controversial. We describe the frequency of urethrectomy by bladder cancer stage and identify clinical characteristics that predict urethrectomy. We also investigated whether urethrectomy offers any additional independent survival benefit.

MATERIALS AND METHODS

A total of 2,401 men who underwent radical cystoprostatectomy between 1991 and 2002 were identified in the Surveillance, Epidemiology and End Results-Medicare database. A multivariate logistic regression model was used to analyze factors driving urethrectomy. We then analyzed the records of 195 men who underwent urethrectomy to find predictors of that procedure as salvage for urethral recurrence vs concurrently with cystoprostatectomy or as a staged procedure. Using multivariate Cox regression analysis we analyzed whether urethrectomy had an independent effect on disease specific survival.

RESULTS

The only significant predictor of urethrectomy was stage. Patients at a teaching hospital were more likely to undergo salvage urethrectomy for recurrence vs immediate urethrectomy compared to those at urban nonteaching hospitals. Patient age, race, number of comorbidities and tumor stage were significant independent predictors of survival. Survival in men who underwent urethrectomy concurrently with cystoprostatectomy was higher than in those who did not undergo urethrectomy but not statistically significant (HR = 0.775, 95% CI 0.592-1.014, p = 0.0632).

CONCLUSIONS

Disease stage is related to urethrectomy performance. Age, race, stage and comorbidities were independent predictors of overall survival in patients with bladder cancer undergoing cystectomy. Urethrectomy did not confer a significant independent survival benefit.

Prostatic urethral biopsy has limited usefulness in counseling patients regarding final urethral margin status during orthotopic neobladder reconstruction

PURPOSE

We determined the value of preoperative transurethral prostatic urethral biopsy in predicting final distal urethral margin status at radical cystectomy.

MATERIALS AND METHODS

Of 1,006 patients undergoing radical cystectomy at our institution between 1990 and 2004, 252 were men who underwent ileal neobladder and form the basis of this report. Variables collected include pathology of prostatic urethral biopsies, final pathology of the prostate, frozen section of the distal urethra, final urethral margins and survival data.

RESULTS

Median patient age was 61 years. Data regarding preoperative transurethral resection prostatic urethral biopsy and/or frozen section of the urethra at the time of surgery were available for 245 of 252 patients (transurethral resection of the prostatic urethra alone in 127, urethral frozen section alone in 68 and both in 50). The incidence of positive distal urethral margin on final pathological examination was 1.1% (3 of 252) and urethral recurrence was 0.7% (2 of 252). The correlation between transurethral resection findings and frozen section margins was only 68%, and 16 patients with positive transurethral resection findings had negative frozen section margins. The negative predictive value of transurethral resection biopsy with respect to final margins was 99.4% and that of frozen section was 100%.

CONCLUSIONS

While patients with no tumor on transurethral resection biopsy of the prostatic urethra have a high likelihood of negative urethral margins on final pathological evaluation, optimal negative predictive value is obtained with frozen sections. Furthermore, a positive transurethral resection prostatic urethral biopsy does not correlate with final margin and should not exclude patients from consideration for orthotopic diversion.

Prostatic transitional cell carcinoma: pathologic features and clinical management

Prostatic involvement by transitional cell carcinoma (pTCC) in patients with bladder cancer is a frequent finding, particularly in patients with high-grade invasive tumor and urothelial carcinoma in situ. Various patterns and levels of prostatic involvement have been described, and their impact in patients' management and their prognosis recognized. The role of prostatic urethral biopsy and intraoperative frozen section in the management of bladder cancer, tailoring to the bladder tumor stage is still not well defined and universally accepted. This review discusses the current understanding of the biology and histological patterns of pTCC and their clinical significance and management options. A rational approach for management of pTCC in patients with bladder cancer will be proposed on the basis of our experience and our review of literature.

Pathological Guidelines for Orthotopic Urinary Diversion in Women With Bladder Cancer: A Review of the Literature

PURPOSE

Before the early 1990s total urethrectomy at radical cystectomy for bladder cancer in women was considered the standard of care. As our understanding of the natural history of urethral urothelial carcinoma in women has improved, neobladders have been increasingly created in carefully selected women with bladder cancer. We reviewed the literature regarding the incidence of urethral involvement, the risk factors for urethral involvement and the incidence of urethral recurrence in women undergoing orthotopic urinary diversion for bladder cancer.

MATERIALS AND METHODS

A comprehensive literature review was performed regarding the natural history of urethral tumor involvement by urothelial carcinoma, risk factors and the incidence of urethral recurrence following radical cystectomy and orthotopic diversion in women with bladder cancer.

RESULTS

Urethral tumor involvement occurs in approximately 12% of female patients with bladder cancer undergoing radical cystectomy for high grade, invasive urothelial carcinoma. Preoperative involvement of the bladder neck or anterior vaginal wall with urothelial carcinoma is an important risk factor for urethral tumor involvement. Intraoperative frozen section analysis of the proximal urethra is an appropriate and reliable method of identifying female candidates for orthotopic diversion. The rate of secondary tumor recurrence in the retained urethra of women following radical cystectomy and orthotopic urinary diversion is low but the condition requires long-term followup.

CONCLUSIONS

Orthotopic urinary diversion can be performed safely in appropriately selected women with bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence. Preoperative bladder neck involvement is an important risk factor for urethral involvement but not an absolute contraindication to orthotopic diversion should intraoperative frozen section of the proximal urethra be without evidence of malignancy.

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.

Therapie und Nachsorge bei malignen Blasentumoren

Treatment and follow up of bladder cancer strongly depends on stage and differentiation of the tumour. Superficial bladder tumours can mostly be controlled by transurethral resection followed by early intravesical application of a chemotherapeutic agent and a further close meshed follow-up. Generally, for muscle-invasive tumours radical cystectomy is indicated, whereas organ-spearing treatment due to combined therapeutic concepts can be offered in selected cases. For advanced and metastatic tumours, despite good response of bladder cancer to chemotherapy, prognosis is still poor. However, implementation of new chemotherapeutic agents indicate a trend towards improved survival rates.

Urothelial carcinoma recurrence in ileal orthotopic neobladder: urethrectomy and creation of ileal conduit

A patient who had previously undergone radical cystoprostatectomy and ileal neobladder with the Studer technique presented with a recurrence of urothelial carcinoma in the neobladder and urethra. Surgical treatment consisted of resection of the neobladder, urethrectomy, and creation of an ileal conduit using a separately isolated segment of ileum. Pathologic analysis revealed high-grade urothelial carcinoma implants to the Studer pouch and urethra, with spread to the mesenteric lymph nodes draining the pouch. Intraluminal tumor cell seeding appears to be an important mechanism of metachronous transitional cell carcinoma recurrence in the urethra and ileal mucosa of a neobladder.

Urothelial Carcinoma of the Prostate

This study was conducted to explore the diagnosis and management of urothelial carcinoma of the prostate in superficial disease and carcinoma in situ, stromal invasion, primary urothelial carcinoma, and urethral recurrence after radical surgery. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) reviewed the diagnosis and management of urothelial carcinoma of the bladder. English-language literature about urothelial carcinoma of the prostate was identified and reviewed. Evidence-based recommendations for the diagnosis and management of urothelial carcinoma were made. Many recommendations were level 3 or 4 citations involving the diagnosis and management of superficial urothelial carcinoma; a few were level 2 citations. Level 1 citations related only to chemotherapy and radiotherapy in patients with stromal invasion, although these were not related specifically to invasive prostatic involvement. More than 130 reviewed citations are summarized in this review. Published reports on the diagnosis and treatment of superficial urothelial disease of the prostate primarily consist of short case series from individual centers. Prospective and multicenter trials are needed to identify the real incidence and the best management of these patients. In invasive disease of the prostate, the only large series were designed to investigate invasive bladder cancer.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

Case report: Laparoscopy-assisted urinary undiversion: transforming an ileal conduit into an orthotopic continent neobladder

PURPOSE

To describe the technique of laparoscopy-assisted undiversion of an ileal conduit into a continent orthotopic ileal neobladder performed on a patient with a previous radical cystoprostatectomy and ileal conduit.

CASE REPORT

A 57-year-old man presented with a prolapsed stoma and a history of a right radical nephroureterectomy for grade 3 ureteral transitional-cell carcinoma and a radical cystoprostatectomy and ileal conduit urinary diversion for in-situ bladder carcinoma, performed 12 and 8 years ago, respectively. After the ileal stoma was resected, five trocars were placed transperitoneally. Partial resection of the distal ileal conduit was performed, leaving in place the proximal segment with its left ureteroileal anastomosis. Flexible urethroscopy revealed a contracting external sphincter, and random urethral frozen-section biopsies ruled out tumor. A 45-cm segment of ileum was isolated and exteriorized through the stoma site, and an ileal neobladder was created extracorporeally, suturing the proximal ileal-conduit segment, with its ureteroileal anastomosis, to it. The ileal neobladder was reintroduced into the abdomen and anastomosed laparoscopically to the urethral stump with six 2-0 polyglactin sutures. The total operative time was 7 hours with a blood loss of 100 mL. There were no intraoperative complications. The hospital stay was 7 days. At a follow-up of 24 months, the patient had total daytime continence and normal renal function, and intravenous urography revealed an unobstructed urinary tract.

CONCLUSION

Laparoscopy-assisted ileal-conduit undiversion into an orthotopic ileal neobladder is technically feasible. It can be considered an alternative to open surgery for patients who have undergone urinary diversion.

Entérocystoplastie de substitution chez l'homme (Hautmann exclu) : principes et applications techniques

Orthotopic urinary reservoir using a bowel segment has become the most favoured form of diversion after radical cystectomy. Ideal neobladder has to (i) store the urine with a low pressure bladder substitute, (ii) protect the upper urinary tract and (iii) provide a better quality of life enabling volitional voiding. A lot of techniques have bee described to construct a reservoir, however, all of them are based on the principle of intestinal loop detubulation. Many intestinal segments have been used, but ileum seems to be preferred in Europe. The upper urinary tract is mainly protected by a low neobladder pressure, rather than an additional antireflux flap-valve-type implantation technique which may increase the risk of uretero-enteric stricture. No significant difference in functional outcome can be observed among the several techniques. In selected cases, orthotopic bladder replacement is well tolerated and feasible and appears to be the gold standard after cystectomy.

The diagnosis and treatment of urethral recurrence after radical cystectomy

OBJECTIVE

To illustrate the problem of urethral recurrence of transitional cell carcinoma (TCC) after radical cystectomy, and define surveillance and treatment algorithms.

METHODS

There are 6 unique cases of urethral tumor recurrence presented, and current relevant literature is reviewed. Three risk groups are defined based on the likelihood of urethral recurrence. Surveillance and treatment options are delineated.

RESULTS

Although the incidence of recurrent tumor in the urethra is low, the prevalence is increasing because of improvements in bladder cancer survival and the fact that the urethra is retained more often for orthotopic urinary diversion. Patients can be categorized as low, intermediate, and high risk based on the pathologic finding of degree of prostatic involvement by the initial tumor.

CONCLUSION

Based on limited available literature, it appears that surveillance strategies range from observation alone to more invasive monitoring that includes urethral wash cytology and urethroscopy. Treatment options include local resection, intraurethral agents, and complete urethrectomy. A surveillance algorithm based on risk for recurrence and a treatment algorithm based on histopathologic risk factors of the recurrent tumor are proposed. This problem will assume increasing importance in the future.

Surgical treatment for urethral recurrence after ileal neobladder reconstruction in patients with bladder cancer

OBJECTIVE

To report a retrospective study evaluating the management of superficial urethral recurrence after ileal neobladder construction in patients with bladder cancer.

PATIENTS AND METHODS

In 77 consecutive patients with ileal neobladder after radical cystectomy for invasive bladder cancer, urethral recurrence was evaluated and transurethral resection (TUR) used as an initial treatment for superficial urethral recurrence. Urethrectomy with urinary re-diversion was performed when further recurrence developed.

RESULTS

Four patients (5%) presented with a superficial urethral recurrence and all four were treated by TUR as initial therapy. One patient has had no evidence of recurrence after initial TUR, although the other three patients were later treated with salvage urethrectomy due to repeated urethral recurrence. As a result, the stage of urethral recurrence advanced from pTa to pT1-pT2 in two of the three patients. For urinary re-diversion, one patient had a conversion from a Studer pouch to an ileal conduit, using the afferent limb, and the other two were converted from a Hautmann pouch to a continent reservoir using the Appe-Mainz procedure. There was no evidence of metastasis or local recurrence in any of the four patients.

CONCLUSION

Urethral preservation at initial therapy for superficial recurrence might be reasonable, and sequential urethrectomy after attempted urethral preservation might be strategically feasible. Urinary re-diversion from a neobladder to a catheterizable continent reservoir using the appendix would be a good choice and maintains the quality of life.

[Indications and techniques in urethrectomy]

The indications for urethrectomy during cystectomy for bladder cancer have substantially changed during the last years. Many years ago, prophylactic urethrectomy was performed in most patients undergoing cutaneous diversion. Today, transitional cell carcinoma at the level of the prostatic urethra or at the bladder neck is recognized to be the most important risk factor of urethral recurrence. Since the development of bladder substitutions, the indications for prophylactic urethrectomy have been dramatically reduced. Pre - and intra operative evaluation of the prostatic urethra in men and that of the bladder neck in women is the major determinant in the appropriate treatment strategy for the urethra in patients with bladder cancer.

Long-term results of standard procedures in urology: the ileal neobladder

Over the past 20 years orthotopic urinary reconstruction with the techniques developed at Ulm and Bern has become a widely accepted form of urinary diversion. So far, both centers together have performed more than 1,300 orthotopic bladder substitutions with an overall rate of neobladder formation in 58% of all cystectomized patients. Today, the absolute contraindications for this procedure are urinary stress incontinence, damaged rhabdosphincter, severely impaired renal and liver function, severe intestinal diseases or an oncologic situation requiring urethrectomy. In patients treated for transitional cell carcinoma of the bladder, the rate of urethral recurrence in both centers was 1.5 and 5%, respectively, and the rate of upper urinary tract recurrence was 2-3%. Local tumor recurrence usually did not affect neobladder function. The rate of outlet obstruction by local recurrence was 2%, that of gross hematuria 1%, and of entero-reservoir fistulas 1-2%. Daytime continence at 12 months was 92%, while nighttime continence was lower around 80%. Transient or permanent urinary retention was seen in 11-12% of male patients. In both series, long-term upper urinary tract safety was good. The risk of stenoses of the uretero-intestinal anastomosis with consecutive loss of renal function decreased with the introduction of non-refluxing implantation techniques. The rate of long-term metabolic complications remains low when adequate substitution with sodium bicarbonate is guaranteed in patients with impaired renal function. Patient selection and meticulous postoperative follow-up contributed to achieve good long-term results after cystectomy and orthotopic ileal neobladder substitution of the two large series of patients from the Universities of Ulm and Bern.

Patterns of Initial Transitional Cell Recurrence in Patients After Cystectomy

PURPOSE

We characterized initial relapse patterns in patients who underwent cystectomy for transitional cell carcinoma of the bladder at our institution.

MATERIALS AND METHODS

Between June 1995 and December 2001 a total of 417 patients underwent radical cystectomy for transitional cell carcinoma. Of the 399 patients treated with orthotopic diversion or incontinent cutaneous diversion, recurrent TCC developed in 86 (21.6%). We retrospectively examined this population to determine if any perioperative variables influenced the first site of disease recurrence.

RESULTS

Of the 86 patients in whom metastatic disease developed after cystectomy, the mean followup was 22.1 months. Mean time to disease recurrence was 15.1 months. Recurrence was most commonly initially in the pelvis (30.2%). Other common sites of first recurrence included the viscera (26.7%), the retroperitoneum (16.3%) and the skeletal system (16.3%). The site of first recurrence did not correlate significantly with gender, age, diversion type, pathological stage, nodal status, prostatic involvement or the presence of a positive surgical margin. Lymphovascular invasion was more prevalent in the pelvic recurrence group (62%) than in the retroperitoneal (36%), visceral (22%) or skeletal metastases (29%) groups (p = 0.03).

CONCLUSIONS

While the pelvis is the most common site of disease recurrence following radical cystectomy, TCC of the bladder recurs in an unpredictable pattern and aggressive surveillance is indicated. Patients with local pelvic recurrence had a higher percentage of lymphovascular invasion on cystectomy than the other recurrence site groups.

Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure

Radical cystectomy with an appropriate lymphadenectomy remains the standard of therapy for high-grade invasive bladder cancer. This surgical approach provides the best survival rates with the lowest local recurrence rates and orthotopic diversion can be performed safely in most patients with an acceptable outcome and quality of life. Pathologic analysis of the bladder tumor and regional lymph nodes will help direct the need for adjuvant therapy in high-risk individuals. Equivalent long-term local control and survival are not seen with other forms of treatment including radiation therapy, chemotherapy, or a combination of the two. The rationale and clinical results of large, contemporary cystectomy series are presented, which provide a benchmark of outcomes with this form of surgical treatment.

Immediate versus staged urethrectomy in patients at high risk of urethral recurrence: is there a benefit to either approach?

OBJECTIVES

To compare treatment-related outcomes of immediate and staged urethrectomy in patients at high risk of urethral recurrence.

METHODS

We retrospectively identified 76 male patients with cystectomy for transitional cell carcinoma of the bladder who had undergone urethrectomy in the absence of established urethral recurrence. Concomitant cystoprostatectomy and urethrectomy was performed in 57 patients and staged urethrectomy in 19 patients. The criteria for staged urethrectomy were the presence of a positive urethral margin or established transitional cell carcinoma of the urethra in the cystectomy specimen. The mean interval from cystectomy to staged urethrectomy was 4.7 months (range 1.4 to 14).

RESULTS

The most common pathologic finding of the urethrectomy specimens was prostatic duct involvement (31.6%) in the immediate urethrectomy group and Stage pT0 in the delayed urethrectomy group (73.7%). No statistically significant difference in disease-specific survival was noted between the immediate and staged groups (P = 0.14). Similarly, no difference was noted in postoperative complication rates or total operative blood loss (P = 0.77 and P = 0.64, respectively). However, a slight benefit for immediate urethrectomy was noted in the total duration of hospitalization (P = 0.01). The presence of local or distant recurrence was a predictor of disease-specific survival (P = 0.02 and P = 0.02, respectively).

CONCLUSIONS

Immediate and staged urethrectomy appear to be similar in surgical morbidity and disease-specific survival. A benefit was noted for the immediate group in the total duration of hospitalization. The development of local or distant recurrence was a predictor of poor survival.

Contemporary Management of the Urethra in Patients After Radical Cystectomy for Bladder Cancer

The incidence of urethral TCC after radical cystectomy is approximately 8% overall. The most important risk factor for urethral TCC after radical cystectomy and urinary diversion is prostatic involvement by TCC, particularly stromal invasion. The safety of using the urethra for orthotopic urinary diversion seems to be best when intra-operative frozen section analysis of the urethral margin is performed at the time of radical cystectomy. There is provocative but unconfirmed evidence that orthotopic urinary diversion may be protective against the development of urethral TCC. Although most urethral "recurrences" occur within 5 years, delayed recurrences have been documented, mandating life-long follow-up of the retained urethra. Follow-up should include urinary cytology, either voided or urethral wash cytology as appropriate, with evaluation by endoscopy of any urethral related symptoms or change in voiding symptoms. The management of urethral TCC after cystectomy remains a total urethrectomy including excision of the meatus; however, in carefully selected patients with superficial disease and an orthotopic urinary diversion, urethra sparing may be attempted after a careful discussion with the patient. Survival after urethral TCC has generally been disappointing. The relative value of urethral versus original cystectomy pathologic stage and symptomatic versus nonsymptomatic recurrence in predicting survival remains controversial and awaits further studies that will most likely require the pooling of data from several large series.

URETHRAL TUMOR RECURRENCE FOLLOWING CYSTECTOMY AND URINARY DIVERSION: CLINICAL AND PATHOLOGICAL CHARACTERISTICS IN 768 MALE PATIENTS

PURPOSE

We evaluated the incidence and risks of urethral recurrence following radical cystectomy and urinary diversion in men with transitional cell carcinoma of the bladder.

MATERIAL AND METHODS

Clinical and pathological results were evaluated in 768 consecutive male patients undergoing radical cystectomy with intent to cure for bladder cancer with a median followup 13 years, including 397 (51%) who underwent orthotopic urinary diversion with a median followup of 10 years and 371 (49%) who underwent cutaneous urinary diversion with a median followup of 19 years. Demographically and clinically these 2 groups were well matched with the only exception being longer median followup in the cutaneous group (p <0.001). Urethral recurrence was analyzed by univariate and multivariable analysis according to carcinoma in situ, tumor multifocality, pathological characteristics (tumor grade, stage and subgroup), the presence and extent of prostate tumor involvement (superficial vs stromal invasion) and the form of urinary diversion (cutaneous vs orthotopic).

RESULTS

A total of 45 patients (6%) had urethral recurrence at a median of 2 years (range 0.2 to 13.6), including 16 (4%) with an orthotopic and 29 (8%) with a cutaneous form of urinary diversion. Carcinoma in situ and tumor multifocality were not significantly associated with an increased risk of urethral recurrence (p = 0.07 and 0.06, respectively). The presence of any (superficial and/or stromal invasion) prostatic tumor involvement was identified in 129 patients (17%). Prostate tumor involvement was associated with a significantly increased risk of urethral recurrence (p = 0.01). The estimated 5-year chance of urethral recurrence was 5% without any prostate involvement, increasing to 12% and 18% with superficial and invasive prostate involvement, respectively. Patients undergoing orthotopic diversion demonstrated a significantly lower risk of urethral recurrence compared with those undergoing cutaneous urinary diversion (p = 0.02). Patients without any prostate tumor involvement and orthotopic diversion (lowest risk group) demonstrated an estimated 4% year chance of urethral recurrence compared with a 24% chance in those with invasive prostate involvement undergoing cutaneous diversion (highest risk group). On multivariate analysis any prostate involvement (superficial and/or invasive) and urinary diversion form remained independent and significant predictors of urethral recurrence (p = 0.035 and 0.01, respectively).

CONCLUSIONS

At long-term followup urethral tumor recurrence occurs in approximately 7% of men following cystectomy for bladder transitional cell carcinoma. Involvement of the prostate with tumor and the form of urinary diversion were significant and independent risk factors for urethral tumor recurrence. Patients undergoing orthotopic diversion have a lower incidence of urethral recurrence compared with those undergoing cutaneous diversion. Although prostate tumor involvement is a risk factor for urethral recurrence, it should not preclude orthotopic diversion, provided that intraoperative frozen section analysis of the urethral margin is without evidence of tumor.

What is the ratio of urethral recurrence risk after radical cystoprostatectomy for bladder cancer?

OBJECTIVE

There is always a risk of urethral recurrence after radical cystoprostatectomy in patients with bladder transitional cell cancer. Taking these risk factors of urethral recurrence into account, orthotopic neobladders or urinary diversions without using the urethra are performed. But urethral tumour recurrence occurs much less than the expected. We assessed the etiological factors that affect the urethral recurrence in orthotopic and nonorthotopic urinary diversion cases.

METHODS

Sixty-four patients with bladder cancer who underwent radical cystoprostatectomy and urinary diversion between 1994 and 2002 were included this study. Conventional risk factors effecting the selection of operation type and urethral recurrence were evaluated in these patients. Cystoscopy and biopsy were done and pathologic specimen was obtained preoperatively, and cystoscopy and urethral washout cytology were done postoperatively. Routine bladder biopsies were done in uncertain cases at follow-up. Risk factors increasing the urethral recurrence are as follows: papillary and multiple tumours, tumour invading bladder neck and trigone, extensive CIS, prostatic stromal and urethral invasion, positive surgical margin and history of upper urinary tract tumour. In 31 patients having one or more of these criteria, continent nonorthotopic urinary diversion was performed, but 33 patients without these risk factors underwent orthotopic urinary diversion. Simultaneous urethrectomy was not done in any of these patients.

RESULTS

Among the patients who underwent radical cystoprostatectomy, none was with positive surgical margin in the distal end of the prostatic urethra. In preoperative cystoscopy, tumoural mass was seen near to collum in eight patients and in the prostatic urethra in three patients. Histopathological examination of cystoprostatectomy specimen displayed transient epithelial cell carcinoma of prostatic urethra in three patients, transient epithelial cell metaplasia inside the prostate in five patients and invasion to the urothelium of bladder neck in three patients. There were not any transient epithelial cell cancer metastases in prostatic stroma in any of these patients. One patient underwent urethrectomy, since atypical cells were observed in postradical prostatectomy urethral washout cytology but there was no tumour found in pathological examination of the specimen. Therefore, urethral tumour recurrence did not occur after 25 months follow up.

CONCLUSION

These findings suggest that some of the conventional risk factors of urethral recurrence were exaggerated. We may also conclude that there is no need for prophylactic urethrectomy unless there is urethral cancer or cancer in the surgical margin. But if utilization of urethra is planned, evaluation of prostatic stroma by TUR biopsies and urethral anastomose margin by frozen section during the operation is necessary.