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

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.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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.

Cystectomy for Benign Indications

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Pelvic reconstruction and lateral prostate capsule sparing techniques improve early continence of robot-assisted radical cystectomy with orthotopic ileal neobladder

PURPOSE

To evaluate urinary outcomes of pelvic construction and lateral capsule sparing techniques in robot-assisted radical cystectomy with orthotopic ileal neobladder (RARC-OIN).

METHODS

A total of 107 male patients who underwent RARC-OIN during January 2017 and February 2021 in Sun Yat-sen Memorial Hospital were analyzed retrospectively. Standard RARC-OIN with or without nerve sparing technique was performed in 44 patients (standard group), lateral prostate capsule sparing technique was performed in 20 patients (LCS group), combined pelvic reconstruction (CPR) technique including anterior suspension and posterior reconstruction were performed in 43 patients (CPR group). The urinary function was assessed by the use of pads and the Bladder Cancer Index (BCI). Continence was defined as the use of 0-1 pad during daytime or night-time.

RESULTS

There was no statistical difference between the three groups regarding demographic, perioperative, and pathological data. Continence rates were 6.8, 50.0 and 34.9% for daytime, 4.6, 40.0 and 32.6% for night-time in the standard group, LCS group and CPR group at 1 month post-operation, respectively. Continence rates were 34.1, 80.0 and 69.8% for daytime, 27.3, 75.0 and 65.1% for night-time in the standard group, LCS group and CPR group at 3 month post-operation, respectively. No statistically significant difference was observed in the daytime and night-time continence rates at 12 months.

CONCLUSIONS

Lateral capsule-sparing and combined pelvic reconstruction techniques are feasible to improve early daytime and night-time continence rates in RARC with orthotopic neobladder.

CLINICAL TRIAL REGISTRATION

The trial registration number: ChiCTR2100047606.

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.

Effect of neurovascular bundle sparing radical cystectomy on post-operative continence and sexual function: A systematic review and meta-analysis

BACKGROUND

It is unclear whether the neurovascular bundle (NVB) sparing could improve post-operative urinary continence and potency. Furthermore, concern remains regarding the impact of nerve-sparing (NS) radical cystectomy (RC) on oncological outcomes.

OBJECTIVES

The primary objective of this meta-analysis was to evaluate whether in men undergoing NS RC could improve post-operative urinary continence and potency. The secondary objective was to assess whether NS RC could compromise the oncological control.

MATERIALS AND METHODS

A systematic search of the PubMed and Web of Science was performed in February 2020, yielding 1446 unique records. A total of 13 comparative cohort studies were included. Risk of bias in each study was assessed separately by two authors using the Newcastle-Ottawa Scale (NOS).

RESULTS

Data from 921 participants in 12 studies were synthesized in the present meta-analysis. Meta-analysis revealed that NS compared with non-nerve sparing (NNS) results in improved post-operative potency, daytime continence, and nocturnal continence. RRs were 9.35 (P < .00001) in potency, 1.11 (P = .045) in daytime continence, and 1.33 (P = .002) in nocturnal continence, respectively. Furthermore, no differences were found in the included studies reporting oncological outcomes. RRs were 0.88 (P = .61) in local and/or distant recurrence between two groups. A sensitivity analysis of prospective studies indicated consistent results.

DISCUSSION AND CONCLUSION

This meta-analysis indicates that NS RC can improve post-operative potency, and daytime and nocturnal urinary continence, without compromising oncological control, compared with NNS RC in men.