FOIU 2018: Prostate Sparing Cystectomy: Functional and Oncological Results

Tel-Aviv, Israel ( Jehonathan Pinthus, MD, gave an overview of the novel procedure of prostate capsule sparing radical cystectomy. Pinthus began his talk by stating that functional outcome must be weighed against any risk for an oncologic outcome. In fact, when performing a prostate capsule sparing radical cystectomy, we are worried about missing urothelial carcinoma in the prostate capsule, and missing prostate cancer (PC). The rate of PC and prostatic urothelial carcinoma in radical cystectomy (RC) specimens in unscreened patients range from 23-48% and 36-46%, respectively. However, we can avoid missing these two entities by performing these steps:

  • For prostate cancer diagnosis:
  1. Preoperative transrectal US guided biopsy, PSA, and multiparametric MRI
  2. If PC develops later on – radical prostatectomy is always a possibility
  • To avoid missing urothelial cancer in the prostate - preoperative TUR of the prostate must be done, as missed urothelial carcinoma of the duct or stroma invasion is unlikely
Additionally, we can exclude patients with bladder neck tumors, performing extensive sampling (TUR) especially proximal to the verumontanum, which is likely to identify urethral ductal and stromal involvement. Gross involvement of the prostate is often palpable and evident on imaging. Lastly, we can do an intra-operative frozen section form the prostate margin. When patients are screened for prostate cancer, the incidence of synchronous or metachronous PC is approximately 2%.

Another concern in prostate capsule sparing RC is the higher rate of local and systemic recurrence. However, early RC for high-risk non-muscle invasive bladder tumor failing BCG will have a very low recurrence rate. Administration of neoadjuvant chemotherapy (especially in the 30% of cases when it results in a pathological T0) will minimize the risk of recurrence. Performing a meticulous pelvic lymph node dissection will also reduce the risk of recurrence.

A study published on the 20-year follow-up of patients who underwent prostate capsule sparing RC for bladder cancer demonstrated 2 and 5-year disease-specific survival rates of 76.2% and 66.5%, respectively. 1 The 2- and 5-year recurrence-free survival rates were 72.1 and 6.6%, respectively. Distant and local recurrence rates were 34.2% and 10% respectively. Recurrence as urothelial carcinoma of the prostate only occurred in one case (<1%). When assessing the functional outcomes, complete daytime and nighttime continence were achieved in 96.2% and 81.9% of patients, respectively. Erectile function and antegrade ejaculation were intact in 89.7% and 35.5%, respectively.

Another study discussed, was a comprehensive systematic review and meta-analysis endorsed by the EAU guidelines committee, analyzing 12 studies, with a total of 1098 patients, between 2000-2015, with a minimum follow-up of 1 year.2 The conclusion of this study is that the evidence suggests that this procedure may yield better sexual outcomes than standard cystectomy, without compromising oncological outcomes. However, the overall quality of the evidence is moderate, and hence if offered, patients must be well selected.

The only randomized trial published on this was done on 40 patients with urothelial carcinoma of the bladder with clinical stage T2 or below, with the negative prostatic urethra and negative preoperative prostate biopsy. Patients were randomized to either prostate capsule sparing RC or nerve-sparing RC. No difference was noted in the functional and oncological outcomes. 3

Pinthus concluded his talk with an important take-home message. Prostate capsule sparing RC probably results in better sexual outcome with a comparable oncological outcome to standard RC in selected patients. Most importantly, patients must be pre-operatively screened and selected for this procedure to succeed in all aspects.

1. Martens LS, et al. J Urol 2014
2. Hernandez V et al. Urologic Oncology 2017
3. Jacobs BL. et al. J Urol 2015

Presented by: Jehonathan Pinthus, MD, McMaster University, Canada

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan  at the 2018 FOIU 4th Friends of Israel Urological Symposium, July 3-5. 2018, Tel-Aviv, Israel