- For prostate cancer diagnosis:
- Preoperative transrectal US guided biopsy, PSA, and multiparametric MRI
- 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
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