ESOU 2019: Optimizing Functional Outcomes in Radical Cystectomy: Prostate Sparing Approaches

Prague, Czech Republic (UroToday.com) In this first talk, Dr. Sanchez-Salaz reviews options of prostate sparing approaches for optimizing functional outcomes in patients undergoing radical cystectomy.

As background, it is well established that 20-30% of newly diagnosed bladder cancers are muscle-invasive (MIBC), and for these patients (and patients who progress to MIBC), the standard of care treatment is neoadjuvant chemotherapy and radical cystectomy with urinary diversion. Alternatives include trimodal therapy, though this is not yet considered a standard of care. Radical cystectomy is associated with significant detrimental effects on patient quality of life, urinary and sexual function, and has an impact on patient social and emotional health, body image and psychosocial stress. While most patients undergo urinary diversion with an incontinent ileal conduit, some patients (male and female) undergo continent neobladder formation. While this traditionally has entailed removal of the prostate/SVs (males) and uterus/ovaries/FT’s (females), there have been modifications proposed and evaluated to help reduce some of the detrimental effects of urinary diversion. These go above and beyond the traditional nerve sparing that will be later discussed.

The primary objectives of these approaches (broadly grouped as prostate sparing approaches) are:
  • Comply with cancer control
  • To improve urinary and sexual functional outcomes
  • To improve operative features such as OR time and blood loss
However, the key to this is patient selection!

Radical cystectomy with nerve-sparing functional and oncologic outcomes was first summarized, as a comparator:
  • Recurrence rates
    1. 30% at 5-years and 40% at 10-years
    2. Local recurrence between 5-20% in most series
  • Functional outcomes:
    1. Daytime continence: 80%
    2. Nighttime continence: 60-70%
    3. Preservation of erectile function:  13-50%
In two papers summarizing prostate sparing radical cystectomy (PSRC) techniques (Klotz et al. 2009 and Avulova & Chang 2018):
  • Recurrence rates
    1. Local recurrence ~5% (0-20%)
    2. Systemic recurrence ~8% (0-34%)
  • Functional outcomes:
    1. Daytime continence: 90% (50-98%)
    2. Nighttime continence: 85% (30-94%)
    3. Preservation of erectile function:  80% (68-96%)
So, while oncologic outcomes are preserved, functional outcomes drastically improve.

Per Dr. Sanchez-Salas, these techniques are viable options for patients with refractory NMIBC (undergoing early radical cystectomy) or patients with low-volume single-site T2 MIBC. However, he accepts that the major issues with this data are:
  • Different authors on each of the series, each with their own modification of the technique
  • Lack of a large series with long term results
But, they all have common goals – sparing the neurovascular bundle, sphincter complex, seminal vesicles (as NVB runs just lateral to it)

What are the risks of these procedures? Two main risks:
  • Undiagnosed prostatic urothelial carcinoma
  • Prostatic adenocarcinoma
These are both real risks. In unscreened populations, 20-48% of men undergoing radical cystectomy had prostatic urothelial carcinoma (1/3 in the apex) and 41-48% of men had prostate cancer (60% apical). But, these are unscreened patients.

In screened patients (evaluated patients), the rates are much better:
  • PUC in 6-10% of men with comparable 5-year DSS compared to radical cystectomy alone (66% vs. 64%)
  • PCa in 8.4% of men – comparable to radical cystectomy series
His recommendations for screening and evaluating patients for these risks:
  • PUC
    1. Intra-op frozen section of the whole prostatic urethra or whole prostate
    2. If positive, complete radical cystectomy
  • PCa
    1. Strict selection based on pre-operative evaluation
    2. Normal DRE, normal TRUS
    3. PSA < 3 ng/mL
    4. %Free PSA >15%
    5. Normal TRUS Bx (12-core systematic) in some patients
Two institutions protocols are found below:
UroToday ESOU19 Prostate Sparing Approaches protocols
Patient selection is the major aspect of the decision to do a PSRC. His take-home slide for patient selection:
UroToday ESOU19 patient selection
Beyond the patient selection, success also depends on the essentials of a radical cystectomy, including extended pelvic lymphadenectomy, avoid intraoperative spillage, and meticulous follow-up (including urinary cytology).

He does note one randomized controlled trial by Jacobs et al. (J Urol 2015) that compared PSRC to nerve-sparing radical cystectomy, and found no difference in functional outcomes or cancer control / oncologic outcomes – but it was very small numbers of patients. In comparison, a study by Saad et al. (2017) in a case-controlled retrospective comparison noted much better 1-year functional recovery in the men undergoing PSRC. In a systematic review by Hernandez et al. (2017), cancer control was similar between both arms (PSRC vs. standard RC), but both continence and sexual functional outcomes favored PSRC.

His concluding remarks are as follows:
UroToday ESOU19 PSRC Conclusions

Presented by: Rafael Sanchez-Salas, Staff Surgeon at the Institute Mutualiste Montsouris. Paris, France.

Written by: Thenappan Chandrasekar, MD. Clinical Instructor, Thomas Jefferson University, Twitter: @tchandra_uromd, @TjuUrology, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

Further Related Content:
Open Nerve-Sparing Radical Cystectomy
Robotic Nerve-Sparing Radical Cystectomy

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