Importance In The Management Of The Prostate And Urethra In Bladder Cancer

UroToday.com - In a session moderated by Dr. Eila Skinner, USC, Dr. Seth Lerner, Baylor spoke about the "Pathologic Assessment of Clinical Significance of Prostatic Involvement by TCC/PCA". Up to 50% of patients with this finding will have nodal metastases. The 5-yr survival of these patients is 30% or less. In a recent pathology report from Baylor (Shen, Human Path. 2006), 214 men had radical cystectomy specimens evaluated. 69% were TCC, and the majority was invasive. They looked at the involvement of the lamina propria and 28% had this feature, while 33% had stromal invasion.

The 5-yr survival decreased from 74% to 44% to 32% with no prostatic invasion, lamina propria invasion and stromal invasion, respectively. There was no difference whether the stromal invasion was extension from the urethra or through the bladder wall. He felt that this was a reflection of separating out the lamina propria invasive patients. The TUR biopsy does adequately sample for prostatic involvement in most cases, he said.

From their data if the TUR biopsy is negative there is a 97.5% likelihood of a negative apical margin at radical cystectomy, which impacts consideration for orthotopic urinary diversion. However, in a recent paper from Memorial Sloan Kettering Cancer Center, the TUR biopsy was only 53% sensitive in detecting prostatic involvement.

Dr. Steve Campbell, Cleveland Clinic provided an "Update on Prostate Sparing Procedures". There is a high likelihood of prostate cancer in TCC patients undergoing cystectomy, up to 47% in a report earlier this year. In one report, Dr. Campbell pointed out; only 26% of cystoprostatectomy specimens were free of any carcinoma. Prostate sparing cystectomy results in better functional outcomes such as continence, potency and fertility.

From a series by Vallancien, using this approach only 5/85 had a recurrence. In a meta-analysis, by Hautmann and Stein in 2005 the local recurrence was 7/252 and systemic recurrence was 34/252. Potency was 85-100% in those who had prostate sparing. In a series from the Cleveland Clinic all patients with TCC in the prostate had CIS, multifocality or trigone involvement as risk factors

Dr. Mark Schoenberg, Johns Hopkins gave an "Update on Nerve Sparing Cystoprostatectomy Outcomes". It has historically been proposed that nerve sparing (NS) may permit cancer to be left behind as it often involves the neuro-vascular bundles. He cited Dr. Studor that NS results in improved sensation in the urethra and greater continence rates. It is unclear if this is true due to preservation of autonomic nerves as opposed to gentler handling of the peri-urethral tissues.

Overall, NS is safe, technically feasible and improves potency, although convincing data that it improves continence is lacking. Sparing the seminal vesicles has unclear consequences.

Report from The Society of Urologic Oncology Winter Meeting - National Institutes of Health - December 1-2, 2006
Reviewed by UroToday.com Contributing Editor Christopher P. Evans, M.D

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