What is the efficacy of prostate-sparing radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

The external urinary sphincter and cavernosal nerves lie in close proximity to the prostate. To enhance urinary continence and potency, certain groups have advocated a prostate-sparing cystectomy in highly select men. By performing this procedure, the surgeon avoids the region of the sphincter and nerves. The primary concern with this surgical approach is leaving residual prostatic TCC or adenocarcinoma. Some studies show a prostate adenocarcinoma incidence as high as 50% in men who undergo radical cystectomy, with one third of these patients having high-risk features such as Gleason disease scores of 7-10 or extracapsular extension. Further, up to one third of patients will have TCC involvement of the prostatic urethra, with two thirds of these involving the prostatic stroma.

One group from the Montsouris Institute in Paris has performed more than 100 prostate-sparing radical cystectomies. Men are selected based on (1) normal digital rectal examination results, (2) low serum prostate-specific antigen (PSA) levels, (3) a percent-free PSA of more than 15%, and (4) normal findings on a transrectal ultrasonography of the prostate. Alternatively, men who did not meet the criteria listed underwent prostate biopsies. If their biopsy samples were negative for cancer, the men were candidates for the prostate-sparing approach. [37]

All men underwent transurethral resections of the prostatic urethra and transition zone. If frozen sections were negative for tumor, a prostate-sparing approach was performed, which included anastomosing the neobladder to the prostate capsule. At a mean follow-up of 38 months, 3 patients were being treated for prostate cancer. Pelvic recurrence of TCC occurred in 5% of men, with recurrence in the prostatic fossa in 2%. Complete continence was retained in 98% of men and, of those with adequate preoperative erectile function, 82% maintained their potency status.

Other groups have noted progression in 8 of 10 patients who underwent prostatic capsule and seminal vesicle–sparing cystectomy for T2 bladder cancer. [38] With such concerns about long-term oncologic efficacy, as well as imperfect patient selection and methods of postoperative surveillance, prostate-sparing cystectomy remains a highly controversial approach to patients with bladder cancer.


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