Urological oncology

Abstract

Conclusions: The majority of prostates from cystoprostatectomies had no involvement of the prostatic apex by Uca or clinically significant Pca. Hence, most patients may be candidates for prostate apical sparing. However, involvement of the apex by Uca in any patient raises concern about procedures that leave portions of the prostate urethra after cystectomy in an effort to improve continence. In candidates for orthotopic neobladder reconstruction removing all of the prostatic urethra and sparing the remainder of the prostatic apex may allow improved preservation of urinary continence with an acceptable low risk of clinical Pca progression. Whether future strategies for preoperative exclusion of apical Pca and intraoperative assessment of more proximal prostate to help exclude apical urothelial disease may identify patients suitable for prostatic apical sparing remains to be determined. The impact on functional outcomes and cancer control also require additional study. Editorial CommentIn older textbooks the preservation of the prostatic apex during cystoprostatectomies for transitional cancer of the bladder was regarded a standard technique. In order to improve nerve preservation and subsequently potency and furthermore to enable postoperative of fertility preservation not only of the prostatic apex but of half of the prostate was suggested by some authors. It is of note that the areas which are than preserved are the ones where the majority of prostatic tumors arise.In the current study 41% of 121 patients undergoing cystoprostatectomy for transitional cell cancer had unsuspected prostate cancer. Half of them were clinically significant. In 60% of the unsuspected prostate cancers and in 33% of the transitional cell cancer invading the prostate the prostatic apex was involved. Overall tumor was found unsuspectedly in the prostatic apex in 40% (39/121 patients).This is actually a very high rate of unsuspected tumor in the prostate and a substantial number were significant tumors. With this number in mind it is therefore very difficult to argue for either an apex or even a fertility preserving cystoprostatectomy. Even if the transitional cell cancers invading the prostate are excluded because they might be seen with a better staging of patients there is still the problem of unsuspected prostate cancer which may not be found despite more efforts in preoperative staging. Neither PSA nor imaging will be able to detect them all. Therefore only partial remove of the prostate in patients with transitional cell cancer of the bladder has to be an absolute exception and patients and surgeons must be aware of the substantial risk of later problems with a secondary prostate cancer. Urol. 2004; 171: 145-8 Purpose: Although rarely curative, chemotherapy remains the mainstay of treatment for metastatic urothelial cancer. The role of surgery for metastatic disease is not well established for urothelial cancer, but is sometimes undertaken in the face of persistent or recurrent disease that can be surgically resected. Dr. Arnu...