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Long‐term Functional and Oncologic Outcomes of nerve sparing and prostate capsule sparing cystectomy: a single center experience

  • Mohamed Saad,
  • Marco Moschini,
  • Armando Stabile,
  • Petr Macek,
  • Camille Lanz,
  • Dominique Prapotnich,
  • Francois Rozet,
  • Nathalie Cathala,
  • Annick Mombet,
  • Rafael Sanchez‐Salas,
  • Xavier Cathelineau

Publication: BJU International, June 2019

DOI: doi.org/10.1111/bju.14850





Objectives

To evaluate technical feasibility, oncological and functional outcomes of nerve sparing cystoprostatectomy (NSCP) and prostate capsule sparing cystectomy (PCSC) for the treatment of organ confined bladder cancer at a single referral center.

Materials and Methods

From April 2001 to June 2012, 60 patients underwent PCSC, while 47 were treated with NSCP. Inclusion criteria for PCSC were: fully informed consent for the well‐motivated patient; negative TUR of the bladder neck; normal PSA (defined as <4 ng/dL during the first year of the study, which was later lowered to 2.5 ng/dL); and normal TRUS, with biopsy for any suspicious nodule. Patients received a complete oncological and functional follow up. The Kaplan‐Meier method was used to depict survival outcomes after surgery.

Results

After a median follow up of 73 months and 62 months for PCSC and NSCP, the 5‐year CSS was 90% for the PCSC group and 78% for the NSCP group, respectively (P = .055). Considering complications within 30 days after surgery, 13% and 21% patients suffered from Clavien III or higher complications in PCSC and NSCP groups, respectively (p=0.2). Considering functional outcomes, at 3 months after surgery, 54 (90%) and 24 (51%) patients reported full recovery of day time urinary continence in the PCSC and NSCP groups, respectively (p<0.001) and considering erectile function recovery, 32 (53%) and 4 (9%) patients in the PCSC group and in the NSCP group were respectively potent without any treatment (p<0.001).

Conclusions

NSCP and PCSC are appropriate indication for a subset of patients with bladder cancer with excellent oncological and functional results. These surgical procedures should be proposed to well‐motivated patients.


Experts comments

In this retrospective single center study, the authors evaluated the technical feasibility, oncological and functional outcomes of nerve-sparing cystoprostatectomy and prostate capsule-sparing radical cystectomy for the treatment of bladder cancer. Overall, 60 patients were treated with nerve-sparing cystoprostatectomy while 47 received prostate capsule-sparing radical cystectomy. Inclusion criteria were: fully informed consent and well-motivated patient, negative transurethral resection of the bladder neck, normal PSA defined as <4 ng/dL during the first year of the study, which was later lowered to 2.5 ng/dL and normal transrectal sonography with biopsy for any suspicious nodule. The 5-year CSS was 90% for the prostate capsule sparing group and 78% for the nerve capsule sparing cystectomy group, respectively (p value = .055). Overall, 13% and 21% patients treated with prostate capsule sparing and nerve sparing cystoprostatectomy recorded Clavien III or higher complications within 30 days after surgery(p=0.2). At 3 months after surgery, 54 (90%) and 24 (51%) patients reported full recovery of day time urinary continence in the prostate capsule sparing and nerve sparing cystectomy groups, respectively (p<0.001) and considering erectile function recovery, 32 (53%) and 4 (9%) patients in the prostate capsule sparing group and in the nerve sparing cystectomy group were respectively potent without any treatment (p<0.001). These data suggest that in the appropriate candidates, these procedures are feasible and associated with excellent survival and functional results. 

Experts summary

Radical cystoprostatectomy is associated with high rates of morbi-mortality and impaired functional outcomes such as urinary incontinence and sexual dysfunction. To improve the latter, several types of surgical techniques such as nerve-sparing radical cystectomy and prostate capsule-sparing cystectomy have been proposed during the years. However, few data exist reporting long term survival outcomes following these procedures and given the aggressiveness of the urothelial disease safety concern exists through the urological community. In this study, Saad and colleagues reported functional and oncologic outcomes of patients treated with nerve sparing and prostate capsule sparing cystectomy showing feasibility in terms of complications and survival and excellent functional outcomes. It has to be highlighted that a careful selection is mandatory, especially during the transurethral resection where all the patients with tumor in the bladder neck need to be excluded and regarding prostate cancer screening. Having that in mind, these procedures seem a valid alternative in selected patients to improve functional outcomes in bladder cancer patients.