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Prostate sparing approaches

Watch the ESOU19 webcast “Optimising functional outcomes in radical cystectomy: Prostate sparing approaches”.

Approximal 20 to 30% of new cases of clinically localized bladder cancer are de novo muscle invasive therefore requiring a radical treatment with surgery or radiation therapy to the bladder. However, the treatments are associated with detrimental effects on quality of life, urinary and sexual function as well as social and emotional health, body image and psychosocial stress.

One of the proposed surgical techniques to decrease the complications and poor functional outcomes is represented by prostate sparing approaches, a group of different surgical approaches that is comprehensive of several techniques such as seminal vesicles sparing cystectomy and prostate capsule-sparing cystectomy.

As a consequence of the aggressiveness of the urothelial cancer, these approaches have been neglected in the past. However, available data suggest excellent oncological and functional outcomes in selected patients.

Preoperative screening is necessary

In unscreened patients, prostatic urothelial carcinoma is found in 20-48% of the patients treated with radical cystectomy, while 41-48% are diagnosed with incidental prostate cancer. However, with a proper preoperative screening, only 6 to 10% of patients are diagnosed with urothelial prostate cancer and only 8.4% with PCa.

Preoperative screening can be performed with a preoperative or intraoperative frozen section the whole prostatic urethra. At Montsouris hospital, some patients received a Millin prostatectomy instead of TURP enabling to analyze the whole prostatic urethra.

Considering prostate cancer, normal digito-rectal examination, normal transrectal sonography, PSA total <3 ng ml, PSA Free/tot < 15% and in some series systematic biopsies are important factors.

However, no standardized criteria have been defined and every center performing prostate sparing surgeries proposed their own.

Selection of the candidates if fundamental

What to expect in term of oncological and functional results?

To date, only one prospective trial has evaluated this clinical question. However, it was closed prematurely due to a lack of accrual therefore reducing the statistical power of the trial.

Considering retrospective studies, Institut Mutualiste Montsouris, Paris, France and Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands shared their series of 185 patients treated with prostate capsule sparing cystectomy. Five-year OS was 71% and 5-year cumulative incidence of recurrence was 31%. Twenty patients (10.8%) had a loco-regional recurrence, two recurrences were in the PU. During follow-up, prostate cancer was detected in six patients (3.2%). Erectile function was preserved in 86.1% of patients, complete daytime and nighttime continence in 95.6% and 70.2%, respectively.

No tumor should be present at the level of bladder neck, no metastases and no prostate cancer. In fact, patients with one of these characteristics suffer from poor survival outcomes and should be treated with more aggressive surgery.

In the only existing metanalyses on this topic, similar survival outcomes were found in patients treated with prostate capsule sparing cystectomy comparing to radical cystectomy, but those treated with prostate capsule sparing approach where found with improved continence and sexual potency.

Important aspects to be considered during this procedure:

– Offer an adequate concomitant extended lymphadenectomy.
– Avoid intraoperative spillage.
– Perform a meticulous frequent follow-up.

What are the future directions?
– Screen prostate cancer with MRI and biomarkers.
– Usage of neoadjuvant chemotherapy.
– Standardized evaluation of outcomes.

In conclusion,
In very selected patients, PSRC offers similar oncological outcomes with standard RC.

Occult prostate cancer may occur even with screening.
Preoperative sexual function, age, performance status and postoperative expectations need to be discussed with the patients.

As a community, we need to improve patients’ selection, diagnoses and surveillance tools.

Suggested articles:
1. Only existing prospective trial on this topic: doi: 10.1016/j.juro.2014.07.090.
2. Institut Mutualiste Montsouris, Paris, France with Antoni van Leeuwenhoek Hospital, Amsterdam: 10.1016/j.ejso.2018.05.032
3. Metanalyses on this topic: 10.1016/j.urolonc.2017.04.013.