SAN FRANCISCO—In patients with advanced or high risk bladder cancer, cystectomy, including removal of the prostate, is generally considered standard of care, but doctors reported here at the 2016 Genitourinary Cancers Symposium that in some cases, the prostate-sparing surgery can be performed with acceptable outcomes (Abstract 413).
“The important thing to understand here,” Jose Perez-Reggeti, MD, attending physician in Urology at Hospital Universitari de Bellvitge in Barcelona, Spain, told OT, “is that these are highly selected patients. You can't do prostate-sparing cystectomy as a routine procedure.”
Study of Cystectomies
In his poster presentation, Perez-Reggeti reviewed 64 prostate-sparing cystectomies between 1992 and 2014. The five-year overall survival in this group of men was 84.7 percent, he said. The 10-year overall survival was 68.3 percent, he added. The study was conducted while Perez-Reggeti was a fellow at Institut Mutualiste Montsouris/Universite Paris Descartes.
The cancer-specific survival was 84.7% at five years and 77.5% after 10 years, Perez-Reggeti said. The recurrence-free survival was 76% at five years and 65.5% at 10 years.
“At the long-term analysis from a pioneer center, prostate sparing cystectomy appears to be an oncologically safe procedure with adequate functional outcomes in treating selected patients with muscle invasive bladder cancer or recurrent high-grade non-muscle invasive bladder cancer,” he said.
Comments on the Research
In commenting on the results, Oliver Sartor, MD, Medical Director of the Tulane Cancer Center and Laborde Professor of Cancer Research at Tulane University, New Orleans, said the results presented indicate that the procedure, at least in the hands of these surgeons, was oncologically safe.
“The typical operation is a cystoprostatectomy,” Sartor told OT. “These are quite reasonable survival figures in this group undergoing prostate-sparing surgery. This type of surgery is done in the context of muscle-invasive bladder cancer, so these survival data are what we would normally see with the larger operation.”
“What we have to make very clear here,” Perez-Reggeti noted, “is that our population did not include the patients with invasive bladder cancer that you see every day and for whom the combined operation of removing the bladder and the prostate is relatively routine. These were very carefully selected patients.”
He said the patients underwent multiple prostate biopsies to ascertain if the prostate was cancer-free before the sparing operation was performed. Inclusion criteria were a normal prostate examination and prostate specific antigen (PSA)-negative transrectal ultrasound guided biopsies. The doctors also made sure the pathology of frozen sections were negative for cancer in the prostatic urethra, the prostate base, the distal ureters and the trigone.
Even with those precautions, three of the patients were found to have cancer in the prostate—two at the time of the adenomectomy. The men were followed with active surveillance, and one of them was later diagnosed with prostate cancer recurrence and is being treated with brachytherapy. No case of recurrence at the remnant prostatic urothelium was observed, Perez-Reggeti said.
For the study, the researchers identified 147 patients who underwent the prostate sparing procedure. From this group, 64 patients received a standardized prostate sparing cystectomy technique featuring a Millin adenomectomy between 2001 to 2014 and composed the population of the study, Perez-Reggeti explained. The patients were diagnosed with muscle invasive bladder cancer and recurrent high-grade non-muscle invasive bladder cancer.
He said the main objective of the prostate sparing procedure was to preserve sexual function—with or without medical treatment. Perez-Reggeti reported that erectile function was preserved in 56.3 percent of the patients. Sexual function was assessed by self-reported erectile function sufficient for intercourse.
Another objective of sparing the prostate was to help in controlling continence. Pad-free daytime continence was achieved by 85.9 percent of the patients and leak-free daytime continence was achieved by 93.8 percent of those men who underwent the procedure, the researchers reported. Night-time pad-free continence was achieved by 50 percent of the men and night-time leak-free continence, they stated.
Median age was 62 years, a relatively young group of patients. Median follow-up was 70 months. Perez-Reggeti said 31 men (or 48.4% of the group) were diagnosed with State T1 disease; 19 men were diagnosed with State T2 disease; and 14 patients were diagnosed with Stage T3 bladder cancer. Lymphadenectomy was performed in 95.3% of the cases. Positive lymph nodes were found in 4.9% of patients and 3.1% of patients showed positive surgical margins.
“This case series represents a lot of patients,” Sartor commented. “You want to preserve the prostate because you are going to do better in terms of sexual function and probably in terms of urinary function as well.
“These results might encourage other groups to look at this as a possible option,” he said. Right now, as a single center experience, he suggested it would be difficult to generalize to an international audience. “If other institutions report on their series, it would take it out of a single institution scenario. It could open surgeons' eyes to the use of this type of prostate-sparing surgery in selected patients.”
The symposium is sponsored by the American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Urologic Oncology.