Original article
High incidence of clinically significant concomitant prostate cancer in patients undergoing radical cystectomy for bladder cancer: A 10-year single-center experience

https://doi.org/10.1016/j.urolonc.2016.11.004Get rights and content

Highlights

  • 53.1% of patients harbored prostate cancer in the radical cystectomy specimen.

  • Patients׳ age, PSA, and also fPSA% were significant predictors for prostate cancer.

  • Adverse bladder histology (≥pT3) was found in 63.7% of patients with prostate cancer.

  • Among them, 28.3% of patients experienced a biochemical recurrence and 40% died of prostate cancer rather than from bladder cancer.

Abstract

Aim

To analyze prostate cancer (PCa) incidence, clinical significance, and recurrence in 213 patients who underwent radical cystectomy (RC) for advanced bladder cancer (BC).

Patients and methods

We conducted a 10-year retrospective analysis of a single-center database comprising the effect of PCa in RC specimens.

Results

In total, 113/213 male patients (53.1%) had PCa in the RC specimen. Patients׳ age, prostate-specific antigen (PSA), and also free PSA% were significant predictors for PCa. In addition, adverse bladder histology (≥pT3) was found in 63.7% of patients with PCa. A total of 52.2% (59/113) of patients had at least a Gleason score (GS) 7 in final pathology and 10.6% of RC specimens showed an organ border growth (≥pT3a). It was noted that 28.3% of patients experienced a biochemical recurrence (PSA≥0.2 ng/ml), among them 86.7% had GS≥7 in the RC specimen; however, 2 patients were diagnosed with a GS 5. Moreover, we found that 80% of patients with biochemical recurrence had an organ-extended (≥pT3) histology of the bladder and 40% of patients with biochemical recurrence died of PCa rather than from BC.

Conclusion

Concomitant PCa is occurring in>50% of RC specimens with a significant proportion having characteristics (GS, pathological stage) of clinically relevant disease. Adverse bladder histology is a risk factor for both PCa and biochemical PSA recurrence. Follow-up analyses after RC should include PSA measurements also in low-risk PCa as a considerable number of patients develop biochemical recurrence and metastases from PCa partly ending up with death related to PCa in patients suffering from BC.

Introduction

Bladder cancer (BC) and prostate cancer (PCa) are the most common genitourinary malignancies worldwide associated with significant morbidity and mortality [1].

Radical cystectomy (RC) with extended bilateral pelvic lymphadenectomy is currently the standard treatment for patients suffering from localized muscle-invasive or recurrent high-risk non–muscle-invasive BC according to the European Association of Urology (EAU) guidelines (www.uroweb.org).

Especially in younger men, there is a recent strong trend toward prostate or at least “prostate apex or capsule-sparing” techniques, whose clear advantages are the functional improvement of voiding and sexual function, whereas oncological outcomes have been reported not as inferior in comparison to standard RC [2].

However, one has to consider that “prostate-sparing” surgery techniques harbor still the risk of a prostate involvement from BC or even the existence of PCa as a second malignancy [3], [4], [5]. Furthermore, no exact consensus exists regarding which approach preserves function best, varying from “prostate-, capsule-, seminal-, and nerve-sparing” techniques [6]. Therefore, regarding the current knowledge, “prostate-sparing cystectomy” may be an option only in a subset of carefully selected patients with BC without primary involvement of the prostatic urethra and without known PCa.

Currently, only few studies analyzed the effect of PCa in RC specimens while most of them argue that PCa is insignificant in patients undergoing RC and that “prostate-sparing cystectomy” technique can be safely offered to patients with bladder-confined disease.

The aim of the present study was to analyze the PCa incidence, histology, and clinical significance, as well their implication for management in patients with advanced BC undergoing standard RC. In addition, we aimed to determinate the effect of PCa recurrence in this 10-year single-center analysis including 213 patients.

Section snippets

Patients and methods

The study was approved by the local ethics committee (study no. UN3532; 274/4.4 and AN2015-0085; 348/4.10).

We retrospectively analyzed 213 male consecutive patients who underwent standard RC including removal of the bladder, prostate, seminal vesicles, distal ureters, bilateral extended pelvic lymphadenectomy, and urinary diversion from January 2006 to December 2015 at our department. All patients met the European Association of Urology (EAU) criteria for cystectomy (www.uroweb.org), with

Results

We analyzed 213 male patients who underwent RC. Histology and pathology of BC specimens are demonstrated in Table 1.

Of 213 male patients, 113 patients (53.1%) were diagnosed with PCa in the RC specimen. Among them, all patients showed the histology of an acinar adenocarcinoma. None of our patients included in the study had a transrectal or perineal prostate biopsy before RC. Further, no prostate biopsies were performed as part of the transurethral resection of the prostate or bladder mapping.

Discussion

Concomitant PCa is a relatively common finding in RC specimens, however, strongly varying between different studies reporting incidences up to 60% [2], [3], [6], [7], [8], [9], [10], [11], [12], [13].

In the present study, we also retrospectively analyzed the incidence of incidental PCa in a large patient collective including 231 male patients undergoing RC for advanced BC in a single-center 10-year analysis of prospectively enrolled patients.

Thereby in more than 50% of RC specimens, PCa was

Conclusion

Concomitant PCa is occurring more than 50% of all RC specimens in men with a significant proportion having characteristics (GS, pathological stage) of clinically relevant disease. Adverse bladder histology (≥pT3) was found in 63.7% of patients with PCa being a potential risk factor for biochemical PSA recurrence.

Follow-up analyses after RC should include PSA measurements also in low-risk PCa as a considerable number of patients develop biochemical recurrence and metastases from PCa partly

Acknowledgments

The authors would like to thank Siegrid Amort for helpful contribution to this work. This study was supported by the Medical Research Foundation Tyrol (MFF Tirol, project number 273).

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    Citation Excerpt :

    The present trial was performed in accordance with the Declaration of Helsinki and its amendments.33 A cystectomy database with prospectively collected data from a single referral center15,34 was reviewed retrospectively after approval from the local ethics committee (study nos. UN3532; 274/4.4, AN2015-0085, and 348/4.10).

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