The case for prostate capsule-sparing radical cystectomy in selected patients

Abstract

Can Urol Assoc J 2009;3(Suppl4): S215-9 R adical cystoprostatectomy and neobladder replacement have become the gold standard for patients with invasive bladder cancer. Although the neobladder represents a significant improvement over ileal conduit, in terms of the effect on body image, the operation has a significant impact on many quality-of-life-related domains. Erectile function and incontinence (particularly nocturnal) are common. Nerve-sparing cystectomy is associated with a relatively low rate of erectile function preservation. 1 The impetus for traditional cystectomy including en bloc dissection of the entire prostate arose because of reports that occult transitional cell carcinoma (TCC) and prostate cancer were prevalent in the prostate of these men. In this article, we present the case that prostate capsule-sparing radical cystectomy, with appropriate and careful patient selection and surgical technique reduces the risk of local recurrence and improves quality of life. Prostate-sparing techniquesDifferent techniques have been described, with several common motifs. All of these techniques preserve a portion of the prostatic capsule, the seminal vesicles and the vas deferens, but vary in the types of prostate resection and neobladder configuration. 2 Importantly, all authors advocate removal of part of the prostate. "Prostate sparing" actually refers either to subtotal prostatic resection or resection of the adenoma with capsule sparing.The two main techniques are (1) removal of the prostatic adenoma using the technique of a Millen simple retropubic prostatectomy, excising the adenoma tissue containing the prostatic ducts and most acini, leaving the surgical capsule and seminal vesicles intact, 3 and (2) a transverse excision through the proximal prostate, leaving the distal prostate, including the distal adenoma and seminal vesicles and utricle, intact. 4 In both cases, the neurovascular bundle, the distal sphinteric complex, and the continuity of the vas, seminal vesicles and ejaculatory duct remain undisturbed.The critical two questions are (1) What is the risk of local recurrence in the residual prostate tissue? and (2) What are the quality-of-life results (e.g., voiding, continence and erectile function)?Patient selection is a critical component of the procedure. Patients who are at increased risk for prostatic urethral involvement should be excluded. Identifying these patients involves several steps. Patients should be candidates for a neobladder on the basis of age, comorbidity, and extent of disease. T4 cases are excluded. The primary cancer should not directly involve the bladder neck or prostatic urethra. Diffuse, multifocal carcinoma in situ (CIS) increases the risk of prostatic involvement and is a contraindication. (Focal CIS in the peri-tumoural area is not a contraindication.) Patients who have no CIS, multifocality or bladder neck involvement have an extremely low rate of prostatic urethral involvement; in one series, 0 of 40 patients experienced prostatic urethral involvement. 5