Selection criteria for urethral preservation
The traditional indications for urethrectomy are multifocal disease within the bladder, diffuse intravesical carcinoma-in-situ, malignancy at the bladder neck or any prostatic transitional malignancy. Previous review of our experience showed no significant risk of cancer death in two equivalent populations, one subjected to urethrectomy and one without urethrectomy. Only patients with prostatic stromal invasive TCC had an increased risk of cancer death which was not associated with urethral recurrence because of urethral preservation. To enhance the population of patients who would be candidates for orthotopic bladder reconstruction, we changed the criteria for urethrectomy to only those patients who had transitional cell malignancy at the apical margin of the prostate, the distal line of resection. Of 70 patients, 48 are living, NED; 5 died NED. 9 of the 53 patients had prostatic involvement, 8 with Cis, 1 with intraductal TCC. None had urethral recurrence. 17 patients had disease recurrence, 15 died of disease, 2 living, 1 with disease. No patient with disease recurrence and death died because of urethral preservation. 4 patients with Cis in the prostatic urethra who died had bladder pathology responsible for death (pT2G4N+, pT3G4N+, pT3bG3No, pT3bG4No). One patient who died had prostatic stromal invasion and pT3bG4No bladder pathology. Two pts. had urethral recurrence, 1 pTisGSNo with pTa urethral recurrence controlled by cold cup biopsy and now disease-free, 1 pT4G3No had urethral recurrence and died 5 mo. postoperatively with hepatic extension. No patient was placed at risk for death by urethral preservation. Only patients with positive distal prostatic margins should not have orthotopic bladder construction.
Iselin, CE; Robertson, CN; Webster, GD; Vieweg, J; Paulson, DF
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