2126 PROSTATE CANCER AFTER CYSTOPROSTATECTOMY FOR BLADDER CANCER

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EDITORIAL COMMENT

To evaluate the risks associated with urethral preservation and orthotopic bladder replacement in bladder cancer the outcome of radical cystectomy was studied in 70 men with bladder cancer and a mean followup of 35 months. Of the 70 patients 14 had concomitant transitional cell carcinoma of the prostate, including 10 who pre- sented with carcinoma in situ, 1 with ductal involvement and 3 with stromal invasion. Of 53 patients without evidence of disease with a mean followup of 38 months (48 patients alive, 5 patients dead) 8 (15%) were initially diagnosed with prostatic transitional cell carci- noma, including 1 with prostatic stromal invasion. Of the 70 patients 17 had recurrent disease, and in 6 of these 17 (35%) concomitant prostatic disease was found at the time of initial diagnosis.

The overall urethral recurrence rate a t 35 months was 3% whereas the bladder cancer patients with prostatic transitional cell carcinoma had a urethral recurrence rate of 7%. The higher inci- dence of urethral tumors in the latter group, however, might be attributable to the more advanced stage of the primary bladder tumors, all of which were muscle invasive grade 3 or 4 cancers. Five of 6 patients in this group had additional perivesical involvement.

Only 1 patient of the entire study group (1.5%) presented with an infiltrative, poorly differentiated recurrent urethral tumor that was difficult to treat. However, this was only part of the disseminated

tumor that had probably been present a t the time of cystectomy consequently, could not have been prevented by concomitant ureth- rectomy. Furthermore, the authors report 1 case in which a super. ficial recurrent urethral tumor WBS successfully treated by transure. thral resection, which is in line with our experience. In this case it was possible to presewe the urethra and the orthotopic neobladder, which implies that urethral recurrence does not necessarily mean radical urethrectomy and taking down the orthotopic neobladder.

Despite prostatic infiltration, the urethral recurrence rate in the 70 neobladder patients (3%) is lower than that in patients with untreated primary bladder cancers1 as well as in cystectomy patients with a different type of urinary diversion (references 2 to 4 in article). Hence, the question arises whether protective factors are present in bowel segments interposed into the lower urinary tract. It has been speculated that certain repair enzymes which are found in large quantities in the ileal segments but only in small amounts in the native urothelium of ileocystoplasties may prevent promutagenic deoxyribonucleic acid addud f o m a t i ~ n . ~ J This may explain why patients with a M e r e n t type of diversion leaving a blind-ending distal urethra appear to have a higher risk of urethral recurrence than patients with a ureterointestinal urethrostomy. In view of these findings it seems to make sense not to perfom

routinely total urethrectomy in patients with prostatic tumor in- volvement who have negative caudal prostatic urethral margins because this will have no impact on the ultimate outcome of the disease. Does this imply that prostatic tumor involvement can safely be disregarded in patients with bladder cancer? By no means. With- out doubt, prostatic involvement is of prognostic significance in blad- der cancer and should not be neglected when considering radical cystectomy. However, if complete resection of the local tumor can be achieved by radical cystoprostatectomy, a6 confirmed by negative margins, additional urethrectomy is unwarranted as it will not im- prove the prognosis.

The results presented are in line with data in the literature sug- gesting that orthotopic neobladder reconstruction is not contraindi- cated in bladder cancer patients with prostatic involvement (refer- ence 17 in article). In contrast to other investigators the authors do not recommend that patients with prostatic transitional cell carci- noma infiltrating the stroma be excluded from a neobladder proce- dure, provided all margins are negative. The arguments are compel- ling but in view of the small number of cases (3 patients, 1 of whom had relapse), future studies will have to show whether this recom- mendation can stand the test of time.

Arnulf Stenzl Department of Urology University of lnnsbruck Medical School Innsbruck, Austria

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2. Barrington, J., Fulford, S., Griffiths, D. and Stephenson, T.: Tumors in bladder remnant after augmentation enterocysto- plasty. J. Urol., 151: 482, 1997.

3. Badawi, A., Cooper, D., Mostafa, M., Aboul-Azrn, T., Barnard, R., Margison, G. and O'COMOr, P.: 06-alkylguanine-DNA alkyl- transferase activity in schistosomiasis-associated human biad- der cancer. Eur. J. Cancer, 30A: 1314,1994.