Transitional cell carcinoma involving the prostate: a clinicopathological retrospective study of 76 cases

PURPOSE: We reviewed the degree to which extension from transitional cell carcinoma into the prostate affects survival. We also compared whether prostatic stromal invasion occurring via direct extension through the bladder wall differs from stromal invasion arising intraurethrally. MATERIALS AND METHODS: A total of 76 men who underwent radical cystectomy for transitional cell carcinoma also had prostate involvement. Patients were separated into group 1-18 with primary bladder tumor extending transmurally through the bladder wall to invade the prostate and group 2-58 with prostate involvement arising from within the prostatic urethra. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement and stromal invasion. RESULTS: The 5-year overall survival and recurrence-free rate were 22% and 28% in group 1 versus 43% and 45% in group 2, respectively. In group 2 survival rates were similar in those with prostatic urethral and ductal tumors (without stromal invasion). Five-year overall survival rates without and with stromal invasion were 49% and 25%, respectively (p = 0.024). Prostate involvement decreased survival, which varied according to primary bladder stages (Pis, P1, P2a/b and P3a/b, p = 0.004) or superficial (Pis, Pa and P1) and muscle invasive (P2a/b and P3/b, p = 0.045), disease in 2 groups. Those with positive lymph nodes experienced poorer outcomes in each group. The 5-year overall survival rate in the 19 men with positive lymph nodes was 13% and it was 44% with negative lymph nodes (p = 0.034). The major prognostic factors were age, degree of prostate invasion and lymph node involvement. CONCLUSIONS: The invasion pathways of prostate invasion in patients with transitional cell bladder carcinoma have a statistically significant prognostic role in survival. Transitional cell carcinoma of the bladder extending into the prostate through the bladder wall and bladder carcinoma that did not directly infiltrate the prostate through the bladder wall are 2 distinct clinicopathological entities that should not be included in the same staging grade.     

Transrectal ultrasound appearance of transitional cell carcinoma involving the prostate

Prostatic involvement with transitional cell carcinoma of the bladder is common. Surveillance for prostatic invasion consists primarily of cystoscopic examination of the urethra. Unfortunately, transitional cell carcinoma may involve other regions of the prostate that are inaccessible by cystoscopy. A total of 58 men with transitional cell carcinoma of the bladder underwent transrectal ultrasound before cystoprostatectomy or, in some cases, ultrasound-guided prostate biopsies and subsequent cystoprostatectomy. Prostatic involvement was found in 20 patients (34.5%). Of those patients 10 (50%) demonstrated prostatic urethra invasion, 7 (35%) stromal invasion, 4 (20%) ejaculatory duct and seminal vesicle invasion, and 3 (15%) involvement of the periprostatic tissues. Invasion of the prostatic urethra was not detected by transrectal ultrasound but 5 of the 7 stromal lesions exhibited hypoechogenicity. All cancer-laden ejaculatory ducts were hypoechoic on ultrasound examination. All cases of periprostatic involvement were also detectable by corresponding areas of hypoechogenicity. Transrectal ultrasound may enhance the surveillance of men with transitional cell carcinoma.     

Clinical study of transitional cell carcinoma of the prostate associated with bladder transitional cell carcinoma

BACKGROUND: Transitional cell carcinoma of the prostate in patients with bladder cancer appears to influence the prognosis and affects the decision about therapeutic modality. Therefore, it is important to characterize transitional cell carcinoma associated with bladder cancer. METHODS: From April 1980 to December 1998, 81 male patients underwent total cystoprostatectomies for transitional cell carcinoma of the bladder. The 81 cystoprostatectomy specimens were examined to clarify the characteristics of prostatic involvement by transitional cell carcinoma. The extent, origin, mode of spread and risk factor of prostatic involvement as well as the prognosis were investigated. In 13 of 15 patients with prostatic involvement the prostate was examined by sequential step sections. RESULTS: Prostatic involvement was observed in 15 of 81 patients (18.5%). Prostatic urethral involvement, invasion to prostatic duct/acinus, prostatic stromal invasion and extraprostatic extension and/or seminal vesicle involvement were recognized in 12 (80%), 14 (93.3%), six (40%), and five (33.3%) of the 15 patients, respectively. Twelve of the 15 patients (80%) with prostatic involvement had papillary or non-papillary tumors (i.e. carcinoma in situ) both in the prostatic urethra and prostatic duct. In 10 of these 12 patients (88.3%), there was contiguity between prostatic urethral and ductal tumors. Seven of the 23 patients (30.4%) with carcinoma in situ of the bladder showed prostatic involvement, which increased to 50% in the presence of carcinoma in situ of the trigone or bladder neck. CONCLUSIONS: Eighty per cent of the patients with prostatic involvement showed papillary or non-papillary tumors both in the prostatic urethra and prostatic duct. There was a high level of contiguity between both tumors. Patients with carcinoma in situ of the trigone or bladder neck revealed significantly higher incidence of prostatic involvement.     

DOES PROSTATE TRANSITIONAL CELL CARCINOMA PRECLUDE ORTHOTOPIC BLADDER RECONSTRUCTION AFTER RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER?

Purpose

We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.

Materials and Methods

The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.

Results

Of 81 patients, 70 were evaluated (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.

Conclusions

The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

PROSTATIC TUMOR RELAPSE IN PATIENTS WITH SUPERFICIAL BLADDER TUMORS: 15-YEAR OUTCOME

PURPOSE: We assessed the outcome of patients with superficial bladder tumors with relapse in the prostate and defined prognostic variables of survival. MATERIALS AND METHODS: A cohort of 186 men with superficial bladder tumors was followed for 15 years. Tumor relapse in the prostate was classified as noninvasive (prostatic urethra and ducts) or invasive (stroma) with intraurethral or direct prostatic invasion. Bladder tumor stage at the time of prostatic relapse was defined as confined or not confined to the bladder. The end point of the study was disease specific survival. The effects of covariates on survival were estimated on multivariate analysis. RESULTS: Of the 186 patients 72 (39%) had relapse in the prostate after a median followup of 28 months (range 3 to 216), including 45 (62%) with noninvasive prostatic tumor and 27 (38%) with stromal invasion. The survival rate was 82% in patients with prostatic urethra or duct involvement compared to 48% with stromal invasion. Intraurethral stromal invasion was associated with a 75% 15-year survival rate versus 9% for extravesical prostatic stromal invasion. Bladder tumor stage and prostatic stromal invasion were independent prognostic variables of survival. CONCLUSIONS: The prostate is a frequent site of tumor relapse in patients with superficial bladder tumors followed for 15 years. Prostatic relapse may portend tumor invasion in the bladder and stromal invasion in the prostate, which significantly reduce survival.     

Prostatic involvement by urothelial carcinoma of the bladder: clinicopathological features and outcome after radical cystectomy

OBJECTIVES: To review the long-term outcome of prostatic involvement in patients with bladder cancer (BC) treated with radical cystectomy (RC), as urothelial carcinoma (UC) involving the prostate occurs in such patients, and prostatic invasion by UC is by transmural invasion (contiguous), or when UC develops from the epithelium of the prostatic urethra (not contiguous). PATIENTS AND METHODS: Between 1992 and 2006, 351 men had RC for BC by one surgeon at our centre; they were stratified into those with contiguous or non-contiguous disease, based on prostatic stromal involvement. Relevant clinical and pathological data were collected and the survival analysed. RESULTS: In all, 24% (78/320) of the patients who had RC had prostatic involvement; 29 (9%) and 49 (15%) had contiguous and non-contiguous involvement, respectively. In the non-contiguous group, there was stromal and non-stromal UC involvement in 18 (37%) and 31 (63%), respectively. The overall 5-year survival of contiguous, non-contiguous and no prostatic involvement was 6%, 57% and 66% (P < 0.001). The 5-year overall survival of stromal and non-stromal UC was 26% and 74% (P = 0.008). There was no statistical difference in survival between contiguous and non-contiguous stromal involvement (P = 0.58). CONCLUSIONS: Prostatic UC with no stromal involvement did not alter the survival predicted by the primary bladder stage. Stromal involvement of the prostate has a poor prognosis regardless of the mode of invasion.     

Risk factors for urothelial carcinoma of the prostate in patients undergoing radical cystoprostatectomy for bladder cancer

OBJECTIVE

To examine the risk factors for urothelial carcinoma (UC) involvement of the prostate in patients undergoing radical cystoprostatectomy (RCP) for bladder cancer, as such involvement has both prognostic and therapeutic implications.

PATIENTS AND METHODS

We examined 308 consecutive men from 1998 to 2005 who had RCP for UC of the bladder, with whole‐mount processing of their prostate. Prostatic involvement was categorized by site of origin (the bladder or the prostatic urethra) and, in the case of prostatic urethral origin, by depth of invasion, i.e. dysplasia/carcinoma in situ (CIS), involving the prostatic urethra, prostatic ductal invasion or prostatic stromal invasion. The impact of pathological characteristics was evaluated.

RESULTS

In all, 121 (39.3%) patients had some form of urothelial involvement of the prostate, of whom 59 (48.8%) had dysplasia/CIS of the prostatic urethra, 20 (16.5%) had ductal involvement and 32 (26.4%) had stromal involvement. Multivariate analysis showed that bladder CIS (odds ratio 2.0, 95% confidence interval, 1.2–3.6, P = 0.012) and trigonal involvement of bladder tumours (2.0, 1.1–3.7, P = 0.028) were independent risk factors for urothelial involvement of the prostate.

CONCLUSION

There was prostatic involvement with UC in nearly 40% of patients undergoing RCP. In this study CIS and trigonal involvement were independent predictors of risk, but were not adequate enough to accurately identify most patients who have UC within their prostate; further prospective studies are needed to more accurately predict risk factors and depth of invasion.     

Transitional cell carcinoma of the prostate in cystoprostatectomy specimens removed for bladder cancer

Specimens from 84 radical cystectomies for bladder carcinoma performed between January 1984 and July 1986 were reviewed to characterize the involvement of the prostate with transitional cell carcinoma. Whole-mount sectioning of the prostate was performed at 4 mm. intervals and processed in the same manner as radical prostatectomy specimens. A total of 36 patients (43 per cent) had transitional cell carcinoma of the prostate: 94 per cent of these had prostatic urethra involvement and 6 per cent had a normal prostatic urethra but transitional cell carcinoma was present in the periurethral structures. In situ prostatic duct or acini, ejaculatory duct and seminal vesicle involvement occurred, respectively, in 67, 8 and 17 per cent of the patients with prostatic involvement. Of the patients with prostatic involvement 39 per cent had stromal invasion (22 per cent focal and 17 per cent diffuse invasion). The incidence of carcinoma in situ of the bladder neck or trigone (59 per cent), previous intravesical chemotherapy (59 per cent) and ureteral carcinoma (79 per cent) was significantly increased in patients with prostatic involvement. In patients with carcinoma in situ of the trigone or bladder neck, or in whom previous intravesical chemotherapy treatments have failed prostatic involvement should be suspected so that this disease can be detected before stromal invasion occurs.     

Outcomes of patients undergoing radical cystoprostatectomy for bladder cancer with prostatic involvement on final pathology

OBJECTIVE

To evaluate the impact of prostatic urothelial carcinoma (PUC) on survival of patients with bladder cancer undergoing radical cystoprostatectomy (RCP).

PATIENTS AND METHODS

From 1998 to 2005, 463 consecutive RCPs were performed for UC of the bladder. Patients with PUC at final pathology were grouped by route of prostatic invasion (bladder origin or prostatic urethral origin) and by depth of invasion (carcinoma in situ, ductal invasion, and stromal invasion). Univariate and multivariate survival analyses were performed.

RESULTS

In all, 35% (162/463) of patients had PUC. The 3‐year overall survival (OS) was 58.2% for patients who did not have PUC, 59.2%, 51.7%, and 16.8% in order of increasing depth of prostatic invasion for patients with PUC of urethral origin, and 6.7% for patients with bladder‐origin PUC. Survival differed significantly between stromal and non‐stromal PUC (P < 0.001). Patients with PUC of bladder origin had a higher rate of positive lymph nodes (LNs) than patients with stromal PUC of prostate origin (74.3% vs 27.8%, P < 0.001), but survival was similar (P = 0.619). On multivariate analysis, age (P = 0.035), increasing bladder stage (P = 0.003), stromal invasion (P = 0.002) and positive LNs (P < 0.001) were predictors of poor OS.

CONCLUSION

Depth of prostatic invasion correlates with outcome. While prostatic involvement originating in the bladder is associated with higher rates of positive LNs, survival is similar to patients with stromal involvement of urethral origin. Age, bladder tumour stage, prostatic stromal involvement and positive LNs predict adverse outcome. Our data support separate staging of the prostate in RCP specimens.     

Upper tract urothelial recurrence following radical cystectomy for transitional cell carcinoma of the bladder: an analysis of 1,069 patients with 10-year followup

PURPOSE: Risk factors for upper tract recurrence following radical cystectomy for transitional cell carcinoma of the bladder are not yet well-defined. We reviewed our population of patients who underwent radical cystectomy to identify prognostic factors and clinical outcomes associated with upper tract recurrence. MATERIALS AND METHODS: From our prospective database of 1,359 patients who underwent radical cystectomy we identified 1,069 patients treated for transitional cell carcinoma of the bladder between January 1985 and December 2001. Univariate analysis was completed to determine factors predictive of upper tract recurrence. RESULTS: A total of 853 men and 216 women were followed for a median of 10.3 years (maximum 18.5). There were 27 (2.5%) upper tract recurrences diagnosed at a median of 3.3 years (range 0.4 to 9.3). Only urethral tumor involvement was predictive of upper tract recurrence. In men superficial transitional cell carcinoma of the prostatic urethra was associated with an increased risk of upper tract recurrence compared with prostatic stromal invasion or absence of prostatic transitional cell carcinoma (p <0.01). In women urethral transitional cell carcinoma was associated with an increased risk of upper tract recurrence (p = 0.01). Despite routine surveillance 78% of upper tract recurrence was detected after development of symptoms. Median survival following upper tract recurrence was 1.7 years (range 0.2 to 8.8). Detection of asymptomatic upper tract recurrence via surveillance did not predict lower nephroureterectomy tumor stage, absence of lymph node metastases or improved survival. CONCLUSIONS: Patients with bladder cancer are at lifelong risk for late oncological recurrence in the upper tract urothelium. Patients with evidence of tumor involvement within the urethra are at highest risk. Surveillance regimens frequently fail to detect tumors before symptoms develop. However, radical nephroureterectomy can provide prolonged survival.     

Risk of Urethral, Vaginal and Cervical Involvement in Patients Undergoing Radical Cystectomy for Bladder Cancer: Results of a Contemporary Cystectomy Series from M. D. Anderson Cancer Center

Purpose

Orthotopic bladder reconstruction in women is the focus of considerable interest. To define suitable candidates for orthotopic reconstruction among women with bladder cancer, we reviewed the risk of secondary urethral, vaginal and cervical involvement by transitional cell carcinoma in patients who underwent radical cystectomy at our institution.

Materials and Methods

We retrospectively reviewed the charts of women who underwent radical cystectomy for primary transitional cell carcinoma of the bladder between 1985 and 1995. These cases also were reviewed pathologically.

Results

Of 115 patients who underwent radical cystectomy for transitional cell carcinoma of the bladder 9 (8%) also had secondary transitional cell carcinoma cell of the urethra, including 2 with concomitant involvement of the vagina or cervix. In 4 patients (3%) the vagina or cervix was involved but not the urethra. Vaginal and cervical invasion correlated with stages T3b and T4 disease (p = 0.04). By logistic regression analysis the sole significant risk factor for urethral involvement was bladder neck involvement (p = 0.0005). Unlike previous studies 2 of 9 patients with secondary urethral transitional cell carcinoma did not have apparent cancer at the bladder neck.

Conclusions

We report secondary urethral involvement without apparent bladder neck involvement in women with transitional cell carcinoma. Women who are candidates for orthotopic reconstruction should undergo biopsies of the bladder neck and urethra as part of the preoperative evaluation. In patients with palpable masses (stage T3b) on bimanual examination, transvaginal biopsies should also be considered. Intraoperative frozen sections of the urethral and vaginal margins should be obtained.     

Dilemmas in the treatment of urothelial cancers of the prostate

ObjectivesThe objective of this paper is to examine the contemporary incidence, diagnosis, and treatment of prostatic urothelial carcinoma and make recommendations on the current dilemmas of treating urothelial cancer of the prostate.MethodsA review of English-language literature from 1990 to the present was performed utilizing the U.S. National Library of Medicine's Pub Med database. Keywords used were urothelial cell carcinoma, prostatic urethral involvement, prostatic duct/acini involvement, carcinoma in situ. Bibliographies of reviewed articles were also searched.ResultsTransitional cell carcinoma of the bladder with involvement of the prostate has been reported in multiple studies with an incidence between 12% and 48%. Stromal invasion of the prostate has a reported incidence between 7% and 17%. The incidence of primary transitional cell carcinoma of the prostate has been estimated at 1% to 4% of prostatic malignancies. Degree and depth of prostatic invasion has prognostic significance with 5-year survival rates being 100% for those with urethral mucosal involvement, 50% with ductal/acinar involvement, and 40% with prostatic stromal invasion. The actual anatomic path that urothelial carcinoma invasion occurs also has prognostic significance. Those with contiguous malignant involvement had a 7% 5-year survival rate compared with those with noncontiguous involvement and a 46% 5-year survival rate.ConclusionsProstatic urothelial carcinoma is often under appreciated and not well understood. Malignant involvement of different anatomic locations of the prostate (i.e., mucosa, ducts, acini, and stroma) influence not only diagnosis but treatment of disease. Although debate exists regarding optimal therapy for mucosal involvement, if the prostatic stroma is involved, radical cystoprostatectomy is the treatment of choice.     

Concomitant pathology in the prostate in cystoprostatectomy specimens: a prospective study and review

OBJECTIVES

To investigate possible associated pathology in the prostate removed from patients with invasive bladder cancer and determine if there is a justification for prostate‐sparing cystectomy.

PATIENTS AND METHODS

Between March 2005 and July 2007, 425 men (mean age 59 years, sd 8.23) had a cystoprostatectomy at our institute. The prostate was step sectioned at 2–3 mm intervals and any associated pathology determined; patient and tumour characteristics were correlated with prostatic pathology. The results were compared with those published previously, and the potential functional advantages of prostate sparing are reviewed and discussed.

RESULTS

Prostatic adenocarcinoma was detected in 90 of the 425 (21.2%) patients. There was no significant correlation between preoperative prostate‐specific antigen level and the presence of adenocarcinoma, Gleason score or prostatic tumour stage. There was prostatic involvement as a result of direct invasion by the primary bladder tumour (contiguous) in 39 cases (9.2%). Concomitant (non‐contiguous) transitional cell carcinoma of the prostatic urethra and/or ducts was detected in 27 specimens (6.4%). Additional findings were high‐grade prostatic intraepithelial neoplasia in 43 patients (10.1%) and benign prostatic hyperplasia in 175 (41.2%).

CONCLUSION

We think that the potential oncological risks of prostate‐sparing cystectomy outweigh any small and possible functional benefits; accordingly, the prostate should not be retained.     

Urethral Recurrence in Patients with Orthotopic Ileal Neobladders

Purpose

We identified the risk of urethral recurrence following cystectomy for transitional cell bladder carcinoma, stratified by pathological characteristics of the bladder tumor and type of urinary diversion.

Materials and Methods

The pathological characteristics and clinical courses of 174 men with a Kock ileal neobladder and 262 with a cutaneous urinary diversion were analyzed for time to urethral recurrence.

Results

Urethral recurrence was identified in 34 patients at a median of 1.6 years after cystectomy, for an overall 7.9 percent 5-year risk of recurrence. Carcinoma in situ (p = 0.71) and multifocality (p = 0.17) did not independently confer an increased risk of recurrence. Prostatic urethral involvement, particularly stromal invasion, significantly increased the probability of recurrence (p less than 0.001). Patients with a Kock ileal neobladder had a significantly lower probability of recurrence compared to those with cutaneous diversion (p = 0.015), even when associated with prostatic urethral involvement.

Conclusions

Patients with a Kock ileal neobladder have a lower risk of urethral recurrence than those with cutaneous urinary diversion, even when associated with a high risk pathological condition predicting increased risk of urethral recurrence.     

ICUD-EAU International Consultation on Bladder Cancer 2012: Urothelial Carcinoma of the Prostate

Context

The Second International Consultation on Bladder Cancer recommendations on urothelial carcinoma (UC) of the prostate were presented at the 2011 European Association of Urology Congress in Vienna, Austria, on March 18, 2011.

Objective

Our aim is to summarize the Second International Consultation on Bladder Cancer recommendations on UC of the prostate to help clinicians assess the current evidence-based management.

Evidence acquisition

The committee performed a thorough review of new data and updated previous recommendations. Levels of evidence and grades of recommendation were assigned based on a systematic review of the literature that included a search of online databases and review articles.

Evidence synthesis

Once a non–muscle-invasive high-grade tumor or carcinoma in situ (CIS) of the bladder has been diagnosed, careful follow-up of the prostatic urethra is necessary. Noninvasive UC including CIS of the prostate should be treated with intravesical bacillus Calmette-Guérin (BCG) following endoscopic resection. A transurethral resection of the prostate may improve contact of BCG with the prostatic urethra, and it appears that response rates to BCG are increased (level of evidence: 3). Transurethral biopsy of the prostatic urethra is effective in identifying prostatic involvement but may not accurately reveal the extent of involvement, particularly with stromal invasion. Stromal invasion by UC of the prostate carries a poor prognosis. Radical cystoprostatectomy is the treatment of choice for locoregional control in patients with prostatic stromal invasion.

Conclusions

These recommendations contain updated information on the diagnosis and treatment of UC of the prostate. However, prospective trials are needed to further elucidate the best management of these patients.     

Intravesical bacillus Calmette-Guerin therapy for in situ transitional cell carcinoma involving the prostatic urethra

A total of 23 patients presenting with multifocal superficial bladder cancer and concomitant in situ transitional cell carcinoma of the prostatic urethra (mucosal in 19 and ductal in 4) underwent transurethral resection and intravesical bacillus Calmette-Guerin therapy. Median followup was 51.6 months (range 6 to 105 months). Of the 23 patients 13 (48 per cent) had a complete response with a median followup of 43.7 months without recurrence. Progression of some type (local, muscle invasion or metastasis) occurred in 10 patients (44 per cent); none occurred in the prostatic urethra. Median interval free of progression was 55.7 months; 7 of 10 patients required cystectomy for progression or refractory disease in the bladder (prostate negative for transitional cell carcinoma). A trial of complete transurethral resection plus intravesical bacillus Calmette-Guerin is a viable alternative to immediate radical cystectomy for patients with mucosal and/or ductal involvement of the prostatic urethra with in situ transitional cell carcinoma.     

Superficial transitional cell carcinoma of the bladder associated with mucosal involvement of the prostatic urethra: results of treatment with intravesical bacillus Calmette-Guerin

Intravesical Pasteur strain bacillus Calmette-Guerin was used to treat 8 patients with mucosal transitional cell carcinoma of the prostatic urethra associated with superficial transitional cell carcinoma of the bladder. Complete initial response in the prostatic urethra was obtained in 7 of the 8 patients. Two patients had progression of disease during intravesical bacillus Calmette-Guerin therapy (1 in the prostate and 1 in the bladder) and they received further surgical therapy. Of the 6 complete responders 1 patient had invasive ureteral, vesical and prostatic tumor 15 months after bacillus Calmette-Guerin therapy, and he underwent nephroureterectomy and cystoprostatourethrectomy. Two patients required additional transurethral therapy for recurrent superficial tumors in the bladder but they have shown no evidence of recurrence in the prostatic urethra. Three patients have remained free of disease at 8 to 36 months. Before radical cystoprostatourethrectomy and urinary diversion are recommended, our study supports a course of bacillus Calmette-Guerin therapy as initial treatment for patients with superficial transitional cell carcinoma of the bladder associated with mucosal involvement of the prostatic urethra.     

Transitional cell carcinoma in prostate after intravesical instillation of Bacillus Calmette-Guerin

We report 3 cases of prostatic involvement of transitional cell carcinomas (TCCs). All cases presented positive urinary cytology after intravesical instillation of Bacillus Calmette-Guerin (BCG) and then random biopsy of bladder and transurethral resection (TUR)-biopsy of prostatic urethra were performed. TUR-biopsy demonstrated TCC in the prostate, although random biopsy failed to detect tumors in the bladder in all cases. Case 1 was treated with cystourethrectomy with ileal conduit, case 2 was treated with cystourethrectomy with bilateral ureterocutaneostomy and case 3 was treated with cystectomy with orthotopic ileal neobladder reconstruction. All cases are alive with no evidence of disease. TUR-biopsy of prostatic urethra should be perfomed when patients present positive urinary cytology after BCG instillation therapy, because prostatic involvement of TCC associated with bladder carcinoma in situ is not rare.     

Pathologic assessment and clinical significance of prostatic involvement by transitional cell carcinoma and prostate cancer

The prostate is commonly involved by transitional cell carcinoma (TCC) in patients with bladder cancer. A number of clinicopathologic factors including multifocal carcinoma in situ, tumor location, and tumor stage are associated with prostatic TCC (pTCC). In addition, the manner and extent of pathologic examination also makes a significant difference in the detection rate. Distinct patterns and extent of pTCC have been described and are associated with pathologic stage of the primary bladder tumor as well as prognosis. Preoperative transurethral biopsy of the prostatic urethra is a sensitive and accurate method to detect pTCC and is helpful for surgical planning. Given the high incidence of pTCC and prostatic adenocarcinoma, radical cystoprostatectomy is the treatment of choice for loco-regional control for patients with T4a disease. Further studies are necessary to establish the role of neoadjuvant and adjuvant therapy for patient with prostatic stroma invasion.     

The optimum timing of radical cystectomy for patients with recurrent high-risk superficial bladder tumour

OBJECTIVE: To establish the optimum time of radical cystectomy (RC) for patients with recurrent high-risk superficial bladder tumours after the failure of intravesical therapy. PATIENTS AND METHODS: Among 318 patients with transitional cell carcinoma treated with RC and with no neoadjuvant therapy, there were 46 with clinical stage Ta, T1 or Tis refractory to transurethral resection associated with intravesical therapy. These patients had at least one of: (i) high-risk superficial bladder tumours after failure of two consecutive induction courses of intravesical therapy; (ii) superficial bladder tumours with prostatic stromal invasion; (iii) superficial bladder tumours with mucosa/ducts involvement after failure of one course of intravesical therapy; (iv) uncontrolled superficial tumours with transurethral resection associated or not with intravesical therapy. Progression and cause-specific survival of these patients were compared to those with muscle-invasive tumours. Univariate and multivariate analyses of predictive factors for cause-specific survival were also used in patients with superficial tumours. The incidence of significant prognostic factors was compared in both superficial and muscle-invasive tumours, as were the progression pattern and survival. RESULTS: The progression-free and cause-specific survival of patients with superficial tumours was 54% and 67%, respectively, with no significant difference from those with muscle-invasive tumours. In multivariate analysis, positive lymph-nodes and prostatic stromal invasion were significant and independent variables for survival. The incidence of positive lymph nodes was 15% vs 30% (P < 0.05) and of stromal invasion was 32% vs 1.5% (P < 0.001) in patients with superficial and muscle-invasive tumours, respectively. Accounting for the progression pattern in patients with superficial tumours, extravesical urothelial recurrence prevailed over local or distant recurrences (30% vs 15%), whereas in patients with muscle-invasive tumours the opposite occurred (5% vs 33%, respectively). The cause-specific survival of patients with superficial tumour and prostatic stromal invasion was one of three, and in those who developed extravesical urothelial recurrence was 28.5%. CONCLUSION: In patients with recurrent high-risk superficial bladder cancer after intravesical therapy, our criteria for RC were inappropriate, and patients had a survival rate similar to those with muscle-invasive tumours. RC might have been used too late, as there was a high incidence of prostatic stromal invasion and extravesical urothelial recurrence after RC. Both events seem to be responsible of the low cause-specific survival. Predictive factors for progression are needed to indicate early RC in patients with recurrent high-risk superficial tumours. From a previous analysis the pathological pattern of the clinical lack of response (T1, G3, bladder carcinoma in situ and prostate involvement) to intravesical therapy evaluated at 3 months might be important for predicting progression, and an early RC at that time might be useful.