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Purpose: We investigated the effect on survival of transitional cell carcinoma of the prostatic urethra, ducts and stroma, and determined the difference between prostatic stromal involvement occurring via direct extension through the bladder wall versus stromal invasion arising intraurethrally. Materials and Methods: Between August 1971 and December 1989, 489 men underwent radical cystoprostatectomy for transitional cell carcinoma, including 143 (29.2 percent) identified with prostate involvement by transitional cell carcinoma in the cystectomy specimen. Patients were separated into 2 groups: 1-19 in whom the primary bladder tumor extended full thickness through the bladder wall to invade the prostate (classified as P4a) and 2-124 in whom prostate involvement arose from within the prostatic urethra. Results: Five-year recurrence-free and overall survival rates were 25 and 21 percent, respectively, in group 1 versus 64 and 55 percent, respectively, in group 2. In the 124 patients in group 2 survival rates were similar for those with prostatic urethral tumors or carcinoma in situ and ductal tumors (no stromal invasion). Five-year overall survival rates without and with stromal invasion were 71 and 36 percent, respectively (p less than 0.0001). Transitional cell carcinoma of the prostatic urethra or ducts does not alter survival predicted by primary bladder stage alone. Prostatic stromal invasion arising intraurethrally significantly decreases survival, which varies based on primary bladder stage (64.6 percent in stage P1, 30.8 percent in stages P2/P3a and 13.6 percent in stage P3b, p = 0.0001). P1 bladder tumors with prostatic stromal invasion arising intraurethrally had a significantly higher survival rate than P4a tumors (64.6 versus 21 percent, p = 0.0001). P3b bladder tumors with stromal invasion had a survival rate similar to that of P4a tumors (p = 0.78). Conclusions: Prostatic urethral or ductal transitional cell carcinoma does not alter survival determined by primary bladder stage alone and it should not be classified as P4a. Prostatic stromal involvement arising intraurethrally significantly decreases survival predicted by primary bladder stage alone. P1 bladder tumors with prostatic stromal invasion arising intraurethrally have a significantly higher survival rate than P4a tumors and they should be separately classified as P1str. Muscle invasive (P2/P3a) bladder tumors with stromal invasion have a higher survival rate than P4a tumors (no statistical significance) and they should be designated separately (that is P2str). P3b bladder tumors with prostatic stromal invasion arising intraurethrally are indistinguishable from P4a tumors.

Purpose: Since 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993. Materials and Methods: Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence was individually evaluated via a detailed patient questionnaire. Results: The pouch related early and late complication rates were 7.2 and 11.6 percent, respectively, and pouch related abdominal reoperation rates were 0.0 and 1.4 percent, respectively. Analysis of late pouch related complications revealed 4.1 percent stone formation and 2.4 percent afferent nipple stenosis rates, and only 1 case (0.3 percent) of ileal urethral anastomotic stricture. Of the patients 87 and 86 percent reported good or satisfactory daytime and nighttime continence, respectively. With regard to age, while overall continence was similar, a significantly greater percentage of patients younger than 70 years experience good daytime and nighttime continence relative to the older counterparts. Of the patients 5 percent perform regular intermittent catheterization and 2.7 percent required an artificial urinary sphincter due to unacceptable continence. Conclusions: The Kock orthotopic ileal neobladder can be constructed with minimal morbidity and extraordinary functional results. We strongly advocate its use when possible.

Purpose: In an attempt to identify women who may be appropriate candidates for orthotopic lower urinary tract reconstruction, archival cystectomy specimens from female patients undergoing cystectomy for primary bladder cancer were reviewed. These pathological findings should provide a better understanding of tumor involvement at the bladder neck (vesicourethral junction) and urethra in women with transitional cell carcinoma of the bladder. Materials and Methods: Cystectomy specimens of 67 consecutive women undergoing surgery for biopsy proved transitional cell carcinoma of the bladder between July 1982 and July 1990 were pathologically reviewed. Results: Histological evidence of tumor (carcinoma in situ or gross carcinoma) involving the urethra was present in 9 patients (13 percent). Tumor was confined to the proximal and mid urethra, and the distal urethra was not involved. All patients with carcinoma involving the urethra had concomitant evidence of carcinoma involving the bladder neck. A total of 17 patients (25 percent) had tumor involvement of the bladder neck and those with an uninvolved bladder neck also had an uninvolved urethra. The association between the presence of tumor in the bladder neck and urethra was highly significant (p less than or equal to 0.00012). Tumor involving the bladder neck and urethra tended to be more commonly associated with high grade and stage tumors, and node-positive disease. Conclusions: Although the fate of the retained urethra following cystectomy for bladder cancer in women is unknown, these results show that women with transitional cell carcinoma of the bladder without evidence of tumor involving the bladder neck are at low risk for urethral malignancy. These patients may be offered lower urinary tract reconstruction that includes preservation of and diversion through the urethra (orthotopic diversion). Urethral surveillance will be necessary, as it is in men after orthotopic urinary diversion.

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.

Purpose: We analyzed the impact on potency and urinary continence of moderate doses of radiation (45 to 54 Gy.) given postoperatively after nerve sparing prostatectomy. Materials and Methods: Between 1983 and 1992, 294 of 762 prostate cancer patients were selected to undergo nerve sparing prostatectomy. Subjective patient reports regarding potency and urinary continence status were obtained preoperatively, 1 year postoperatively or 1 year after completion of radiation. Results: Of the 294 patients 105 received postoperative radiotherapy (45 to 54 Gy.) to the prostatic bed. There were patients with more advanced stages of disease in the irradiated group, including 89 percent with stages C and D1 (pT3N0 and pT1 to 3, N1 to 3), compared to 14 percent with stages C and D1 (pT3N0 and pT1 to 3, N1 to 3) in the nonirradiated group (p less than 0.001). No difference in urinary continence was noted in the irradiated (94 percent) compared to the nonirradiated group (92 percent, p = 0.64). Of the patients who underwent bilateral nerve sparing prostatectomy 44 percent who received and 48 percent who did not receive radiation had recovered potency at 1 year (p = 0.76). Of those who underwent unilateral nerve sparing prostatectomy 10 percent who received and 33 percent who did not receive radiation had recovered potency at 1 year (p = 0.14). Using multivariate analysis patient age younger than 63 years and bilateral versus unilateral nerve sparing procedures were significant predictors of potency. Conclusions: Our retrospective study suggests that at 1 year after treatment moderate doses of postoperative radiotherapy did not have a significant impact on the recovery of urinary continence and potency after nerve sparing prostatectomy. However, longer followup is required to determine the impact of this radiation protocol on long-term preservation of potency after nerve sparing prostatectomy.