Preoperative and perioperative assessment of the prostatic urethra

When the urethral involvement is the determining factor in the decision to perform a prophylactic urethrectomy or to leave the urethra behind (to be used for a bladder replacement), the assessment of the prostatic urethra before surgery is of great importance. The need for accurate sampling of the prostatic urethra was first suggested by prostate mapping studies, which showed malignant changes in the prostatic urethra in 50-70% of patients.14,15 In another extensive study, 4-mm step sections were performed in 84 cystoprostatectomy specimens.16,17 Thirty-six patients (43%) were found to have transitional cell carcinoma of the prostate. Of this group, 94% had prostatic urethra involvement and 6% had a normal prostatic urethra, but transitional cell carcinoma was present in the periurethral structures. This high incidence of involvement suggests that increasing the intensity of the search for prostate invasion results in an increased incidence of this diagnosis.

Not all patterns of prostatic urethral involvement present an equal risk for recurrence. The tumour involvement can be limited to the urethra or to the epithelium of the periurethral ducts, or it may include the prostatic stroma. Duct and stromal invasion has been the most striking prognostic factor for subsequent urethral recurrence and survival. Therefore, pre-operative staging with transurethral and transrectal biopsy techniques has been advocated.5,6 Although several authors have confirmed the necessity of a thorough pre-cystectomy assessment, or rigorous screening of the prostatic urethra, the technique of endoscopic assessment has not always been described in detail. Random biopsies, either cold punch or resection biopsies of the prostatic urothelium, have been proposed. It is now agreed that transurethral resection biopsy of the prostate is necessary in order to screen for prostatic involvement and that this biopsy should be routinely performed in patients with bladder cancer. In most patients the prostatic urethra will appear normal cystoscopically. As regards the extent of prostatic resection, it has been pointed out that an insufficient or limited transurethral resection biopsy of the prostatic urethra could fail to detect prostatic involvement. Therefore, extensive biopsies are now advocated.5,6,16,17 Such biopsies will help to correctly diagnose the prostatic involvement in 90% of patients, as was shown in a detailed examination of cystoprostatectomy specimens.16,17 This problem was further studied by Sakamoto et al., and it was demonstrated that transurethral resection random biopsies of the prostate may frequently fail to detect prostatic invasion.18 An appropriate transurethral resection sampling of the prostatic tissue at the 5 and 7 o'clock positions of the verumontanum portion proved necessary to detect any prostatic duct and acinar involvement. More recently, Lebret et al. have reported in a prospective study that only positive frozen section of the urethral stump at the time of the radical cystectomy is the contra-indication to urethra sparing and to continent urinary diversion to the urethra.19 It is, therefore, important to perform frozen sections of the ureters during surgery in order to recognize carcinoma in situ.

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