title: Incidental prostate cancer at radical cystoprostatectomy: implications for apex-sparing surgery.
abstract: OBJECTIVE
  To analyse retrospectively the clinicopathological features of incidental prostate cancer in patients undergoing radical cystoprostatovesiculectomy (RCP) for invasive bladder cancer, as recent studies suggest that prostatic apex-sparing surgery in patients undergoing RCP improves urinary continence and erectile function after surgery, but in those with incidental prostate cancer, leaving the apical region endangers the oncological outcome.
  
  
  METHODS
  From 2004 to 2007, at our institution, 95 men had RCP for invasive bladder cancer. We reviewed their clinicopathological variables, especially apical involvement, and the course of prostate-specific antigen (PSA) levels before and after surgery. We compared clinically significant and insignificant prostate cancers.
  
  
  RESULTS
  Of the 95 patients, 26 had incidental prostate cancer (mean age 68 years, range 53-80) on definitive histological examination. The mean (sd, range) preoperative PSA level in all 26 men was 3.6 (0.8, 0.2-14) ng/mL, but six of the 26 patients had preoperative PSA levels of >4 ng/mL and one other had suspicious findings on a digital rectal examination. Involvement of the apex was histologically confirmed in seven of the 26 patients (27%), including four with significant prostate cancer (P = 0.039). Preoperative PSA levels did not differ significantly between the seven patients with significant and 19 with insignificant prostate cancer, but seven patients with apical involvement had significantly higher PSA levels before RCP than the 19 who did not (P < 0.04). PSA levels after RCP remained below the limit of detection in all patients over a mean (range) follow-up 14.3 (3-32) months.
  
  
  CONCLUSIONS
  In our series, preserving the apex of the prostate to decrease morbidity after RCP carried a 7.3% risk (seven of 95 patients) of leaving significant cancer in the residual prostatic tissue. No preoperative clinical value could exclude apical involvement. Therefore, our findings stress the oncological need for a careful and complete excision of the prostate during RCP.
authors.affiliation: Department of Urology, Eberhard-Karls University, Tübingen, Germany. georgios.gakis@web.de
authors.forename: Georgios
authors.initials: G
authors.lastname: Gakis
authors.forename: David
authors.initials: D
authors.lastname: Schilling
authors.forename: Jens
authors.initials: J
authors.lastname: Bedke
authors.forename: Karl D
authors.initials: KD
authors.lastname: Sievert
authors.forename: Arnulf
authors.initials: A
authors.lastname: Stenzl
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015653:Cystectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D018783:Impotence, Vasculogenic / Q000517:prevention & control; D033162:Incidental Findings; D008297:Male; D008875:Middle Aged; D018365:Neoplasm, Residual; D009378:Neoplasms, Multiple Primary / Q000601:surgery*; D011467:Prostate / Q000473:pathology; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D020196:Trauma, Nervous System / Q000517:prevention & control; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D014549:Urinary Incontinence / Q000517:prevention & control
chemical_list: D017430:Prostate-Specific Antigen