Abstract

Introduction: Adenocarcinoma of the prostate is the most prevalent visceral malignancy in the male

population and one of the leading causes of death of men. Despite such a high incidence, the prevalence of

silent or latent cancers is shown to be much higher than the clinically diagnosed cases. Previous data on men

undergoing radical cystoprostatectomy for muscle-invasive bladder cancer showed a 17-70% incidence of

unsuspected prostate cancer which is higher than expected in general population. In addition to this,

involvement of the apical and near apical tissue with prostate cancer and prostatic involvement by the bladder

transitional cell carcinoma (TCC) is reported to be high. These findings attract attention to the apical resection

margin in radical cystoprostatectomy as an area where incomplete excision of cancer may be a more common

problem than other anatomical locations. The aim of this study was to evaluate the rate of incidental prostate

adenocarcinoma in patients undergoing radical cystoprostatectomy for muscle-invasive bladder cancer and to

imply the importance of removal of all prostatic tissue at radical cystoprostatectomy to prevent the residual

disease.

Materials and Methods: From 2002 to 2004, 55 patients who underwent radical cystoprostatectomy for

muscle-invasive bladder cancer were studied retrospectively. Four patients were excluded because of

inadequate data and 1 patient was excluded because of known or suspected prostate cancer. A total of 50

patients were included in the study. All patients had no evidence of prostatic malignancy on preoperative

clinical assessment and underwent radical cystoprostatectomy with removal of all prostatic tissue including the

apex. Of these 50 patients 11 (22%) had orthotopic bladder replacement with intestinal reservoirs and 39

(78%) had ileal conduit.

Results: A total of 5 unsuspected adenocarcinomas of the prostate were identified in 50 patients, for an

incidence of 10 percent. Mean age of the patients with prostate cancer (70.2 years) was greater than those

without prostate cancer (62.0 years). Of these 50 patients 7 (14%) had prostatic intraepitelial neoplasiz (PIN),

2 of 7 patients were in group with unsuspected prostate adenocarcinoma. Additionally, 9 patients had TCC

metastasis to prostate (18%). All patients with unsuspected cancer had Gleason score of 3+3=6. There was no

evidence of full thickness penetration of the prostatic capsule in any of the 5 patients. Similarly, no evidence of

seminal vesicle involvement or metastasis to lymph nodes was found in any of the specimens.

Conclusion: Preservation of apical prostatic tissue to improve urinary continence and sexual function

postoperatively is not advisable if a significant number of bladder cancer patients are expected to have

incidental prostate cancer. Since apex is the most common site, with mapping studies showing 41-75%

involvement of the apical and near apical tissue with prostate cancer and an additional 5-43% prostatic

involvement by the bladder TCC, we suggest complete removal of prostate at radical cystoprostatectomy for

bladder cancer. Additionally, because of the association between these cancers, the high coincidence of cancers

of the bladder and prostate must always be kept in mind and should be followed closely for the detection of

latent prostate adenocarcinoma.