Prostatic urethral involvement predicts cancer recurrence and premature death in men undergoing cystectomy for nonmuscle-invasive bladder cancer (NMIBC) even without upstaging.

Aaron Brant, MD, of the Brady Urological Institute at Johns Hopkins in Baltimore, and colleagues studied outcomes from 177 NMIBC patients at the institution. Two-thirds chose cystectomy after Bacillus Calmette–Guérin (BCG) failure, another 20% had high-grade T1 disease, and 11% had an unresectable large volume or multifocal tumor. Upon final pathology, cancer staging remained pT1, pTis, or pTa, and N0. Of the cohort, 63 men had prostatic urethral involvement (PUI) observed in pathological specimens. PUI was non-invasive (Ta or Tis) in 89% of affected men and superficially invasive (T1) in 11%; none had stromal invasion.

According to results published in the World Journal of Urology, men with PUI had worse recurrence-free, cancer-specific, and overall survival than men without it. Patients with PUI were significantly more likely to experience cancer recurrence in the urinary tract. They also were significantly more likely to have multifocal tumor (91% vs 52%), positive urethral margins (8% vs 0%), positive ureteral margins (19% vs 5%), and intravesical therapy (85% vs 64%). On multivariate analysis, PUI independently predicted a significant 2-fold increased risk for overall mortality.

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“These findings indicate that PUI is an adverse pathologic feature of NMIBC independent of its association with CIS [carcinoma in situ], positive urinary tract margin, multifocal tumor, and pathologic upstaging,” Dr Brant and the team stated. The investigators believe PUI may indicate a “pan-urothelial” phenotype rather than localized cancer. They suggested men with PUI should be monitored closely for recurrence.

“In our practice, patients with PUI undergo urine cytology testing and CT imaging every 3–6 months for the first 2 years after surgery and then annually thereafter. In the patients who do not undergo urethrectomy, urethroscopy is performed every 6–12 months for 3 years.”

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Brant A, Daniels M, Chappidi MR, et al. Prognostic implications of prostatic urethral involvement in non‑muscle‑invasive bladder cancer. World J Urol. DOI:10.1007/s00345-019-02673-2