Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan.
Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan.
Clin Genitourin Cancer. 2024 Dec;22(6):102146. doi: 10.1016/j.clgc.2024.102146. Epub 2024 Jun 26.
The optimal indication and survival benefits of prophylactic urethrectomy (PU) during radical cystectomy remain unclear. Therefore, this study aims to evaluate the impact of urethra-preserving surgery (UPS) on oncological outcome including its recurrence patterns, and to establish an optimal urethral management strategy with a novel UPS technique in the robotic era.
We retrospectively analyzed 281 male patients with bladder cancer who received radical cystectomy (RC) (115 with and 166 without PU) at our institutions between 2010 and 2023. Subsequently, perioperative and oncological outcomes were assessed between propensity score-matched cohorts.
Urethral recurrence (UR) occurred in 5 patients (5/166, 3.0%), all of whom underwent open-RC. Three among those (1.8%) with concomitant metastasis were died of cancer. There were no statistically significant differences between the PU and UPS groups in urethral-recurrence free survival (urethral-RFS) (P = .14), local-RFS (P = .59) and overall survival (OS) (P = .84) in the entire cohort. However, the UPS group showed significantly worse urethral-RFS (P = .008), local-RFS (P = .005) and OS (P = .03) in patients with high-risk of UR. Analysis of recurrence patterns revealed that UPS in high-risk patients significantly increased local recurrence (25.8% vs. 5.0%, P = .02). Conversely, a novel robotic-UPS technique demonstrated significantly favorable perioperative outcomes, comparable local-RFS (P = .79) and OS (P = .16) without UR (0/134, 0%) when compared to robotic-PU. Robotic-UPS also exhibited significantly better local-RFS (P =.007) and OS (P < .001) than open-UPS.
UR-related death was rare and PU did not show a survival benefit for the entire cohort. However, inappropriate UPS in patients at high-risk of UR may increase local recurrence which might be responsible for poor survival after UPS rather than disease progression derived from UR. The robotic-UPS has the potential to reduce unnecessary PU, urethral and local recurrence without compromising survival.
根治性膀胱切除术（RC）中预防性行尿道切除术（PU）的最佳适应证和生存获益仍不明确。因此，本研究旨在评估保留尿道手术（UPS）对包括复发模式在内的肿瘤学结局的影响，并建立一种新的 UPS 技术在机器人时代的最佳尿道管理策略。
我们回顾性分析了 2010 年至 2023 年期间在我院接受 RC 的 281 名男性膀胱癌患者（115 例行和 166 例行 PU）。随后，通过倾向评分匹配队列评估围手术期和肿瘤学结局。
5 名患者（5/166，3.0%）发生尿道复发（UR），均行开放 RC。其中 3 名合并转移的患者死于癌症。整个队列中，PU 组和 UPS 组在尿道无复发生存率（URFS）（P =.14）、局部无复发生存率（LRFS）（P =.59）和总生存率（OS）（P =.84）方面无统计学差异。然而，在高危 UR 患者中，UPS 组的 URFS（P =.008）、LRFS（P =.005）和 OS（P =.03）明显较差。对复发模式的分析表明，在高危患者中，UPS 显著增加了局部复发（25.8% vs. 5.0%，P =.02）。相反，与机器人 PU 相比，新型机器人 UPS 技术在没有 UR 的情况下具有显著良好的围手术期结局、可比的局部 LRFS（P =.79）和 OS（P =.16），局部 LRFS（P =.007）和 OS（P <.001）明显优于开放 UPS。
UR 相关死亡罕见，PU 对整个队列的生存获益无意义。然而，在高危 UR 患者中不适当的 UPS 可能会增加局部复发，这可能是 UPS 后生存较差的原因，而不是 UR 导致的疾病进展。机器人 UPS 有可能减少不必要的 PU、尿道和局部复发，而不影响生存。
