Should orthotopic bladder substitution be omitted if pre-cystectomy biopsies of the prostatic urethra (male) or bladder neck (female) are positive?

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When considering an orthotopic bladder substitution (OBS) preoperative biopsies of the prostatic urethra (in male) or bladder neck (in female) are usually performed to evaluate a potential involvement of the urethra. In case of positive preoperative biopsies, a non-orthotopic diversion is recommended in order to avoid positive urethral margin and to prevent local recurrence. Our aim was to investigate the influence of positive preoperative biopsies on local recurrence, cancer- specific (CSS) and overall survival (OS) after OBS.


Retrospective analysis of 776 consecutive patients (77% [601/776] MIBC; 23% [175/776] recurrent NMIBC) who had undergone radical cystectomy with ileal OBS between 04/1985 and 01/2016 at our institution.


94% (731/776) of patients had negative (Group A) and 6% (43/776) of patients (36 male, 7 female) had positive (Cis: 32/43 [74%]; pTa/pT1 G3: 11/43 [26%]; Group B) pre-cystectomy biopsies. Median follow-up was 71.5mts (range: 1-323). 32% (251/776) of patients experienced local and/or distant recurrences: 12% (31/251) urethral (23/31 CIS, 5/31 pTa, 3/31 ≥ pT1),14% (34/251) local recurrences other than urethral, and 74% (186/251) distant metastases. Urethral recurrence developed significantly more often (p


Although positive biopsies of the prostatic urethra or the bladder neck prior to OBS increase the rate of urethral recurrences this does not translate into decreased CSS and OS. Most urethral recurrences could be managed successfully with local treatment; thus, OBS is an option in highly selected patients with positive, non-invasive preoperative biopsies provided that patients have regular follow-up including urethral washout cytology.

Funding: None