Open Access

ARTICLE

The role of preoperative prostatic urethral biopsy in clinical decision-making at the time of radical cystectomy

Josep M. Gaya^1,2, Justin Matulay¹, Gina M. Badalato¹, Dara D. Holder¹, Gregory Hruby¹, James McKiernan¹

1 Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York, USA
2 Department of Urology, Fundació Puigvert, Universitat Autonòma de Barcelona, Barcelona, Spain
Address correspondence to Dr. J. M. Gaya, Department of Urology, Fundació Puigvert, Cartagena 340-350, 08025 Barcelona, Spain

Canadian Journal of Urology 2014, 21(2), 7228-7233.

Abstract

Introduction: Involvement of the prostatic urethra by bladder cancer directly impacts prognosis, risk of urethral recurrence, and timing of radical cystectomy (RC); it also affects the type of urinary diversion chosen. Both cold cup biopsies and transurethral (TUR) loop biopsies have been used to evaluate the status of the prostatic urethra. We report our 20 year experience with preoperative and intraoperative prostatic urethral biopsies to determine relative efficacy and associated treatment implications.
Materials and methods: The Columbia University urologic oncology database was reviewed and yielded 234 men who underwent preoperative endoscopic biopsies of the prostatic urethra before RC between 1990 and 2010. Two techniques were described: 1) cold cup biopsy, and 2) TUR loop biopsy. We evaluated the sensitivity, specificity, and predictive values for these respective techniques relative to the final pathological status of the prostatic urethra (PU) in the RC specimen.
Results: Of the 234 urethral biopsies 115 (49.1%) were cold cup and 96 (41.1%) were TUR loop biopsies. In the remaining 9.8% of patients, the technique could not be determined. Eighty-one preoperative biopsies (34.6%) revealed involvement of the urethra. No differences were observed in predictive values, sensitivity, and specificity between the two preoperative techniques. The negative predictive value (NPV) was higher than positive predictive value (PPV) for both preoperative approaches. Thirty-eight patients (16.2%) had a urethral frozen section analysis done intraoperatively. Only 1 patient (3%) had an abnormality on frozen section, with the negative predictive value (NPV) higher than the positive predictive value (PPV) for the test's ability to predict the status of the final urethral margin. Urethrectomy was performed at cystectomy in 52 patients with a positive biopsy; 15 (28.8%) of these patients ultimately had a negative PU on final pathology. Only 2/182 (1%) of the patients with an intact urethra presented with a urethral recurrence with a median follow up of 30.5 months.
Conclusions: Preoperative prostatic urethral biopsy does not adequately predict final prostatic urethral status at radical cystectomy. No differences in predictive capacity could be detected with either cold cup biopsy or TUR biopsy. Intraoperative biopsy of the prostatic urethra is predictive of a negative urethral margin. Simultaneous radical urethrectomy should not be performed based upon preoperative prostatic urethral biopsy results alone.

---

Keywords

---