EURURO Vol. 71 No. 4

553 692

prostatic urethral involvement in the RC specimen was 71%
and 100%, respectively, with an overall accuracy of 89%.
However, this study did not compare biopsy results with
frozen or permanent section analysis of the distal urethral
margin, which is the key clinical question. Futhermore,
prostatic urethral biopsy failed to detect prostatic stromal
invasion of the urothelial carcinoma in 11 of 15 patients
( 73%). Apart from this study, it should be emphasized that
a prostatic cold cup urethral biopsy results in lower
accuracy rates compared with a transurethral loop biopsy
for the detection of prostatic urothelial malignancy .
Given the high rates of concomitant prostatic urethral
malignancy (37–38%) and low rates of distal urethral
malignancy ( 6–9%) at the level of urethral transection
, the routine use of preoperative prostatic urethral
biopsy is likely to unnecessarily exclude a considerable
number of patients who desire OBS as their preferred type
of diversion. Furthermore, as there is a relatively low
positive predictive value of prostatic urethral biopsy for
predicting disease at the urethral margin at RC, collective
data suggest that a FSA of the urethral margin should be
performed for men scheduled for OBS . Therefore, in the
authors’ opinion a positive transurethral biopsy before
cystectomy is not a reason to exclude a patient a priori from
undergoing an orthotopic diversion.
3.4. What are treatment options and outcomes of secondary
urothelial tumors after RC?
3.4.1. Treatment of secondary upper tract tumors
provides a comprehensive overview on the available
data on treatment and outcomes of secondary upper
recurrences. Thirteen studies reported explicitly on the
location of recurrences (urothelial and/or local [retro-
peritoneum/pelvic] and/or distant) during staging of
238 patients with secondary upper tract recurrence. Of
these, 210 (88.2%) patients had urothelial recurrence
without evidence of local/pelvic or distant disease at the
time of diagnosis. Concomitant urothelial and distant
recurrence was present in 21 (8.8%) patients and concomi-
tant urothelial and pelvic recurrence in seven (2.9%).
Modality of treatment of upper tract recurrence was
reported in 14 studies in a total of 263 patients. Of these
patients, 160 (60.4%) were treated with radical nephro-
ureterectomy, which was done with preoperative or
postoperative [80_TD$DIFF]systemic chemotherapy in nine cases (3.4%).
Three (1.1%) patients were treated with segmental ureter-
ectomy, while endoscopic surgery was utilized in 21 (7.9%)
patients. Systemic chemotherapy alone was administered in
17 (6.4%) patients and topical chemotherapy or immuno-
therapy with Bacille Calmette-Guerin (BCG) in nine (3.4%).
In 53 (33.1%) patients some kind of surgical treatment
was performed but not further defined in the respective
publications.
Survival outcomes after treatment of secondary upper
tract recurrence were reported in 13 studies including a total
of 464 patients. Survival data with regard to duration of
follow-up was available in nine studies with a median
follow-up of 88 mo (range: 26–126). Overall survival status
with information on disease status was reported in
363 patients. Of these, 259 (55.2%) died of disease and 58
(12.4%) died of other causes. Thirty-three (7.0%) patients
were living without evidence of disease and 13 were alive
with disease (2.8%). Overall survival status without infor-
mation on disease status was additionally reported in
101 patients. Of these, 58 (12.4%) were reported to be alive
and 43 (9.2%) to have died.
Altogether, these findings suggest that although most
recurrences were detected in nonmetastatic stages, out-
comes were poor possibly due to the presence of micro-
metastatic disease at the time of surgery. These data
reinforce our suggestion for a risk-adapted approach to
identify recurrences at the earliest possible to stage in order
to treat in a curative intent. However, there is some
evidence supporting renal-sparing approaches for the
treatment of upper tract recurrences with low-grade,
low-volume disease . These include endoscopic ablation
of tumor or open kidney-sparing surgery with reconstruc-
tion of the upper tract . Similar to patients with urethral
CIS, those with CIS of the upper tract can be managed
effectively with antegrade instillation of BCG via a
percutaneous nephrostomy .
3.4.2. Treatment of urethral recurrences
provides a comprehensive overview of the available
data on recurrence patterns, treatment, and outcomes of
patients with secondary urethral recurrences. Eight studies
reported on recurrence patterns in 51 patients with
secondary urethral recurrences after RC. Urothelial recur-
rence was identified in the [81_TD$DIFF]urethra only in 34 (66.7%) of the
patients. Urethral plus distant recurrences were present in
11 (21.6%). Concomitant urethral and pelvic recurrences
were noted in four (7.8%) patients and concomitant
urethral, pelvic, and distant recurrences in two (3.9%).
The modality of treatment of urethral recurrence was
reported in 10 studies including 223 patients. Of these
patients, 153 (66.2%) were treated with partial or complete
urethrectomy. Systemic chemotherapy and/or radiotherapy
were utilized in 34 (14.7%) patients, of whom eight
underwent also surgery. Topical chemotherapy or immuno-
therapy with BCG was administered in 18 (7.8%) patients.
Transurethral resection was conducted alone in three
patients (1.3%). In 15 (6.5%) patients some kind of surgery
was performed but not further defined in the respective
publications.
Survival outcomes after treatment of urethral recurrence
were reported in nine studies including a total of
202 patients with a median follow-up of 97 mo (range:
29–155). Overall survival status with information on
disease status was reported in 162 patients. Of these, 87
(43.1%) patients died of disease and 55 (27.2%) died of other
causes. Nineteen (9.4%) patients were living without
evidence of disease and one was alive with disease
(0.5%). Twenty-four (11.9%) patients were reported to be
alive and 16 (7.9%) to have died with no further information
on disease status at the time of analysis.
As for secondary upper tract recurrences, outcomes after
treatment of urethral recurrence are poor despite use of
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