PROSTATE CANCER IN PATIENTS UNDERGOING RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER

Th e objective of this work is to verify the incidence of incidental prostate adenocarcinoma in patients who underwent radical cystoprostatectomy for invasive bladder carcinoma. We have retrospectively reviewed patients who underwent radical cystoprostatectomy for infi ltrative bladder tumors in period between  and  year,  men with bladder cancer underwent radical cystoprostatectomy at Urology ClinicUniversity of Sarajevo Clinics Centre. Mean age of patients was  years, with age limits ranging between  and  years. Pathohystological evaluation was used for all specimens from RCP. We found that , of cystoprostatectomy specimens in patients with bladder cancer also contained incidental prostate cancer. Th is result was much lower than overall mean frequency of incidentally detected prostate cancer in other series of cystoprostatectomy cases (range, -). In conclusion we recommended digital rectal examination (DRE) and prostate-specifi c antigen (PSA) test as part of the bladder cancer work up and complete removal of the prostate at cystoprostatectomy to prevent residual prostate cancer.


Introduction
Prostate cancer is one of the most common malignance among males.Th e distribution of cancer varies significantly from country to country all over the world.Th e latest estimates of global cancer incidence show that prostate cancer has become the third most common cancer in men, with half a million new cases every year, almost  of all cancers in men.Th e lifetime risk of clinically detected prostate cancer is ,, and the probability of dying from prostate cancer is .The frequency of incidentally detected cancer is approximately  in men older than  years of age, and frequency is higher than  in men older than  years.Th e frequency of autopsy-detected cancer is similar or higher.In no other malignancy, there is such a vast reservoir of undetected cases that may never be clinically significant or cause death.This incidentally detected tumors are usually small, well or moderately diff erentiated tumors, localized in prostate.Only  of all prostate cancers are considered as clinically relevant.Most of prostate cancers incidentally detected in pathohystological specimens after radical cystoprostatectomy are clinically not signifi cant.Th e aim of this study was to determine incidence, patohystological features, clinical results in patients with incidental prostate carcinoma after radical cystoprostatectomy for invasive bladder cancer and also to determine if prostate cancer have affected on patients follow up after RCP.Pathohystological reports and clinical results were analyzed for each patient.Tumor localization, Gleason score and grade, seminal vesicle invasion, surgical margin and prostate capsular penetration hade been determined.Also category ASAP and HGPIN had been also mentioned.

Patients and Methods
We have retrospectively reviewed patients who underwent radical cystoprostatectomy for infi ltrative bladder tumors in period between  and  year,  men with bladder cancer underwent radical cystoprostatectomy at Urology Clinic-University of Sarajevo Clinics Centre, Bosnia and Herzegovina; Mean age of patients was  years, with age limits ranging between  and  years.Th e inclusion criteria comprised a serum PSA level <  ng/cm  and normal digital rectal examination.Routine evaluation before RCP includes digital rectal examination (DRE), PSA level, chest X-ray, CT urography and also CT abdomen and pelvis.Bone scan has been done only in patients who had subjective pain in bones or high AP level and serum calcium.Patients with preoperative high PSA level and suspicion DRE were not included in this study.In this study observe criteria for clinically significant prostate cancer were: tumor volume <,ml; Gleason score ≥ ; extracapsular extension; seminal vesicle invasion; lymph node metastasis; positive resection margins.All patients who underwent radical cystoprostectomy for invasive bladder tumor, had been done bilateral pelvic lymph node dissections and one of urinary diversion.Pathohystological evaluation was used for all specimens from RCP. Pathohystological reports and clinical results were analyzed for each patient.Tumor localization, Gleason score and grade, seminal vesicle invasion, surgical margin and prostate capsular penetration hade been determined.Also category ASAP and HGPIN had been also mentioned.

Results
 patients with invasive bladder tumor underwent radical cystoprostatectomy what include bilateral pelvic lymph node dissection and urinary diversion.Th e mean age was  years (range - years).Th is was , and , years for patients with and without prostate cancer, respectively.In  patients was preformed an ileal conduit, in  patients an orthotopic ileal neobladder, in  patients Mainz Pouch II procedure, in  patients Mainz pouch I operation and in remaining  UCS.We evaluated distant lymph node metastasis of  patients (Figure .) positive hade for TCC, and for PCa ; Infi ltration of perivesical tissue ,; Localization of prostate cancer: apex,; base,; middle gland ,; Infiltration of seminal vesicle ,; No one patient had positive margine ().Of  patients,  (,) had the incidental fi nding of PCa within the radical cystoprostatectomy specimen (Figure .).Th e mean serum PSA level was , ± , and , ± , ng/cm  in patients with and without prostate cancer, respectively.The majority  () was pT and pT and  () was pT-, and pT-,.In  of cases, Gleason scores were , , and  respectively.The most prevalent (,) Gleason histological pattern was +=.All patients were pN for prostate cancer and no one had positive surgical margin.High-grade PIN was present in , of incidentally detected prostate cancer. (,)patients of the cystoprostatectomies without prostate cancer had HGPIN.As defined, clinically significant cancers were present in  of the studied patients having a mean age of  ± , years (range -).The remainder  had insignificant prostate cancer (Figure , Figure ).

Discussion
The incidence of prostate cancer varies considerably across populations.The frequency of incidentally detected cancer is approximately - in men older than  years of age, the frequency of autopsy-detected cancer is similar or higher.We found that , of cystoprostatectomy specimens in patients with bladder cancer also contained incidental prostate cancer.Th is result was much lower than overall mean frequency of incidentally detected prostate cancer in other series of cystoprostatectomy cases (range, -) and also much lower than the age-adjusted frequency of autopsy-detected prostate cancer (mean frequency, ; range, -.Incidental prostate cancer in our cystoprostatectomy cases was usually stage pT or pTb (, respectively).Of incidentally detected prostate cancer,  were low grade (Gleason scores , , and ) and  were high grade (Gleason scores  and ).Th e discrepancies between studies could be related to the method of pathologic evaluation employed, all indicate the presence of a signifi cantly high incidence of prostate cancer.High-grade PIN was present in association with , of cases of incidentally detected prostate cancer and in , of cystoprostatectomies without prostate cancer.Th is percentage was lower in our clinic and it was lower than the percentages reported in the other countries.Th e incidence of prostate cancer varies considerably.Prostate cancer shows signifi cant racial variation.Possible explanations for low rates of cancer may be due to under-reporting.Incidental prostate tumors present characteristics that are similar to latent tumors found in autopsy series, some have a proven potential of progressive disease.Th e objective of this work is to verify the incidence of incidental prostate adenocarcinoma in patients who underwent radical cystoprostatectomy for bladder urothelial carcinoma.Our study was limited by the moderate number of cases studied in patient selection for surgery at our medical centers.Merscheimer et al. () have been reported that bladder and prostate cancers frequent rate is second after colon and skin cancer frequent rate.Coincidental rate of prostate cancer and TCC in cystoprostatectomy specimens is - and that is high prevalence in relation to autopsy (-).Montie et al. () reported  rate of incidental prostate cancer  had apical and  multifocal lesions.Th is group of authors suggests complete prostatic extraction (apical).One of patients had prostate carcinoma in apex and he had recurrent disease on urethra-intestinal anastomosis new orthotopical substitutional bladder.Sheng-Hui Lee and al. () reported incidental prostate carcinoma rate of  after RCP ( of  );  patients were T- stage in reference to  patients inT - stage.Preoperative PSA level was ,-, ng/ml.Chun et al. () reported  patients with bladder cancer (TCC) who underwent RCP,  () among them had incidental prostate cancer and at  patients with prostate cancer who underwent RP,  patients (,) had incidental TCC.Incidental rate for bladder cancer in patients with prostate cancer is  x time higher (p > ,) and incidental rate for prostate cancer with bladder cancer is  x time higher than expected ( p < ,).Abbas et al. ()

Conclusion
Th e majority  () was pT and pT and  () was pT-, and pT-,.In  of cases, Gleason scores were , , and  respectively.Th e most prevalent (,).Gleason histological pattern was +=.All patients were pN for prostate cancer and no one had positive surgical margin.High-grade PIN was present in , of incidentally detected prostate cancer. (,)patients of the cystoprostatectomies without prostate cancer had HGPIN.Th e present results indicate that the percentage of incidentally detected prostate cancer in cystoprostatectomies specimens in at our clinical centre is much lower (,) than reported rates in the world until now (-).We therefore assumed regional diff erences in prostate cancer incidence rates to be related to environmental and racial factors.Also the method of pathohystological examination of the prostate varies considerably and can be main cause of these frequency diff erences.In conclusion we recommended digital rectal examination (DRE) and prostate-specifi c antigen (PSA) test as part of the bladder cancer work up and complete removal of the prostate at cystoprostatectomy to prevent residual prostate cancer.
reported incidental prostate cancer in  of  patients with TCC (). patients had PHD of pT;  patients of pT;  patients of pT.Moutzouris et al. () reported incidental rate of  ( of  patients).Revello et al. () reported the prevalence of incidental prostate cancer of , ( of  patients), among them  () with clinically signifi cant and  () nonsignificant patients, cancer was located in apex.Sanli et al. () operated  patients with bladder cancer, among them  patients (,) had incidental prostate cancer, organ confi ned in  patients ( , ) and  patient was with capsular invasion.Abdelhadey et al. () reported incidental prostate cancer at  patients () of  patients who were operated because of invasive TCC,  with Gleason score ≥.Yumura et al. () found from  patients with bladder cancer,  patients (,) who had incidental prostate cancer.