Bladder neck involvement at radical prostatectomy: Positive margins or advanced T4 disease?

Objectives, To assess the prognosis of patients with bladder neck (BN) invo lvement in radical prostatectomy specimens and compare it with patients wit h seminal vesicle invasion (SVI) presumed to have an inferior stage accordi ng to the TNM classification. Methods. Two hundred eighty-six case files of consecutive radical prostatec tomies were reviewed. The records of patients with pathologic BN involvemen t (pT4a) or SVI (pT3c) were thoroughly analyzed and compared. The mean and median follow-up periods were 30.8 and 35.5 months (range 9 to 40), respect ively, for the patients with Stage pT4a and 40.8 and 44.1 months (range 8 t o 86), respectively, for the patients with Stage pT3c. Particular attention was paid to the preoperative clinical and pathologic evaluation, the patho logic analysis of the prostatectomy specimen, and the postoperative follow- up data. Progression was defined as a prostate-specific antigen level of 0. 2 ng/mL and rising. Adjuvant therapy was not initiated unless prostate-spec ific antigen failure had occurred. Results. BN involvement was identified in 25 patients (8.7%) and SVI was fo und in 26 patients (9.1%). In 7 patients (2.4%), the BN was the only site o f positive margins. Thirty-six percent of patients with BN involvement and 62% of patients with SVI demonstrated biochemical progression. Disease-free survival and metastasis-free survival rates were significantly better for the patients with Stage pT4a than for the patients with Stage pT3c at 24 an d 36 months after surgery. Univariate analysis identified the prostate-spec ific antigen nadir to be the most significant predictor of prognosis. Conclusions. In this study, BN involvement in the surgical specimen carried a lower risk of progression than SVI. On the basis of our preliminary resu lts and those in other studies, a conceivable downstaging of BN involvement in the TNM staging system should be considered. Possibly, additional modif ication of the TNM staging system should be contemplated on the basis of th e results of pathologic analysis and prognosis. The significance of BN invo lvement and the role of adjuvant therapy in this group of patients need fur ther evaluation. UROLOGY 56: 448-452, 2000. (C) 2000, Elsevier Science Inc.