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radical cystoprostatectomy

Thursday 2 January 2014

Medscape

ln case of muscle invasive urothelial carcinoma (UC), radical cystoprostatectomy (RCP) is the gold standard of treatment. Appropriate sampling of RCP specimen is necessary to obtain correct pTNM stage and treatment.

Handling protocol

After taklng material for snap frozen specimen if possible, the RCP is fixed in 10% neutral buffered formalin, 15 times the volume of the total specimen. Fixation lasted between 24 to 48 hours according to the spedmen’s size.

After orientation and measuring and describing the RCP specimen, the apex, a slice in the middle of the prostate and a slice at the base of prostate are taken. Afterwards the bladder is sampled according to necessity of macroscopic aspects.

After orientation, measuring and describing the lesions and macroscopic fîndings, the RCP specimen is eut sagitally to separate the right and left half from anterior to posterior. Photos are taken systematically.

Prostate tissue is inked to be able to mark resection margins precisely in case of concomitant prostate cancer as well as in case of invasion of the prostate by UC. The most apical portion of the prostate is transected and submitted as for cone biopsies of cervix for evaluation of the apical margin, according to the Stanford protocol.

Then the urethra is taken on bath sides (right and left) in its total length to be able to study the whole PU.

The next step is sampling the bladder neck according to macroscopic findings including a sample of seminal vesicles and prostate tissue.

Prostate samples are taken in the middle of the prostate (1to 2 slices according to the size of the prostate). The procedure was similar on bath sides.

Afterwards the bladder is sampled according to the recommendations published by Lopez-Beltran et al. .

Tumors are classified according to the WHO classification 2004.

- anterior pelvectomy

  • ln case of anterior pelvectomy cervix, uterus, annexa and ovary should be taken separately. Furthermore the reports between the bladder wall, cervix and parametrium have to be examined. Limits of urethra, vagina, cervix and ureter have to be taken. the rest of the sampling is the same as in cystoprostatectomies.

Specific topics

- prostatic urethra

  • Staging UC in the prostatic urethra (PU) is controversial. The PU mucosa and large prostatic ducts that empty into the urethra are also lined by the same urothelium.
  • ln case of invasion of the PU, prostatic ducts or acini with UC without invasion of the prostatic stroma, the tumor has to be considered as pTis, making no difference whether it’s a primary tumor or extension of an already existing UC of the bladder.

- involvement of the prostatic stroma

  • ln case of involvement of the underlying prostatic stroma, the UC becomes a pT4 tumor.
  • The proximity of prostatic urethra and bladder neck facilitate spreading of in situ carcinoma into prostatic urothelium.
  • Many patients with involvement of the bladder neck have spread of UC into the PU.
  • To determine that the carcinoma does not invade the stroma of the underlying gland is a very important challenge in pathology.
  • Up to now no standard protocol for sampling the prostate in RCP specimens has been established. lt’s left to the pathologist to decide how many blocs should be taken. Montironi et al. suggest in a recent paper whole-mounted prostate sections with inclusion of the whole gland.

Reporting

- Histological type

  •  % subtype
  • Single : multiple lesion(s)
  • Size

- Depth ofinvasion

  • Invasion of adjacent organs

- Lymphovascular invasion
- Cis, other lesions
- Urethra margin
- Ureteral margin
- Peritoneal margin
- Vagina/cervix
- Lymph node
- pervesical fat++
- Size
-  % invasion
- Lymph node capsule
- pTNM stage