Prostate cancer with bladder neck involvement: pathologic findings with application of a new practical method for tumor extent evaluation and recurrence-free survival after radical prostatectomy.

Background: Recent studies have questioned the high risk for disease recurrence in cases of bladder neck involvement by prostate cancer (pT4 disease).

Design: The study was based on 141 patients submitted to radical prostatectomy. PSA-recurrence was defined as 0.5 ng/ml or rising at three different examinations. Bladder neck invasion was correlated to Gleason score (<7 or > or =7), urethral or lateral positive surgical margins, tumor size (extensive or not extensive) using a new simple point-count method, race and preoperative PSA levels (<10 or > or =10 ng/ml). The mean and median follow-up periods were 17.2 and 15 months (range 3-55). Recurrence-free survival curves were constructed using the Kaplan-Meier survival method with tests of significant differences based on the log-rank statistic.

Results: Bladder neck invasion was seen in 30/141 (21.27%) patients; 9 (6.38%) had also concomitant positive surgical margins in the sections. Extraprostatic extension was seen in 39/141 (27.65%) and seminal vesicle invasion in 18/141 (12.76%) patients. Patients with bladder neck invasion significantly correlated to Gleason score (P = 0.04), preoperative PSA (P < 0.001), and tumor extension (P= 0.04). No correlation was found to age (P = 0.44), race (P = 0.12) and positive urethral or lateral margins (P = 0.32). The PSA-recurrence relative risk in patients with bladder neck invasion was 0.17 (P = 0.68), with extraprostatic extension 0.53 (P = 0.47) and with seminal vesicle invasion 5.76 (P = 0.02).

Conclusions: Bladder neck involvement correlates with pathologic unfavorable findings on radical prostatectomy specimens as well as to preoperative PSA levels. However, the PSA-recurrence risk associated with bladder neck involvement (pT4) was similar to extraprostatic extension (pT3a) and substantially lower than seminal vesicle invasion (pT3b). The findings favor a need for downstaging of bladder neck involvement in the next version of the TNM system. The method proposed for tumor extent evaluation is simple and accessible to all pathologists working in routine pathology laboratories.