Do we use the right criteria for determining the clinical significance of incidental prostate cancer at radical cystoprostatectomy?

Prostate-sparing techniques have been advocated to improved functional outcomes after radical cystoprostatectomy (RCP) for invasive bladder cancer, but this may endanger the oncological outcome. This review addresses the current status of risk factors of prostate cancer (PCa) recurrence in patients with incidental PCa after RCP. The overall 7-year risk of PCa recurrence after RCP is approximately 9%. Increased risk has been suggested in the presence of clinically significant PCa as: ≥ pT3a stage, presence of lymph-node metastasis, positive surgical margins, Gleason pattern ≥ 4, tumour multifocality (three or more foci) and tumour volume >0.5 cm(3). However, the prognostic significance of these parameters has not been evaluated within multivariable analyses so far. Preoperatively elevated prostate-specific antigen (PSA) values correlate weakly with the clinical significance of incidental PCa, while prostate biopsy has a limited accuracy for detecting incidental PCa in the preoperative setting. Genetic markers, e.g. the prostate stem cell antigen (PSCA) gene, have recently been associated with risk of recurrence in patients with incidental PCa. Incidental PCa at RCP is usually clinically insignificant. Yet, clinicopathological parameters for clinical significant cancers have not been investigated independently in the literature so far. Consequently, lifelong PSA surveillance should be conducted in all patients with incidental PCa after RCP. In the presence of clinically significant PCa treatment decisions should be based not only on histological criteria but also on patient-centred parameters (e.g. patient age and comorbidities). Assessment of PSCA expression in RCP specimens may enable improved risk assessment for PCa recurrence after RCP.