Introduction:

Prostatic urethral urothelial carcinoma (PUC) represents a rare form of the disease arising from the prostatic urothelium. Standard of care for high grade non-invasive PUC is intravesical bacillus Calmette-Guerin (BCG). A transurethral resection of the prostate (TURP) is often performed prior to BCG instillation to facilitate surface contact of BCG with the prostatic urothelium. While prior studies have described the potential impact of TURP on response to induction BCG, no contemporary series has been reported. Our goal is to describe our experience with TURP prior to induction BCG in patients with PUC.

Methods:

We performed a retrospective cohort study of all patients at a single institution who received BCG induction from 1996 to 2023 for NMIBC. All patients with pathologically confirmed PUC prior to BCG induction were included. The medical record was manually reviewed to document management of the prostatic urethra. TURP was defined as any resection or ablative procedure of the prostate. Biopsies and fulguration of the prostatic urethra were not considered a TURP. We performed descriptive statistics of the presentation, management, and clinical outcomes of patients with PUC treated with BCG.

Results:

727 patients were treated with BCG. Of these, 24 patients (3.3%) had PUC with/without disease in the bladder prior to initial BCG induction. 14 patients (58%) had a biopsy/fulguration of the prostate and 10 patients (42%) underwent a TURP prior to initiation of intravesical therapy. 5 patients (50%) recurred in the urethra after TURP and 3 patients (21%) recurred after biopsy/fulguration. Median time to urethral recurrence from diagnosis in patients who received a TURP was 1.8 years while the median was not reached for patients with biopsy/fulguration (log-rank, p=0.19). Accounting for urethral and bladder recurrences, 7 patients (70%) recurred after TURP and 9 patients (64%) recurred after biopsy/fulguration. Median time to any recurrence (urethral/bladder) from diagnosis in patients who received a TURP was 1.1 years (95% CI: 1.0-6.9) compared with 0.4 years (95% CI: 0.2-1.1) in patients managed with biopsy/fulguration (log-rank, p=0.8).

Conclusion:

PUC is a rare entity usually occurring simultaneously with bladder urothelial carcinoma. While TURP prior to induction BCG did numerically improve the time to any recurrence (urethral or bladder), this was not statistically significant. It is possible that the observed relatively higher rates of recurrence in the TURP subgroup are due to uncaptured higher risk disease that warranted full TURP versus biopsy/fulguration. Finally, despite a cohort of >700 patients treated with BCG, our sample of patients with PUC was small and limited our ability to detect significant differences in clinical outcomes. Therefore, multi-institutional collaborations are warranted to evaluate the impact of TURP on this rare disease. 

Funding: N/A