The efficacy of transurethral biopsy for predicting the long-term clinical impact of prostatic invasive bladder cancer

Purpose: Involvement of the prostate by bladder cancer directly impacts survival, the risk of urethral recurrence, and treatment decisions concerning the timing of cystectomy and type of urinary diversion. Transurethral lateromontanal loop biopsies are proposed as the most accurate method for evaluating the prostatic urethra. Due to the potential clinical impact on individuals we assessed its accuracy in a large cohort. Materials and Methods: Transurethral lateromontanal loop biopsies were performed in 246 of 416 male patients at our institution between 1989 and 1997. The predictive value and sensitivity of transurethral biopsy, patterns of recurrence, survival and clinical impact were assessed in a cohort with 10 years of followup. Results: The sensitivity of transurethral biopsy for prostatic stromal invasion was 53%, specificity was 77%, positive predictive value was 45% and negative predictive value was 82%. At the 10-year followup 129 patients (52.4%) were dead, 85 (32%) had no evidence of disease, 16 (6.5%) had disease and 16 (6.5%) were lost to followup. Mean followup in patients at risk for urethral recurrence was 61.7 months (range 0.56 to 134.1, median 56.8). Delayed urethrectomy was performed in 15 of 235 cases (6.4%) at a mean of 15.2 months. Of the 246 patients 99 had prostatic disease at transurethral biopsy and/or cystectomy, including 11 (11%) with urethral recurrence. No patient required continent diversion takedown or died of urethral recurrence. Conclusions: Transurethral biopsy did not accurately determine prostatic involvement. Prostatic involvement at biopsy or cystectomy translated into a higher risk of urethral recurrence. However, it did not have significant clinical impact or affect survival and should not be an absolute contraindication to urethral diversion.