Prophylactic urethrectomy at the time of radical cystectomy for bladder cancer: does it really have an effect on oncological outcomes?

Abstract

To assess the oncological impact of prophylactic urethrectomy (PU) on recurrence, metastasis, and survival outcomes, as PU was historically performed alongside radical cystectomy (RC) in men but has become rare with the increasing use of orthotopic neobladder substitution and uncertain survival benefits. A total of 1028 patients underwent RC at a single tertiary referral center between 1996 and 2022. Among them, 581 males who received either incontinent urinary diversion or continent cutaneous diversion were identified. A propensity score matching was performed to minimise selection bias, yielding a cohort of 332 patients, of whom 166 underwent PU and 166 did not. Kaplan-Meier survival analysis was conducted to evaluate recurrence-free survival (RFS), urethral recurrence-free survival (URFS), cancer-specific survival (CSS), and overall survival (OS) at multiple time points postoperatively. Differences in survival outcomes between the two groups were assessed using the log-rank test. A trend toward improved CSS was observed in the PU group; however, the difference was not significant, and no notable variation was found in RFS. At 10 years, URFS was higher in the PU group (97.9% vs 90.9%, P = 0.05), but after matching, this difference (98.2% vs 95.9%) was no longer significant. A significant improvement in OS was observed among patients who underwent PU, with a 10-year survival rate of 47.3% compared to 27.5% in those who did not receive the procedure (P = 0.002). Independent predictors of OS included age ≥80 years (P = 0.013), Charlson Comorbidity Index score ≥3 (P = 0.002), pathological N-stage ≥N1 (P < 0.001), positive surgical margins (P < 0.001), and performing PU (P = 0.015). Patients undergoing PU had significantly improved OS at 2-, 5-, and 10-year follow-up compared to those who did not. No significant differences were found in CSS and RFS. While PU was associated with a reduced risk of urethral recurrence at 10 years, this advantage was no longer significant after adjusting for confounders. The procedure may be most beneficial for select patients, particularly those with prostatic urethral involvement.