Possible risk factors:
- Urethral strictures
- Chronic inflammation (ISC, urethroplasty)
- EBRT
- Brachytherapy seeds
- Chronic urethritis
- Urethral HPV / condylomata
- Lichen sclerosis / BXO
- ? Urethral diverticulum in women
Histology:
- Urothelial cancer 55 – 65 %
- SCC 15 – 20 %
- Adenocarcinoma 10 – 15 %
SCC and adenocarcinoma rates higher in women.
Staging
| Tx | Tumour can’t be assessed |
| T0 | No evidence primary tumour |
| Ta | Non invasive papillary, polypoid or verrucous |
| Tis | Carcinoma in situ |
| T1 | Invades subepithelial connective tissue (lamina propria) |
| T2 | Invades corpus spongiosum, prostate or periurethral muscle |
| T3 | Invades corpus cavernosum, beyond prostate capsule, anterior vagina or bladder neck |
| T4 | Invades bladder |
| Nx | Nodes can’t be assessed |
| N0 | No nodal metastasis |
| N1 | Single nodal met |
| N2 | Multiple nodal mets |
| Mx | Can’t be assessed |
| M0 | No metastatic disease |
| M1 | Metastatic disease |
Work-up:
- When presenting symptomatically, often presents late
- Examination should include inguinal node assessment
- Cystoscopy should be done for concurrent bladder cancers
- MRI for local staging can be useful
- CT for nodal staging (or MRI)
Distal urethra generally drains to inguinal nodes prior to pelvic nodes, while proximal urethra drains straight to pelvic nodes.
Enlarged lymph nodes in urethral cancer usually indicate metastatic disease (more often so cf. penile cancer)
54 % 5 year overall survival.
Bad prognostic factors:
- Older
- Higher grade, stage
- Nodes and mets
- Increased size
- Proximal tumour location
- Concomitant bladder tumours
- Non urothelial cancers
Treatment is variable depending on location and invasiveness
Treatment – men:
- Distal urethral tumours previously treated aggressively a la penile cancer – but now standard of care is partial urethrectomy with 5 mm margins +/- nodal staging if feasible
- Perineal urethrostomy diversion if appropriate
- Invasive penile/distal urethral tumours may be better treated with partial or radical penectomy
- Bulbar tumours more difficult to treat surgically
- Endoscopic in very superficial cases with high likelihood of stricture
- Partial urethrectomy with urethroplasty
- Cystoprostatectomy with urethrectomy + LND +/- penectomy +/- pubectomy is required for locally advanced cases
Treatment – women:
- Aggressive treatment – urethrectomy with removal of all peri-urethral tissue to bulbocavernosus, with a cylinder of soft tissue including bladder neck
- Bladder neck closure and appendicovesicostomy
- Or – cystectomy/urethrectomy and conduit
- Anything less radical – partial distal urethral excision, laser, etc. – high local recurrence rates and may still have significant local complications – stenosis, fistula, incontinence
- Local radiotherapy has been used – high rates of complications including stenosis, fistula, necrosis, cystitis and bleeding
Multi-modal treatment:
- Neoadjuvant chemotherapy for locally advanced urethral cancer prior to surgery has been described and can be offered (platinum based)
- For SCC – chemorads may offer genital-sparing option (5-FU/MMC with concurrent XRT)
- Salvage surgery may be required
MDT and referral to subspecialists probably very appropriate.
Prostatic urethral cancer / CIS
TURP followed by induction BCG is recommendation – TUR prior to BCG have higher PFS, lower recurrence rates and better staging.
Consider cystoprostatectomy with LND if extensive ductal or stromal invasion
Urethral recurrence after continent diversion / neobladder
CIS may be able to be managed with urethral BCG.
After cutaneous diversion / conduit:
- Can be difficult removing proximal stump from scarred pelvic floor
- High lithotomy, catheter in urethra
- Perineal incision and division of bulbospongiosus and exposure of spongiosum
- Circumferential dissection of sponge and subsequent separation from cavernosa – proceed distally with traction and penile inversion as far as able to glans
- Requires separate circumferential meatal incision to excise navicular fossa – marry up to proximal penile urethral dissection
- Proximal dissection – staying close to bulb – being wary of bulbar arteries
- Care during membranous urethral dissection – possibility of bowel adhesions to superior urogenital diaphragm
After orthotopic neobladder:
- Requires conversion to ileal conduit
- Abdominoperineal approach with IDC placed (positioned in lithotomy)
- Perineal incision and urethrectomy largely as per urethrectomy above but with abdominal incision and mobilisation, adhesionolysis and exposure of urethral anastomosis prior to completion of membranous urethral dissection
- Combined dissection above and below with excision of circumferential margin around urethra and anastomosis
- Excision of dependent portion of pouch
- Use Studer afferent limb to create a conduit if able, or use part of the neobladder with care to preserve mesenteric blood supply