Urethral Cancer
Male urethra and associated cancer pathology, from Campbell's
TNM staging for urethral cancer, from Campbell's
NCCN treatment recommendations for urethral cancer, from Campbell's
NCCN treatment recommendations for localized prostatic urethral cancer, from Campbell's
Urethral Tumors
Benign tumors
- Leiomyoma: hormone sensitive, found submucosally, can assess on exam and MRI, excise transurethrally or transvaginally
- Hemangioma: may be associated with cutaneous hemangioma syndromes, may cause hematuria and discharge, can cause pain if thrombosed, visualize with cystoscopy, MRI may be beneficial (larger/deeper than appearing on cystoscopy), treat with fulguration, ablation, or open excision/reconstruction
- Fibroepithelial polyp: rare, cause filling defect on RUG/VCUG, seen as smooth tumor with stalk on cystoscopy, treated with resection
Male urethral cancer
- Stricture disease is most common risk factor, seen in 50+% urethral cancer
- Other risk factors: lichen sclerosis, STIs, urethritis, hx XRT, trauma, instrumentation, HPV
- Presents with hematuria, LUTS, discharge, and penile/perineal mass
- Anterior urethra drains via inguinal and external iliac lymph nodes, posterior urethra drains via pelvic lymph nodes, palpable inguinal nodes seen in 20-30% cases at presentation, always represent metastatic disease
- MRI is best imaging for assessing disease spread, can consider RUG and US as adjuncts
- Pendulous urethra treatment: TUR, urethrectomy +/- penectomy, questionable benefit to prophylactic node dissection
- Bulbar urethra treatment: TUR, excision and anastomosis, radical cystoprostatectomy + penectomy
- Superficial prostatic disease: consider TURP + BCG to remove affected tissue and increase BCG exposure - 56% response, 44% progression
- Deep prostatic disease (ductal/stromal): radical cystoprostatectomy +/- urethrectomy +/- (neo)adjuvant chemotherapy
- Lymphadenectomy: perform pelvic LND during cystoprostatectomy, inguinal LND only if palpable/enlarged (< 10% risk for metastatic disease if clinically negative nodes)
- 5yr prognosis: cancer specific survival 50-70%, overall survival 40-50%
Female urethral cancer
- Adenocarcinoma most common type
- Increased prevalence in setting of urethral diverticulum (6%)
- MRI best modality to assess disease extent
- Management: local excision (works for distal tumors), urethrectomy, exenteration, XRT, chemo - multimodal therapy recommended
- TUR has high risk for incontinence
- Prognosis: 5yr survival 40-60%, 20% have ILND recurrence at 2yrs
Chemotherapy
- Urothelial: MVAC, gem/cis
- Squamous: PMB, TPF, VBM, TIP (B=bleomycin, F=5-FU, I=ifosfamide, M=methotrexate, P=cisplatin, T=paclitaxel, V=vincristine)
- Adenocarcinoma: FOLFOX (5-FU + folinic acid + oxaliplatin), FOLFIRI (5-FU + folinic acid + irinotecan + cetuximab)
References
- AUA Core Curriculum
- Anderson, C. and J. McKiernan. "Tumors of the Urethra." Campbell-Walsh Urology 12 (2020).
- Chang, Sam S., et al. "Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline." The Journal of urology 196.4 (2016): 1021-1029.
- Chang, Sam S., et al. "Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/ASTRO/SUO guideline." The Journal of urology 198.3 (2017): 552-559.
- Djaladat, Hooman, et al. "Reproductive organ involvement in female patients undergoing radical cystectomy for urothelial bladder cancer." The Journal of urology 188.6 (2012): 2134-2138.
- El-Achkar, Adnan, Luis Souhami, and Wassim Kassouf. "Bladder preservation therapy: review of literature and future directions of trimodal therapy." Current urology reports 19.12 (2018): 1-10.
- Grossman, H. Barton, et al. "Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer." New England Journal of Medicine 349.9 (2003): 859-866.
- Guzzo, T., J. Christodouleas, and D. Vaughn. "Management of Muscle-Invasive and Metastatic Bladder Cancer." Campbell-Walsh Urology 12 (2020).
- Jarret, T., S. Matin, and A. Smith. "Surgical Management of Upper Urinary Tract Urothelial Tumors." Campbell-Walsh Urology 12 (2020).
- Kallidonis, P., and E. Liatsikos. "Urothelial Tumors of the Upper Urinary Tract and Ureter." Campbell-Walsh Urology 12 (2020).
- Kates, M., and T. Bivalacqua. "Tumors of the Bladder." Campbell-Walsh Urology 12 (2020).
- Lamm, Donald L., et al. "Maintenance bacillus Calmette-Guerin immunotherapy for recurrent TA, T1 and carcinoma in situ transitional cell carcinoma of the bladder: a randomized Southwest Oncology Group Study." The Journal of urology 163.4 (2000): 1124-1129.
- Margulis, Vitaly, et al. "Preoperative multivariable prognostic model for prediction of nonorgan confined urothelial carcinoma of the upper urinary tract." The Journal of urology 184.2 (2010): 453-458.
- Navai, N. and C. Dinney. "Surgical Management of Bladder Cancer: Transurethral, Open, and Robotic." Campbell-Walsh Urology 12 (2020).
- Sheldon, Curtis A., et al. "Malignant urachal lesions." The Journal of urology 131.1 (1984): 1-8.
- Svatek, Robert S., David Lee, and Yair Lotan. "Correlation of office-based cystoscopy and cytology with histologic diagnosis: how good is the reference standard?." Urology 66.1 (2005): 65-68.
- Swinn, M. J., et al. "Biopsy of the red patch at cystoscopy: is it worthwhile?." European urology 45.4 (2004): 471-474.
- Sylvester, Richard J., et al. "Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials." European urology 49.3 (2006): 466-477.
- Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.
- Woldu, Solomon L., Aditya Bagrodia, and Yair Lotan. "Guideline of guidelines: non‐muscle‐invasive bladder cancer." BJU international 119.3 (2017): 371-380.
- Zabell, J., and B. Konety. "Management Strategies for Non-Muscle-Invasive Bladder Cancer." Campbell-Walsh Urology 12 (2020).