Urethral Cancer

General

While urethral cancer can be related to prior or concurrent bladder, primary urethral cancer is a rare event.)

Etiology

Not well understood, but thought to be related to chronic inflammation. No identifiable genetic predisposition.

Risk Factors

Chronic inflammation, urethral stricture, sexually transmitted diseases, urethritis, HPV viral infection, more common in females, urothelial carcinoma of the upper portions of the urinary tract increase the risk of disease downstream (i.e. secondary urethral cancer).

Signs and Symptoms

  • Symptoms tend to develop late in the course of disease.
  • Typical symptoms: urinary tract obstruction, hematuria (i.e. blood in the urine), dysuria (i.e. burning or discomfort with urination), purulent urethral discharge (i.e. puss draining from the urethra), periurethral abscess (i.e. pocket of puss next to the urethra), urethral fistula (i.e. connection between the uretha and the skin), penile erosion, impotence (i.e. inability to get an erection.

Pathology

  • 75% Squamous cell carcinoma
  • 15-20% Transitional cell carcinoma.
  • 5-7% Adenocarcinoma
  • Rarely small cell carcinoma, paraganglioma, melanoma, carcinoid, leiomyosarcoma, lymphoma

Staging (TNM)

Primary Tumor (T):

  • TX-primary tumor cannot be assessed
  • Ta-No evidence of tumor
  • Tis-Carcinoma In-Situ
  • T1-Tumor invades subepithelial connective tissue
  • T2-Tumor invades periurethral muscle in women or any of the following in men: corpus spongiosum, prostate, or periurethral muscle.
  • T3-Tumor invades anterior vagina or bladder neck in women or any of the following in men: corpus cavernosum, beyond the prostatic capsule, or bladder neck.
  • T4-tumor invades other adjacent organs

Urothelial (Transitional Cell) Carcinoma of the Prostate: Primary Tumor (T)

  • Tis pu-Carcinoma in-situ involvement of the prostatic urethra
  • Tis pd-Carcinoma in-situ involvement of the prostatic ducts
  • T1-Tumor involving the urethral subepithelial connective tissue
  • T2-Tumor involving any of the following: prostatic stroma, corpus spongiosum, periurethral muscle
  • T3-Tumor involving any of the following: corpus cavernosum, beyond the prostatic capsule, Bladder Neck (Extraprostatic extension)
  • T4-Tumor invades adjacent organs (invasion of the bladder)

Regional Lymph Nodes (N):

  • Nx-Regional Lymph nodes cannot be assessed
  • N0-No regional Lymph node metastasis
  • N1-Metastasis in a single Lymph node 2cm or less in greatest dimension
  • N2-Metastasis in a single node >2cm in greatest dimension or in multiple nodes

Distant Metastasis (M):

  • M0-No distant metastasis
  • M1-Distant metastasis

Evaluation

  • General laboratory tests (i.e. electrolytes, blood count, BUN/creatinine to evaluate kidney function)
  • Urine tests: Urinalysis, urine culture/sensitivity, urine cytology to evaluate for tumor cells
  • Cystourethroscopy (i.e. scoping of the lower urinary tract)
  • Imaging:
    • Possibly retrograde urethrogram to better evaluate the lower urinary tract
    • CT scan and/or MRI, Chest X-ray, and possibly bone scan for improved staging

Treatment Options

  • Treatment options typically depend upon the extent of disease present
  • Limited resection or ablation is possible for solitary, superficial, low stage lesions.
  • Lesions that are more invasive and those with loco-regional spread typically require aggressive surgical management with consideration for multimodality therapy (i.e. addition of radiation and/or chemotherapy)
  • Patients who are not candidates for aggressive surgical therapy or who are not willing to undergo aggressive surgical therapy may be candidates for chemotherapy or radiation alone or in some combination.

Recommended Follow-up

In patients who maintain their urethra, follow-up typically involves surveillance cystourethroscopy (i.e. scoping the lower urinary tract), urine tests for cytology (i.e. looking for tumor cells in the urine), and imaging to evaluate the lower urinary tract and to evaluate for any advancement or recurrence of disease.

In patients who have more advanced disease at diagnosis and who undergo more aggressive surgical management, imaging is typically used to monitor for any advancement or recurrence of disease.