Editing Urethral Tumours (section)

==== Management ====

* '''Surgical excision is the primary form of treatment'''
* '''Depends on the tumour location and clinical stage'''
* '''Anterior urethra'''
** '''In general, more amenable to surgical control and better prognosis than posterior urethral carcinoma, which is often associated with extensive local invasion and distant metastasis'''
** '''Carcinoma of the Penile Urethra'''
*** '''Superficial, papillary, or low-grade tumors'''
**** '''Options (3):'''
****# '''Transurethral resection'''
****# '''Local excision'''
****# '''Distal urethrectomy and perineal urethrostomy'''
*** '''In patients with invasive disease'''
**** '''Localized to the distal half of the penis, partial penectomy with a 2-cm negative margin remains the traditional treatment for pT2 tumors (infiltrating the corpus spongiosum)'''
***** Excellent local control after this procedure has been documented
***** '''For patients with invasive anterior urethral cancer with the intent of genital preservation, chemoradiation has been reported as an option'''
**** '''Extending to or involving the proximal penile urethra, total penectomy is required to obtain an adequate margin of excision'''
*** '''Inguinal lymphadenectomy in penile urethral carcinoma'''
**** '''Non-palpable (cN0): not recommended'''
***** '''Unlike penile cancer with high-risk features, survival benefit from prophylactic inguinal lymph node dissection in patients without palpable inguinal nodes has not been demonstrated with urethral cancer'''
**** '''Palpable (cN+ [, resectable]): recommended'''
***** Cases of cure with limited nodal disease have been reported and therefore inguinal lymphadenectomy should be considered in the presence of palpable inguinal lymph nodes.
** '''Carcinoma of the Bulbomembranous Urethra'''
*** '''Radical cystoprostatectomy, pelvic lymphadenectomy, and total penectomy are often required'''
**** '''Poor survival''' has been recorded for all forms of treatment, but radical excision continues to be an important component of treatment in some patients.
*** Summary of steps:
**** Position: low lithotomy to allow perineal access.
**** [Further details in Campbell’s]
*** '''Because of the relatively poor outcomes after surgery alone for advanced tumors of the posterior urethra, multimodal therapy in this setting is increasing'''
**** '''Squamous cell cancers respond poorly to the M-VAC regimen''' [SASP]
* '''Posterior Urethra'''
** '''Carcinoma of the Prostatic Urethra'''
*** See Urothelial Carcinoma of the Prostate Chapter Notes
** '''Management of the urethra after cystectomy'''
*** '''Timing of urethral recurrence post-cystectomy'''
**** ≈40% of urethral recurrences are diagnosed within 1 year after cystoprostatectomy, with a median time to diagnosis of 18 months
**** Late urethral recurrence have been reported, indicating the need for prolonged surveillance in these patients
*** '''Diagnosis and Evaluation'''
**** '''After non-orthotopic diversion, urethral wash cytology has traditionally been recommended and leads to earlier diagnosis of urethral recurrence than when evaluation is delayed until symptoms occur'''
**** '''After orthotopic, diversion, voided urine cytology is part of standard surveillance'''
**** '''Patients with positive results for urine or urethral wash cytology or symptoms of urethral bleeding, discharge, or palpable mass are evaluated with cystoscopy and biopsy.'''
***** '''Pelvic CT or MRI may be necessary to aid in assessment of the local extent of larger invasive tumors and to assess for metastatic disease'''.
**** '''Management'''
***** '''Patients who develop urethral carcinoma in situ after orthotopic diversion may respond to urethral perfusion with BCG, but this treatment is ineffective for those with papillary or invasive disease and these patients may require urethrectomy'''
***** '''When a delayed urethrectomy is performed in a male patient after radical cystectomy, it is important to remove the fossa navicularis and urethral meatus''' because of the high incidence of involvement of the squamous epithelium
***** '''Total urethrectomy after cutaneous diversion'''
****** Technique: The high or exaggerated lithotomy position provides optimal exposure for total urethrectomy, with the hips and knees gently flexed and the lower limbs abducted in boot-type stirrups. [Further detail’s in Campbell’s]
***** '''Total urethrectomy after orthotopic diversion'''
****** Technique: Total urethrectomy after orthotopic urinary diversion is performed through an abdominoperineal approach [Further detail’s in Campbell’s]
****** In most situations, urinary diversion is accomplished with an ileal conduit