Editing Urethral Tumours (section)

== Female urethral cancer ==

=== Epidemiology ===

* Rare
* Most diagnosed in the 5th and 6th decade

=== Pathogenesis ===

* '''Risk factors for female urethral cancer (7):'''

# '''Leukoplakia'''
# '''Chronic irritation'''
# '''Proliferative lesions e.g. caruncles'''
# '''Polyps'''
# '''Parturition'''
# '''Urethral diverticulum'''
# '''HPV (particularly HPV 6) or other viral infections'''

* Childhood UTIs is not a risk factor

=== Anatomy ===

* '''The female urethra has been divided into an anterior segment (distal 1/3rd) and a posterior segment (proximal 2/3rd)'''
** '''Anterior segment'''
*** '''Lined by stratified squamous epithelium''' '''Posterior segment'''
*** '''May be excised while urinary continence is maintained'''
*** '''Lined by typical urothelium'''
* '''Lymphatic drainage:'''
** '''Anterior urethra and labia'''
*** '''Drain into'''
**** '''Superficial inguinal nodes and then to the deep inguinal nodes''' '''Posterior urethra'''
*** '''Drains into'''
**** '''External iliac nodes (primarily)'''
**** '''Internal iliac/hypogastric and obturator lymph node (secondarily)'''
** Crossover and communications are possible

=== Pathology ===

* '''Squamous cell carcinoma'''
** '''Most common (30-70%) histologic type overall'''
*** '''Recall in men, overall ≈80% are urothelial'''
* '''Urothelial (10%)'''
* '''Adenocarcinomas (25%)'''
** '''Most common malignant pathology in female urethral diverticulum is adenocarcinoma'''
* '''No difference in survival based on histologic subtype'''

=== Diagnosis and evaluation ===

* '''History and Physical exam'''
** A thorough pelvic examination, evaluating for a palpable anterior vaginal mass
*** '''Differential diagnosis of a palpable anterior vaginal mass:'''
***# '''Urethral diverticulum'''
***# '''Urethral cancer'''
***# '''Urethral polyp'''
***# '''Other benign neoplasm, such as urethral caruncle, leiomyoma'''
***#* '''Most common urethral mass in a female: urethral caruncle'''
** Speculum examination should visualize the urethral meatus directly and evaluate for potential involvement of the vaginal wall and vulva
* '''Imaging'''
** '''Primary'''
*** '''MRI'''
**** Soft tissue contrast is superior to that with CT and MRI gives the best anatomic detail in this area.
**** MRI can assess local extension and lymph node involvement.
** '''Metastasis'''
*** Additional staging studies with chest radiograph or chest CT are appropriate.
*** Bone scan may be performed if clinical suspicion exists of bone involvement due to symptoms or laboratory abnormalities such as elevated alkaline phosphatase or serum calcium
* '''Other'''
** '''Cystourethroscopy and examination under anesthesia'''

=== Management ===

* '''Depends primarily on tumor location and clinical stage'''
* '''Options:'''
*# '''Surgery'''
*# '''Radiation therapy'''
*# '''Chemotherapy'''
*# '''Combination therapy'''
*** '''Treatment has trended toward a multimodality approach'''
* '''Distal 1/3rd urethra'''
** '''Distal lesions are associated with improved survival compared with proximal urethral cancers'''
*** Tumors in the distal (anterior) urethra tend to be low stage
** '''Small, exophytic, superficial tumors arising from the urethral meatus or distal third of the urethra'''
*** '''Options:'''
***# '''Circumferential excision of the distal urethra and inclusion of a portion of the anterior vaginal wall via a transvaginal approach'''
***#* ,Cure rates of 70-90% have been achieved with local excision alone
***# '''Radiation'''
***** '''Effective for low-stage distal urethral carcinomas; an alternative in women when surgical resection would negatively affect functional outcomes'''
** '''Indications for groin dissection (2):'''
**# '''Patients without distant metastasis who present with inguinal or pelvic lymphadenopathy'''
**#* '''Clinically palpable inguinal nodes are found in up to 20-30% of patients overall, and these are confirmed to be malignant in ≈90% of cases'''
**# '''Patients who develop regional adenopathy during surveillance'''
* '''Proximal 2/3rd urethra'''
** '''More likely to be high stage and may extend into the bladder and vagina'''
** '''Anterior exenteration (cystourethrectomy), pelvic lymph node dissection, and wide vaginal or complete vaginal excision are often required to obtain negative surgical margins'''
** '''Radiotherapy alone for proximal invasive urethral carcinoma has yielded poor local control'''
** '''A combination of chemotherapy, radiation therapy, and surgery has been recommended for optimal local and distant disease control in advanced female urethral cancer'''
* '''Urethral Recurrence after Cystectomy for bladder cancer in Women'''
** Incidence ranges from 1-13%
** '''No definitive treatment recommendations for women with urethral cancer recurrence after orthotopic diversion due to limited literature'''.
*** Urethrectomy and surgical resection of the area of the urethra-pouch anastomosis with conversion to a continent cutaneous urinary diversion seem feasible and reasonable in the absence of metastatic disease