Lesions of the posterior or entire urethra are usually associated with invasion and a high incidence of pelvic nodal metastases. The prospects for cure are limited except in the case of small tumors. The best results have been achieved with exenterative surgery and urinary diversion with 5-year survivals ranging from 10% to 20%. It is reasonable to recommend adjunctive radiation therapy, which is administered preoperatively, in an effort to shrink tumor margins. Pelvic lymphadenectomy is performed concomitantly since an occasional patient with nodal metastases will be cured. Ipsilateral inguinal node dissection is indicated only if biopsy of ipsilateral palpable adenopathy is positive on frozen section. For tumors that do not exceed 2 cm in greatest dimension, radiation alone, nonexenterative surgery alone, or the combination may be sufficient to provide an excellent outcome.
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As with male urethral carcinoma, it is reasonable to consider removal of part of the pubic symphysis and the inferior pubic rami to maximize the surgical margin and hopefully to reduce local recurrence. The perineal closure and vaginal reconstruction can be accomplished with the use of myocutaneous flaps.
The prognosis of female urethral cancer has been related to the size of the lesion at presentation. For lesions less than 2 cm in diameter, a 60% 5-year survival can be anticipated; for those greater than 4 cm in diameter, the 5-year survival falls to 13%.[2,3,4,5]
Standard treatment options:
Preoperative radiation followed by anterior exenteration and urinary diversion with bilateral pelvic node dissection with or without inguinal node dissection.
For tumors that do not exceed 2 cm in greatest dimension, radiation alone, nonexenterative surgery alone, or the combination may be sufficient to provide an excellent outcome.
Male Posterior Urethral Cancer
Lesions of the bulbomembranous urethra require radical cystoprostatectomy and en bloc penectomy to achieve adequate margins of resection, minimize local recurrence, and achieve cure. Pelvic lymphadenectomy is also recommended in view of the significant incidence of positive nodes, the limited added morbidity from such dissection, and the potential, though limited, possibility for cure. Despite extensive surgery, local recurrence does occur frequently and this event is invariably associated with eventual death from disease. Five-year survival can be expected in only 15% to 20% of patients. In an effort to shrink tumor margins, the use of preoperative adjunctive radiation therapy must be considered. In an effort to increase the surgical margins of dissection, resection of the inferior pubic rami and the lower portion of the pubic symphysis has been used. Urinary diversion is required.[6,7,8,9,10]
Ipsilateral inguinal node dissection is indicated if palpable ipsilateral inguinal adenopathy is found on physical examination and confirmed to be neoplasm by frozen section.