Female Proximal Urethral Cancer
Lesions of the proximal or entire length of the 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 survival rates ranging from 10% to 20%.
To increase the resectability rate of gross tumor and decrease local recurrence, in an effort to shrink tumor margins, it is reasonable to recommend adjunctive, preoperative, radiation therapy. Pelvic lymphadenectomy is performed concomitantly. Ipsilateral inguinal node dissection is indicated only if biopsy specimens of ipsilateral palpable adenopathy are positive on frozen section. For tumors that do not exceed 2 cm in greatest dimension, radiation alone, nonexenterative surgery alone, or a combination of the two may be sufficient to provide an excellent outcome.
It is reasonable to consider removal of part of the pubic symphysis and the inferior pubic rami to maximize the surgical margin and reduce local recurrence. The perineal closure and vaginal reconstruction can be accomplished with the use of myocutaneous flaps.
The prognosis of female urethral cancer is 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%.
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.[1,2]
The level of evidence for these treatment options is 3iiiDiv.
Male Proximal 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 long-term, disease-free survival. Pelvic lymphadenectomy is also performed because of the high incidence of positive nodes and the limited added morbidity.
Despite extensive surgery, local recurrence is common, and this event is invariably associated with eventual death from the 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 may 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.