38

Tumors of the Urethra

David S. Sharp; Kenneth W. Angermeier

Questions

1.What is the most frequent site of both stricture disease and urethral cancer in the male?

a.Pendulous urethra

b.Fossa navicularis

c.Bulbomembranous urethra

d.Prostatic urethra

e.Urethral meatus

2.Which of the following is TRUE concerning distal urethral carcinoma in the male?

a.Prognosis depends on histologic cell type.

b.Penectomy is usually indicated for tumors infiltrating the corpus spongiosum.

c.Prognosis is worse than for bulbomembranous urethral cancer.

d.Conservative surgical therapy is not effective.

e.Biopsy most commonly demonstrates transitional cell carcinoma.

3.When a delayed urethrectomy is performed in a male patient after radical cystectomy, which of the following is necessary to ensure a complete dissection and decrease the risk of a local recurrence?

a.Removal of the fossa navicularis and urethral meatus

b.Bilateral groin dissections

c.Total penectomy

d.Intraoperative ultrasound imaging

e.Cauterization of the urethral bed

4.Which of the following statements regarding urethral tumor recurrence after cystectomy and orthotopic urinary diversion is FALSE?

a.It seems to occur more frequently than after cutaneous diversion.

b.Some patients with carcinoma in situ may be successfully treated with urethral infusion of bacillus Calmette-Guérin (BCG).

c.Urethrectomy and cutaneous diversion can often be done using bowel tissue from the existing neobladder.

d.Surveillance consists of urine cytology and symptom assessment.

e.Urethrectomy with conversion to a continent cutaneous diversion may be possible in some patients.

5.Possible causes for female urethral carcinoma include all of the following EXCEPT:

a.childhood urinary tract infections.

b.leukoplakia.

c.chronic irritation or urinary tract infections.

d.proliferative lesions such as caruncles.

e.human papillomavirus infection.

6.What is the most common histologic type of proximal urethral cancer in women?

a.Adenocarcinoma

b.Squamous cell carcinoma

c.Melanoma

d.Transitional cell carcinoma

e.Lymphoma

7.What is the most significant prognostic factor for local control and survival in female urethral cancer?

a.Anatomic location and extent of the tumor

b.Age at presentation

c.Histologic type of the tumor

d.Hematuria

e.Urinary retention

8.Radiation therapy for female urethral carcinoma is most successful:

a.as a single modality for proximal invasive tumors.

b.when used in conjunction with chemotherapy for low-stage distal urethral tumors.

c.at controlling distant metastatic disease.

d.at controlling small lesions in the distal urethra.

e.as neoadjuvant therapy before excision of locally advanced proximal urethral cancer.

Pathology

1.A 64-year-old woman has had urethral pain for the past 6 months. A 0.5-cm mass is palpable in the distal urethra. A biopsy of the mass reveals adenocarcinoma and is depicted in the figure. The next step in management is:

a.Imaging to rule out a primary gastrointestinal origin.

b.Cystouretrectomy.

c.Local excision.

d.Radiation therapy.

e.Pelvic magnetic resonance imaging (MRI).

FIGURE 38-1 (From Bostwick D, Cheng L. Urologic surgical pathology. 3rd ed.

Philadelphia: Elsevier; 2014.)

Answers

1.c. Bulbomembranous urethra. The incidence of urethral stricture in men later developing a carcinoma of the urethra ranges from 24% to 76% and most frequently involves the bulbomembranous urethra, which is

also the portion of the urethra most commonly involved by tumor.

2.b. Penectomy is usually indicated for tumors infiltrating the corpus spongiosum. In general, anterior urethral carcinoma is more amenable to surgical control, and the patient's prognosis is better than that for posterior urethral carcinoma, which is often associated with extensive local invasion and distant metastasis.

3.a. Removal of the fossa navicularis and urethral meatus. It is important that the fossa navicularis and meatus also be taken in the dissection, because of the high incidence of involvement of the squamous epithelium.

4.a. It seems to occur more frequently than after cutaneous diversion.

Studies to date suggest that urethral tumor recurrence after orthotopic urinary diversion is less common than after cutaneous diversion. In the presence of an orthotopic neobladder, urethral surveillance consists of urine cytology and symptom assessment. Success has been reported in selected patients treated with urethral infusion of BCG for urethral carcinoma in situ after orthotopic diversion. After urethrectomy, cutaneous diversion can often be done using bowel tissue from the existing neobladder, eliminating the need to take additional small bowel tissue out of the circuit.

5.a. Childhood urinary tract infections. Causes associated with subsequent development of urethral malignancy in females include chronic irritation or urinary tract infections; proliferative lesions such as caruncles, papillomas, adenomas, and polyps; leukoplakia of the urethra; parturition; and human papillomavirus infection.

6.b. Squamous cell carcinoma. Carcinomas of the proximal or entire urethra tend to be high grade and locally advanced, with squamous cell carcinoma accounting for 60%; transitional cell carcinoma 20%; adenocarcinoma 10%; undifferentiated tumor and sarcomas 8%; and melanoma 2%.

7.a. Anatomic location and extent of the tumor. The most significant prognostic factor for local control and survival is the anatomic location and extent of the tumor, with low-stage distal urethral tumors having a better prognosis than high-stage proximal urethral tumors.

8.d. At controlling small lesions in the distal urethra. Radiation therapy alone, as with surgical excision, is often sufficient to control small lesions in the distal urethra.

Pathology

1.e. Pelvic MRI. An MRI may be very helpful in evaluating the extent of surgery required in this patient. If confined to the distal urethra, the adenocarcinoma may be removed by distal urethrectomy with inclusion of the anterior vaginal wall. In the female, adenocarcinoma accounts for about a third of the urethral tumors and is the most common tumor found in a urethral diverticulum.

Chapter review

1.The most common benign urethral tumors are leiomyoma, hemangioma, and fibroepithelial polyp.

2.In the male, the histology of cancer in the prostatic urethra is transitional cell in 90% and squamous cell carcinoma in 10%; in the penile urethra, 90% are squamous cell cancers and 10% are transitional cell tumors; and in the bulbomemebranous urethra 80% are squamous cell, 10% are transitional cell, and 10% are adenocarcinoma. In the female, squamous cell carcinoma accounts for one third, adenocarcinoma for one third, and transitional cell carcinoma for one third.

3.In the male, the anterior urethra lymphatics drain to the inguinal nodes, and the posterior urethra lymphatics drain to the pelvic nodes.

4.In the female, the anterior urethra (distal third) lymphatics drain to the inguinal nodes. The posterior urethra lymphatics (proximal two thirds) drain to the external and internal iliac and obturator lymph nodes.

5.Transitional cell carcinoma, which involves the prostatic urethral stroma, significantly increases the probability of urethral recurrence.

6.Adenocarcinoma is the most common type of tumor to occur in a urethral diverticulum.

7.Distal urethral cancers in both men and women have a more favorable prognosis than proximal urethral cancers.

8.The distal third of the female urethra may be excised with maintenance of continence.

9.Carcinomas of the proximal or entire urethra tend to be high grade and

locally advanced, with squamous cell carcinoma accounting for 60%; transitional cell carcinoma 20%; adenocarcinoma 10%; undifferentiated tumor and sarcomas 8%; and melanoma 2%.

Because of the poor prognosis of invasive proximal urethral cancers in both

men and women, consideration should be given to multimodality therapy.

10.Survival in patients with invasive urethra cancer does not appear to be correlated with histologic type.

11.Causes associated with subsequent development of urethral malignancy in females include chronic irritation or urinary tract infections; proliferative lesions such as caruncles, papillomas, adenomas, and polyps; leukoplakia of the urethra; parturition; and human papillomavirus infection.

12.Radiation therapy alone, as with surgical excision, is often sufficient to control small lesions in the distal urethra.