Urethral Cancer

Prof RR Unit
Kathirvel Kumaran
 Anatomy of Male Urethra
Male
 Prostatic
 Membranous Posterior
 Bulbar
 Penile Anterior
Epithelium
 Prostate – Transitional
 Membranous, bulbar and
penile – pseudostratified
columnar
 Meatus and fossa navicular –
keratinized stratified
squamous
 Anatomy of female urethra
Female Female
 4 cm in length
 Placed behind the symphysis
pubis,
 Direction is obliquely
downward and forward;
 Its diameter when undilated is
about 6 mm
 External orifice is situated
directly in front of the vaginal
opening and about 2.5 cm.
behind the glans clitoridis.
 Nodes
Male
 Fossa/pendulous urethra -
superficial inguinal nodes
 Bulbar/membranous/prosta
tic urethra - iliac,obturator
and presacral nodes
 May be crossover at
prepubic lymphaticplexus
Almost always metastatic disease 20-50%
Female
 DISTAL (anterior) urethra
and labia -superficial and
deep INGUINAL nodes
 PROXIMAL (posterior)
urethra – deep PELVIC
nodes - iliac, obturator,
presacral and para-aortic
lymphatic chains
 EPIDEMIOLOGY
 RARE
 F:M - 4:1 .
 Only urological cancer common in female.
 Sixth decade of life
 Urethral cancer invade locally an metastasize to
nodes early compared to sequential spread in penile
cancer .
 Etiology
 Chronic irritation and infection
 24-76% associated with stricture in male
 HPV 16/18.
 Pathology
Male Female
 80% Squamous cell ca.  60% Squamous cell ca.
 15% Transitional cell ca.  20% Transitional cell ca.
 5% Adeno ca.  10% Adeno ca.
 8% Undiffrentiated
Site  2% melanoma
 Prostatic 90% transitional
10% squamous .
 Penile 90% squamous &
10% transitional ca.
 Pathology
Male Female
 Bulbomembraneous – 60%  Clear cell – urethral
 Penile - 60% diverticulum
 Prostatic -10%
 Clinical features
 Proximal - obstructive symptoms
 Distal - urethral bleeding and palpable mass
 Perineal pain, Stream disturbances , fistula
 New onset of urethrorrhagia or urethral stricture
without trauma or venereal disease –suspect
uretheral ca in Males

 Bimanual exam
 Lymph node survey (palpable inguinal nodes)
 Investigation
 Urine cytology- transitional ca
 Urethrogram -stricture, luminal
filling defect, fistula)
 Cystourethroscopy +/- biopsy
 CT or MRI
 +/-Bone scan (for disseminated disease)
 MRI

 Mass with decreased signal

intensity relative to the
normal corporal tissue at
both T1- and T2-weighted
 MR imaging can depict
invasion of the corpora
cavernosa and is useful for
demonstrating tumor
location and size and local
staging
Staging
Staging
Staging
Stage grouping
 Treatment
 Surgery is the mainstay of Treatment.
 Anterior urethral ca more amenable for surgery.
 Posterior often presents with extensive local
invasion and distal metastasis.
 Anterior good prognosis than posterior .
 Male- Site Specific treatment
Distal Urethra
 Ta, Tis & T1- transurethral resection and follow up.
 T2- partial penile amputation if 2 cm clearance
 Total penile amputation
 Penile sparing approach ( Uretherectomy )- high
failure.
 No role for prophylactic groin dissection
 Male- Site Specific treatment
Bulbomembranous
 Ta, Tis & T1- fulguration/ segmental resection and
end to end anastomosis.- rare such cases.
 T2, T3- Radical cystoprostatectomy with enbloc
penectomy and pelvic lymphadenectomy .
 Male- Site Specific treatment
Prostatic urethra
 Ta, Tis & T1- fulguration/ segmental resection and
end to end anastomosis.- rare such cases.
 T2, T3- Radical cystoprostatectomy with enbloc
penectomy and pelvic lymphadenectomy .( poor
survival 5yr 32%)
 T3-4 N1-3 - Neoadjuvant with MVAC consolidate
with surgery / radiation
 Female- Site Specific treatment
Distal :
 Ta, Tis & T1-local excision and spatula tion.
 Small T2- Brachytheraphy

Proximal :
 Multimodal approach preferred
 Neo-adj chemo (5-FU with mitomycin) and
Pre-op RT followed by surgery ( Anterior Pelvic
Exenteration)
 Prognosis
DISTAL ( Anterior ) PROXIMAL ( Posterior )
 Often low stage  Often high stage
 Accessible  Distal metastasis
 amenable to local excision common
 Multimodal treatment
 Major surgery.
 Radiotheraphy
 Low stage cure upto 75%
 50-60Gy brachy or 45 Gy EBRT with boost 20-25 Gy
for distal tumors
 Proximal urethral cancer with bladder neck invasion
and bulky tumors – requires both EBRT with Brachy.
 Complications 20% - uretharal stricture and stenosis ,
fistulae , incontinence and bowel obustruction
 Summary
 Rare tumor requires high index of suspicion.
 Chronic irritation and infection risk factors.
 Proximal and distal presents as late and early
respectively
 Surgery primary modality of treatment
 Anatomical location and stage important for local
control and survival
Thank u