Urethra-Urethral Cancer

Front 1

Is Urethral cancer more common in men or women?

Back 1

*Women - rate of 4 to 1

*Only urological malignancy that is more common in women than in men.

Front 2

What is the typical age distribution that women with urethral cancer are diagnosed with this?

Back 2

*50-60s.

Front 3

Ddx for the etiology of urethral cancer in women?

Back 3

*leukoplakia, chronic irritation, caruncles, polyps, parturition, HPV or other viruses

*Diverticulum - may cause increased risk.

Front 4

What percentage of urethral cancer in women arises in a diverticulum?

Back 4

*Around 5%

Front 5

How do you evaluate a woman w/ suspected urethral carcinoma?

Back 5

*Cystourethroscopy
*CT or MRI abdomen & pelvis
*EUA
*C-xray

Front 6

What is the anatomy of the female urethra, lymphatic drainage, etc.?

Back 6

*Broken up into distal 1/3 & proximal 2/3.

*Anterior (distal) - can be removed & still maintain continence, lymphatics drain to superficial & then deep inguinal lymph nodes, stratified squamous epithelium

*Proximal (Posterior) - transitional epithelium, drains to external, internal, & obturator node packets.

Front 7

What is the most common histological subtype of urethral carcinoma in the female, what other subtypes are there?

Back 7

*Squamous cell carcinoma - 50-70%

*2nd & 3rd are TCC & adenocarcinoma

*Other rarer cell types include lymphoma, neuroendocrine carcinoma, sarcomas, paragangliomas, melanoma, and metastasis

Front 8

What is different about the histological subtype of urethral carcnioma in diverticula in women?

Back 8

More commonly adenocarcinoma or increaed incidence of adenocarcinoma, still might be more common to be SCC...not sure.

Front 9

What is advanced female urethral cancer?

Back 9

*Tumors in a proximal location,
*Lesion that encompasses the entire urethra
*Locally invasive lesion that involves external genitalia, vagina, or bladder.

Front 10

What if a woman gets urethral recurrence after orthotopic neobladder for bladder cancer?

Back 10

*Urethrectomy & 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.
*Conversion to a cutaneous urinary conduit with use of reconfigured bowel from the existing orthotopic diversion is another option.

Front 11

If a woman has bladder cancer at her bladder neck does that preclude her from an orthotopic urinary diversion?

Back 11

*Prospective study has revealed that although all patients with urethral TCC on final path of the cystectomy specimen had involvement of the bladder neck, but more than 60% of women with bladder neck involvement had no evidence of urethral transitional cell carcinoma
*so Intraoperative frozen-section analysis of the urethral stump has been subsequently espoused by some authors to determine the feasibility of urethra-sparing cystectomy and orthotopic diversion.

Front 12

Is it common for a woman to get a urethral recurrence after undergoing cystectomy for bladder cancer?

Back 12

No extremely rare, around 1% probably

Front 13

What is the treatment for proximal urethral cancers in women?

Back 13

*Remeber that most of these are advanced & higher stage.
*Must involve multi-modal therapy
*Surgical excision includes anterior exoneration w/ wide excision at the urethra getting good margins & including anterior vaginal wall & poss external genitalia if involvement.
*Lymph node dissection similar to bladder Ca down to node of Clouquet
*Many recomend a combination of intra-operative radiation & adjuvant radiation +/- chemo.

Front 14

What is the treatment of choice for T2 uerthral cancer in men that has invaded into the corpus spongiosum?

Back 14

Partial penectomy with a 2-cm negative margin is the treatment of choice for tumors infiltrating the corpus spongiosum and localized to the distal half of the penis. Excellent local control after this procedure has been documented

Front 15

Is there a benefit to inguinal lymph node dissection prophylactically for urethral cancer in men?

Back 15

*Ilioinguinal lymphadenectomy is indicated in the presence of palpable inguinal lymph nodes without evidence of metastatic disease. Benefit from prophylactic inguinal lymph node dissection has not been demonstrated in urethral cancer.

Front 16

Is there a role for local excision in urethral cancer of the bulbomembranous urethra?

Back 16

There is for superficial disease that is caught early, but this is rare. have been treated successfully by transurethral resection or by segmental excision of the involved urethral segment with an end-to-end anastomosis

*Most likely it would be invasive and need radical excision. Poor survival figures have been recorded for all forms of treatment, but it appears that radical excision offers the best opportunity for long-term disease control and the lowest incidence of local recurrence. Radical cystoprostatectomy, pelvic lymphadenectomy, and total penectomy are usually required

Front 17

In a woman with invasive carcinoma of the proximal urethra, the primary lymphatic site for metastatic disease is what?

Back 17

The anterior distal urethra and labia drain into the superficial and then the deep inguinal nodes, while the posterior (proximal) urethra drains primarily into the external iliac, and then secondarily to the hypogastric and obturator lymph nodes.

Front 18

What is the effect of finasteride on serum and intraprostatic testosterone?

Back 18

There are two isoenzymes of 5-alpha-reductase (type I and type II). Dutasteride blocks both, Finasteride blocks only type II. Therefore DHT levels are decreased in the prostate thus causing increased levels of intraprostatic and serum testosterone.

Serum DHT is typically decreased by about 85% but not to castrate levels.

Front 19

In a woman with urethral cancer of the proximal urethra where is the primary site for metastatic disease or lymphatic drainage?

Back 19

the distal urethra will drain to teh superficial and then deep inguinal nodes wheras the proximal urethra will first drain to the external illiac nodes.

Front 20

A 76 year old woman has urethral bleeding and a 0.7cm mass at the urethral meatus. Biopsy is positive for stage A scc of the urethra. No inguinal lymphadenopathy is present and meatstatic evaluation is negative. What is the appropriate treatment for this patient?

Back 20

*The recommended treatment of choice for urethral cancer confined to the distal urethra in a female is distal urethrectomy. You may have to perform a partial vulvectomy for good surgical margins. There is no role for prophylactic lymph node dissection in this patient it can however cause significant harm.

Front 21

Back 21

Front 22

Name three risk factors for urethral carcinoma.

Back 22

Frequent STDs (especially HPV16)
Urethritis
Urethral stricture

Front 23

What are the most common locations of urethral carcinoma?

Back 23

Bulbomembranous urethra (60%)
Pendulous urethra (30%)
Prostatic urethra (10%)

Front 24

How does male urethral carcinoma spread?

Back 24

Direct invasion, vascular as well as nodal (superficial/deep inguinal nodes) although posterior urethral lesions may spread to the pelvic lymph nodes first

Front 25

What is the general treatment for urethral carcinoma?

Back 25

Surgical excision with partial penectomy and 2cm margins (especially for anterior urethral lesions). Posterior lesions are often associated with extensive local invasion and distant metastasis.

Front 26

When should inguinal lymphadenectomy be performed for urethral carcinoma?

Back 26

Only in the presence of palpable inguinal lymph nodes without evidence of metastatic disease

Front 27

n cases of urethral carcinoma after orthotopic neobladder, can one use the existing bowel to reconfigure this into a cutaneous ileal conduit?

Back 27

Yes- This can be done with blood supply left intact

Front 28

Is primary urethral carcinoma more common in men or women?

Back 28

Women (4:1) but it is still rare (0.2% of all female cancers)

Front 29

Risk factors for urethral carcinoma in women include:

Back 29

Leukoplakia, chronic irritation, caruncles, polyps or urethral diverticulum, parturition, HPV infection or other viral infection

Front 30

How is the female urethra anatomically divided and why is this important in surgical planning?

Back 30

Anterior urethra is the distal third and Posterior is the proximal two thirds
The distal third may be excised while maintaining urinary continence

Front 31

Which urethral carcinoma has a better prognosis, proximal or distal? What is its cure rate with local excision alone?

Back 31

Distal- 70-90% cure with local excision alone

Front 32

When does one perform a lymphadenectomy in female urethral carcinoma?

Back 32

in cases of positive inguinal or pelvic lymphadenopathy without distant mets or patients who develop regional adenopathy during surveillance