Carcinoma in situ in urethral diverticulum: pitfalls of marsupialization alone

Urethral diverticulum carcinoma in females-a case series and review of the English and Japanese literature

The aims of our study were to describe our case series of three urethral diverticulum carcinomas (UDC) in women and to review the literature on UDC in females to determine patient characteristics, presenting symptoms and outcomes along with optimal investigations and treatment modalities. A literature search was performed utilizing Medline, EMBASE and the Cochrane library for all papers including case reports on UDC in women published to date. The results along with those of our three cases are detailed. A total of 126 cases of UDC in women have been reported; 75% adenocarcinoma (Adenoca), 15% transitional cell carcinoma (TCC) and 10% squamous cell carcinoma (SCC). Median age at presentation was 53 years (range, 14-81 years). The commonest presenting symptoms were bleeding and retention. Cystoscopy, MRI and trans-urethral biopsy were the commonest methods of diagnosis. Treatment was radiotherapy +/- chemotherapy alone in 21%, local excision +/- radiotherapy in 44%, urethrectomy in 3% and anterior exenteration +/- radiotherapy in 32%. At last follow-up 63% were alive and well, 10% were alive with recurrent cancer and 25% had died from their disease. UDC is rare in women. It is predominantly adenocarcinoma. There is no established treatment and survival is at best moderate. An international registry and consensus on management is needed if this is to be improved.

Carcinoma in female urethral diverticulum: case reports and review of management

We report on 4 women ages 31 to 65 years with adenocarcinoma of urethral diverticulum. One patient presented with metastatic disease and died after refusing post-radiation surgery. The other 3 women were without evidence of disease 9 to 44 months after diverticulectomy with radiation (1) or radical surgery (2). Review of our 4 cases and 64 cases documented in the literature showed that irritative voiding symptoms and hematuria were the most common findings. A palpable urethral mass was described in only 56% of reported cases but was observed in all of our patients, with the smallest mass measuring 2 x 2 cm. Urethroscopy with biopsy is the most important diagnostic test. Aggressive treatment is appropriate in most patients, since local recurrence has been documented in 44% of those treated by diverticulectomy and/or radiation.

Urethral diverticular carcinoma

BACKGROUND

Urethral diverticular carcinoma is an unusual finding in a urologic lesion commonly found in female patients.

METHODS

This report presents 6 new cases and reviews the other 53 cases in the English literature.

RESULTS

Adenocarcinoma occurs more frequently than transitional and squamous cell cancers combined.

CONCLUSION

The prognosis of the former is more favorable. In general, radical therapy is recommended. However, in some instances of localized disease, and with careful follow-up, a more conservative approach might be attempted.

Adenocarcinoma arising in female urethral diverticulum

Cancer arising from a female urethral diverticulum is rare, and because of its rarity, a review of the medical literature reveals significant nonuniformity in its management. We report an additional 2 cases of this disease, one of which has an even rarer feature of being mucin-producing. The management of our 2 cases is presented in detail and in line with the management of female urethral cancer. From our extensive literature search, diverticulectomy alone showed poor results with the highest rate of recurrence (67%). Extensive surgery, either in the form of cystourethrectomy or anterior exenteration, offered results comparable with those of combined therapy (diverticulectomy and full course of irradiation for early cases; preoperative irradiation followed by cystourethrectomy for late cases). Individualization of radiation treatment and cooperative effort between urologist and radiation oncologist are essential if best results are to be achieved.

Experience with a laterally based vaginal flap approach for urethral diverticulum

We found 15 cases of urethral diverticula in female patients who were evaluated for recurrent urinary tract infection. A voiding cystourethrogram was the most useful investigative technique. All cases were managed by a vaginal approach, using a laterally based flap incision. There were no complications with this easily learned technique, which makes full exposure of the diverticulum easy and covers the urethral defect with intact vaginal wall. Using this technique we have had no delayed healing, fistula formation or incontinence. A history of gonorrhea may have an etiologic role in acquired diverticula.

Postvoid film of intravenous pyelogram in diagnosis of urethral diverticulum

Urethral diverticulum is a correctable cause of lower urinary tract symptoms in women. It has been found to be present in from 1.85 to 4.7 per cent of all females. The postvoid film of the intravenous urogram (IVP) is the simplest and least invasive method available to diagnose urethral diverticula. It should be a routine part of the IVP in women with lower urinary tract symptoms.

Urethral diverticulum in females

Thirteen cases of urethral diverticulum in females are reported. Symptoms were non-specific. Two cases presented with suppuration in previously undiagnosed diverticula. The most important physical sign was palpation of the sac on vaginal examination. Micturating cystourethrography was the most useful investigation. An association with carcinoma makes excision mandatory and in 10 cases this was performed by a vaginal approach. A laterally based flap incision is described which was used in 7 cases without complication. In one case the diverticulum recurred after 5 years and was removed in the same way. Two cases that presented with suppuration were treated by incision and drainage: in one the diverticulum re-formed and the other case was lost to follow-up. The aetiology of the condition is unknown but we believe, on histological evidence, that it is congenital.

Carcinoma within urethral diverticula

Because diagnosis of urethral diverticulum is often elusive the presence of a tumor within the diverticular cavity may be overlooked until it has grown beyond the confines of the diverticulum. A search of the medical records from 1940 to 1975 at the University of California Medical Center in San Francisco and Alta Bates Hospital in Berkeley has revealed only 3 cases of carcinoma within a urethral diverticulum. Two are presented here and the third was reported by Hinman in 1960. The paucity of cases in the literature reflects the rarity of such location for the tumor--or, perhaps, rather its evasive diagnostic nature. Undoubtedly, many cases are unreported but the important message for the clinician is that he suspect a urethral diverticulum (with the possibility of underlying neoplasm) in any patient with unexplained persistent irritative symptoms of the lower genitourinary tract.