Carcinoma of deep male urethra

Urethral cancer: a comprehensive review endorsed by the Global Society of Rare Genitourinary Tumours

OBJECTIVE

To determine the effectiveness and adverse effects of urethrectomy alone or as part of multimodal therapy (MMT).

METHODS

A comprehensive search was conducted across MEDLINE (OVID), EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL) databases, from their inception to the present date. The study cohort comprised individuals aged 16 years and older diagnosed with urethral tumours at any stage who underwent either isolated urethrectomy or urethrectomy as an integral component of MMT.

RESULTS

Ninety-two studies comprising 25 480 patients met the inclusion criteria. Surgical outcomes for urethral cancer vary considerably, with 5-year overall survival (OS) ranging from 10% to 68% based on disease extent, approach, and gender. Radiotherapy (RT) alone provides 5-year OS of approximately 40%. Combined regimens provide better outcomes compared to single modalities, including reduced recurrence and enhanced survival. However, trimodal therapy showed survival benefits only for urothelial subtypes, indicating the need to tailor management according to cancer type. MMT with neoadjuvant chemotherapy prior to surgery demonstrated the most consistent survival gains.

CONCLUSIONS

The management of urethral cancer demands a nuanced, personalised approach, accounting for factors such as tumour location, sex, and tumour stage. MMT combining surgery, chemotherapy and RT has shown the ability to enhance outcomes in advanced disease. More extensive collaborative studies through specialised centres are imperative to advance evidence-based protocols and refine treatment in order to improve survival.

Current Perspectives on the Diagnosis and Management of Primary Urethral Cancer: A Systematic Review

Primary urethral cancer (PUC) is a rare but highly aggressive malignancy that causes malignant urethral obstruction. We conducted a literature review using PubMed to identify original research studies that assessed the diagnosis and management of primary urethral cancer. PUC affects men more than women, is more common in African Americans than Caucasians, and is associated with history of chronic inflammation and irritation of the urinary tract. Patients suspected of PUC should undergo a complete work-up including cystoscopy, magnetic resonance imaging, and biopsy. In men and women, surgical monotherapy ranging from organ-sparing to more radical reconstructive procedures has adequate survival rates for early stage PUC and has been shown to be similarly as effective as radiation monotherapy, while multimodal therapy has become the standard of treatment for advanced stage PUC. Salvage surgery or radiation therapy has been linked with increased survival rates. Nodal involvement at the time of diagnosis is a negative prognosticator and should be treated with multimodal therapy. Further prospective studies with greater sample sizes and standardized clinical trials would allow for greater consistency in evaluating the different treatment modalities for PUC.

Primary Squamous Cell Carcinoma of the Male Proximal Urethra: Outcomes from a Single Centre

BACKGROUND

Primary squamous cell carcinoma (SCC) of the male proximal urethra is an aggressive and rare urogenital malignancy.

OBJECTIVE

To review the surgical management and outcomes for male proximal urethral SCCs within a single centre and to suggest an algorithm for the surgical management of these rare tumours.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective study of patients undergoing surgery for male proximal urethral SCC within a single tertiary academic centre managing rare genital tumours. Ten patients with a histological diagnosis of proximal urethral SCC were identified from an institutional database over a period of 10 yr with a median follow-up of 22.5 mo (standard deviation±25.77 mo).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Pathological staging, surgical treatment, and neoadjuvant and adjuvant treatment were recorded. Complications according to the Clavien-Dindo classification and overall survival rates were recorded. Kaplan-Meier curves were used for overall survival.

RESULTS AND LIMITATIONS

A total of 10 patients were identified of whom eight underwent panurethrectomy and radical prostatectomy. Radical inguinal lymphadenectomy was performed in five patients, which confirmed bilateral metastatic disease. Perioperative complications were reported in six patients (Clavien I and II). Within 6 mo of surgery, 90% of patients developed distant metastatic disease. Nine patients died of urethra cancer during the follow-up. One patient is still on follow-up. The median overall follow-up was 13.92 mo (range: 5-91 mo). At 5 yr, cancer-specific/overall survival was 10%. A limitation of this study is the retrospective design, which is unavoidable for such a rare disease.

CONCLUSIONS

Radical surgery allows local disease control, but despite neo/adjuvant treatment, proximal urethral SCC is associated with poor survival outcomes and progression to distant metastatic disease within 6 mo.

PATIENT SUMMARY

Proximal urethral squamous cell carcinoma is a rare cancer in men which is often detected late. Patients often present with problems such as voiding, urethral bleeding, or a palpable mass. Aggressive surgery allows local control, but despite this the overall survival is poor. Adjuvant and neoadjuvant radiochemotherapy can improve survival. Multicentric randomised trials are needed to identify the correct treatment modality.

A Challenging Surgical Approach to Locally Advanced Primary Urethral Carcinoma: A Case Report and Literature Review

Primary urethral carcinoma (PUC) is a rare and aggressive cancer, often underdetected and consequently unsatisfactorily treated. We report a case of advanced PUC, surgically treated with combined approaches.A 47-year-old man underwent transurethral resection of a urethral lesion with histological evidence of a poorly differentiated squamous cancer of the bulbomembranous urethra. Computed tomography (CT) and bone scans excluded metastatic spread of the disease but showed involvement of both corpora cavernosa (cT3N0M0). A radical surgical approach was advised, but the patient refused this and opted for chemotherapy. After 17 months the patient was referred to our department due to the evidence of a fistula in the scrotal area. CT scan showed bilateral metastatic disease in the inguinal, external iliac, and obturator lymph nodes as well as the involvement of both corpora cavernosa. Additionally, a fistula originating from the right corpus cavernosum extended to the scrotal skin. At this stage, the patient accepted the surgical treatment, consisting of different phases. Phase I: Radical extraperitoneal cystoprostatectomy with iliac-obturator lymph nodes dissection. Phase II: Creation of a urinary diversion through a Bricker ileal conduit. Phase III: Repositioning of the patient in lithotomic position for an overturned Y skin incision, total penectomy, fistula excision, and "en bloc" removal of surgical specimens including the bladder, through the perineal breach. Phase IV: Right inguinal lymphadenectomy.The procedure lasted 9-and-a-half hours, was complication-free, and intraoperative blood loss was 600 mL. The patient was discharged 8 days after surgery. Pathological examination documented a T4N2M0 tumor. The clinical situation was stable during the first 3 months postoperatively but then metastatic spread occurred, not responsive to adjuvant chemotherapy, which led to the patient's death 6 months after surgery.Patients with advanced stage tumors of the bulbomembranous urethra should be managed with radical surgery including the corporas up to the ischiatic tuberosity attachment, and membranous urethra in continuity with the prostate and bladder. Neo-adjuvant treatment may be advisable with the aim of improving the poor prognosis, even if the efficacy is not certain while it can delay the radical treatment of the disease.

Management of advanced primary urethral carcinomas

Primary urethral carcinoma (PUC) is a rare malignancy accounting for <1% of genitourinary cancers, with a predilection for men and African-Americans. The sites and histology of urethral carcinoma vary by gender and anatomical location. Squamous cell carcinoma is most common among both genders but adenocarcinomas are noted in 15-35% of cases among women. Obstructive or irritative symptoms and haematuria are common modes of presentation. Clinical evaluation includes cystourethroscopy with biopsy and examination under anaesthesia. Magnetic resonance imaging provides a highly effective method to image the primary tumour while defıning the potential involvement of surrounding structures. Most tumours are localised, with regional metastases to nodal sites seen in up to 30% of cases in both genders, while distant metastases at presentation are rare (0-6%), but occur in up to 40% of cases with recurrent disease. Among men, the two most important prognostic factors are disease location and stage. Low-stage tumours (T1-2) and tumours involving the fossa navicularis or the penile urethra have a better prognosis than higher stage tumours (>T2 or N+) and lesions involving the bulbomembranous urethra. In women, in addition to stage and location, the size of the tumour has also prognostic implications. While surgery and radiation therapy (RT) are of benefit in early stage disease, advanced stage PUC requires multimodal treatment strategies to optimise local control and survival. These include induction chemotherapy followed by surgery or RT and concurrent chemoradiation with or without surgery. The latter strategy has been used successfully to treat other human papillomavirus-related cancers of the vagina, cervix and anus and may be of value in achieving organ preservation. Given the rarity of PUC, prospective multi-institutional studies are needed to better define the optimal treatment approach for this disease entity.

Prognostic factors in male urethral cancer

BACKGROUND

Male urethral cancer is a rare neoplasm, with the published literature consisting of small single-institution retrospective series. As such, there is no objective analysis of prognostic factors and treatment outcome. The author sought to use the population-based Surveillance, Epidemiology, and End Results (SEER) database to evaluate prognostic factors in male urethral cancer.

METHODS

From 1988 to 2006, 2065 men were identified in the SEER database as having primary urethral cancer. Median follow-up was 2.5 years. Cancer-specific and overall survival was computed using the Kaplan-Meier method, and Cox proportional hazards analysis was used to evaluate patient age at diagnosis, year of diagnosis, race, histologic type, grade, T stage, nodal status, M stage, extent of surgery, and type of radiation as potential significant independent predictors of survival.

RESULTS

Overall survival at 5 and 10 years was 46.2% (95% confidence interval [CI], 43.9-48.6%) and 29.3% (95% CI, 26.6-32.0%), respectively, whereas cancer-specific survival at 5 and 10 years was 68.0% (95% CI, 65.5-70.5%) and 60.1% (95% CI, 57.0-63.2%), respectively. Advanced age, higher grade, higher T stage, systemic metastases, other histology versus transitional cell carcinoma (TCC), and no surgery versus radical resection were predictors of death and death from disease, whereas adenocarcinoma was associated with a lower likelihood of death and death from disease as compared with TCC. In addition, nodal metastasis was a predictor of death. Surgery had a better outcome than radiation for stage T2 -T4 nonmetastatic disease.

CONCLUSIONS

Age, grade, TNM stage, histology, and extent of surgery were predictive of overall and cancer-specific survival.

Surgery for urethral cancer

Primary urethral cancers represent less than 1% of genitourinary malignancy. Given this is an uncommon disease, there are limited data to guide diagnostic and treatment strategies. Surgical extirpation remains the standard for most patients, with the addition of chemotherapy and radiation therapy in select patients. The surgical approach to urethral cancer depends largely on the location and extent of the tumor.

Carcinoma of the urethra: radiation oncology

Urethral cancer is a rare but aggressive neoplasm. Early-stage distal lesions can be successfully treated with a single modality. Results for definitive radiotherapy using either or both external beam radiation therapy and brachytherapy have shown excellent cure rates in men and women. The primary advantage of radiotherapy is organ preservation. Advanced tumors, however, have poor outcomes with single modality treatment. Results have been improved using a combination of radiotherapy and chemotherapy, chiefly 5-fluorouracil and mitomycin C. Although literature is limited to case reports because of the rarity of the disease, the markedly improved results compared with older results of surgery with or without radiation warrant consideration.

Coordinated chemoradiation therapy with genital preservation for the treatment of primary invasive carcinoma of the male urethra

PURPOSE

We evaluated the efficacy of a combined chemoradiation therapy protocol for the primary treatment of primary invasive carcinoma of the male urethra.

MATERIALS AND METHODS

From January 1991 to December 2006, 18 patients with invasive carcinoma of the male urethra referred to our institution were treated with a chemoradiation therapy protocol, consisting of 2 cycles of 5-fluorouracil (1,000 mg/m(2)) on days 1 to 4 and days 29 to 32, and mitomycin-C (10 mg/m(2)) on days 1 and 29 with concurrent external beam radiation therapy (45 to 55 Gy in 25 fractions during 5 weeks) to the genitalia, perineum, and inguinal and external iliac lymph nodes. Kaplan-Meier curves were constructed to assess overall, disease specific and disease-free survival.

RESULTS

The stage and node distribution was T2N0 in 2 patients (11%), T3N0 in 8 (44%), T4N0 in 2 (11%), TXN1 in 1(6%) and TXN2 in 5 (28%). The most prevalent histology was moderately (7 of 18 patients or 39%) or poorly (10 of 18 or 56%) differentiated squamous cell carcinoma (17 of 18 or 95%). Overall 83% (15 of 18) of the patients had a complete response to the primary chemoradiation therapy protocol, and the 5-year overall and disease specific survival rates were 60% and 83%, respectively. Five-year disease-free survival rates after chemoradiation therapy and after chemoradiation therapy with salvage surgery were 54% and 72%, respectively. The 3 nonresponders died of disease after undergoing salvage surgery and 5 of the 15 complete responders (30%) had recurrence. Complex urethral reconstruction was required in 3 of 10 patients (30%) who had prolonged disease-free survival.

CONCLUSIONS

The chemoradiation therapy protocol is an alternative primary treatment modality for invasive urethral carcinoma. It enables an unprecedented potential for organ preservation.

Clinical outcome of 36 male patients with primary urethral carcinoma: a single center experience

AIM

Retrospective analysis of male urethral carcinoma to assess the best therapeutic approach to the management of this tumor.

METHODS

A review of 36 cases of male urethral carcinoma diagnosed and treated at our center was performed. Clinical features, treatment modality and outcomes were analysed.

RESULTS

The overall median survival time was 55.16 months. The 5-year overall and disease-free survival rate for the cohort was 49% and 23%, respectively. The 5-year survival is 67% for low-stage versus 33% for high-stage tumors and is significantly different (P = 0.001). The survival was 72% for tumors of the distal urethra versus 36% for tumors of the proximal, with a P-value of 0.02.

CONCLUSION

The tumor location and clinicopathological stage were the most important predictors of the disease-free and overall survival. Multimodal approach is necessary for achieving local control especially for proximal and higher stage tumors.

Urethral Reconstruction after Total Penectomy for Urethral Cancer

A 59-year-old white man developed a ventral ulcer with irregular limits in the middle portion of the penis. The result of the pathologic analysis was compatible with invasive squamous cell urethral carcinoma. A total penectomy was performed. In these cases, the usually recommended urinary diversion is perineal urethrostomy. However, due to the specifications of the case, perineal urethrostomy could not be performed. The literature did not offer any other alternative for patients with this same condition. Therefore, a urethral reconstruction using a groin skin flap had to be performed.

[Ureteral adenocarcinoma in men: a case report]

Adenocarcinoma of urethra is a rare tumour, which occurs more often in female than in male. The localizations on bulbomenbranous urethra, most frequent, have worse prognostic than those of penile urethra. Because of scarcity of these tumours there is not therapeutic consensus. The treatment is based on the tripod surgery, more or less mutilating, chemotherapy and radiotherapy associated or managed in a separate way. We report the case of a young patient with adenocarcinoma of the posterior urethra treated by a protocol of radio-chemotherapy.

[Primary adenocarcinoma of the male urethra. A case report]

Primary adenocarcinoma of the male urethra is very uncommon, accounts for 5% of primary urethral cancers. All types of urethral carcinomas account for less than 1% of urinary malignancies in man. The prognosis remains poor despite the wide surgical treatment. The place of chemotherapy combined with radiotherapy must be defined by other studies. We report a case of primary locally advanced adenocarcinoma arising in the bulbo-membranous urethra. The patient was 29 years old, without any previous history of venerian disease. He was treated by combined external beam radiotherapy (total dose 67Gy) and chemotherapy (Cisplatinum). A marked reduction of tumor volume has been noted but the patient died because of the appearance of bone metastasis which failed to the systemic therapy.

Management of primary urethral cancer

OBJECTIVES

To determine the best therapeutic approach for treatment of patients with urethral cancer according to tumor location and clinical-pathologic stage.

METHODS

A retrospective review of 21 consecutive patients diagnosed with primary urethral carcinoma was performed. Clinical-pathologic staging, treatment modality, and outcome were analyzed.

RESULTS

The overall survival rate was 62%. In patients with clinical Stage Ta-2N0M0 tumors, 8 of 9 patients (89%) are free of disease compared to 5 of 12 patients (42%) with Stage T3-4N0-2M0 tumors (P = 0.03). Best treatment outcome for patients with Stage T3 disease or higher was obtained when multimodality therapy (neoadjuvant chemotherapy and radiation therapy with or without surgery) was administered, with a disease-free survival rate of 60%.

CONCLUSIONS

Clinical-pathologic stage was a strong predictor of disease-free survival rate. For patients with Ta-2N0M0 tumors, multimodality therapy may not be required. Conversely, best treatment outcomes in patients with T3-4N0-2M0 tumors are obtained by administering a multimodal therapy combining chemotherapy and radiation therapy with surgical resection.

Primary adenocarcinoma of the urethra with metastasis to the glans penis: successful treatment with chemotherapy and radiation therapy

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in males. A 54-year-old man with primary adenocarcinoma of the urethra with metastasis to the glans penis and lymphadenopathy in the right groin was treated successfully by combined chemotherapy (5-fluorouracil and cis-platinum) and external beam radiotherapy (total dose of 75 Gy). Short-term remission using multimodal approach with penile preservation was achieved in the present case.

Therapy and prognosis for male anterior urethral carcinoma: an update

OBJECTIVE

The scarcity of reports evaluating the effect of current treatment strategies for male urethral carcinoma has prompted a review of our recent experience. Since our last report (1980), we have seen 23 patients with this disease.

METHODS

We performed a retrospective chart review of 23 patients seen in our institution between 1979 and 1990 with this type of cancer.

RESULTS

Fifty-two percent of our patients are alive without evidence of disease, after a mean follow-up of fifty months (range, 5 to 156 months). Treatment analysis indicates that distal urethrectomy and partial penectomy are adequate in controlling local disease for tumors arising in the fossa navicularis and penile urethra, respectively, and that en bloc excision of the penis, scrotum, prostate, and bladder together with resection of the inferior pubic rami, using myocutaneous flaps to cover the surgical defect, can provide long-term disease-free survival for patients whose tumor originates in the bulbomembranous urethra. Use of cisplatin-based chemotherapy resulted in a prolonged survival for patients who presented with metastatic disease.

CONCLUSIONS

We conclude that the prognosis for patients with urethral carcinoma has improved, and some of the patients are having a prolonged disease-free survival due, in part, to more effective local and regional control and improved chemotherapy.

Carcinoma of male urethra: management of locally advanced disease with combined chemotherapy, radiotherapy, and penile-preserving surgery

Squamous cell carcinoma of the urethra is a rare urologic malignancy. In spite of aggressive management with radical and often times disfiguring surgery and/or radiation therapy, prognosis remains poor. Initial success in treating squamous cell carcinoma of the esophagus and anal canal has been reported with a combined radiation and chemotherapy protocol. In hopes for improving the treatment outcome for patients with squamous cell carcinoma of the urethra, we have applied the new combination chemotherapy/radiation therapy protocol. Herein, we report the successful downstaging (clinical Stage C to pathologic Stage TO) and treatment of squamous cell carcinoma of the anterior urethra with combination chemotherapy/radiation therapy. This was followed with penile-preserving surgery to document local control of disease and to avoid the morbidity of a radical disfiguring operation.

Primary carcinoma of the distal male urethra: a case treated with lymphadenectomy and interstitial radiation therapy

We report a case of primary squamous cell carcinoma of the distal male urethra with a single inguinal node metastasis. Treatment consisted of unilateral pelvic and inguinal lymphadenectomy, and a combined course of external beam and interstitial radiation therapy to the distal urethra and penis by the Henschke modification of the Paris technique.

Primary squamous cell carcinoma of the male urethra: nuclear deoxyribonucleic acid ploidy studied by flow cytometry

Flow cytometry analysis was performed on 30 primary male urethral squamous cell carcinoma specimens. Nuclei were extracted from paraffin-embedded archival material and isolated nuclei were stained with propidium iodide. Bulbomembranous urethral tumors had a higher incidence of abnormal deoxyribonucleic acid ploidy patterns than penile urethral tumors (69 and 29 per cent, respectively). Of the tumors exhibiting a deoxyribonucleic acid diploid pattern and an abnormal (deoxyribonucleic acid tetraploid or aneuploid) histogram 18 and 93 per cent, respectively, showed tumor progression (p less than 0.001). None (0 per cent) of the low grade (grade 1 or 2) tumors with a deoxyribonucleic acid diploid pattern developed local recurrence or distant metastases, whereas 90 per cent of the low grade tumors with an abnormal deoxyribonucleic acid pattern progressed (p less than 0.002). Patients with tumors exhibiting deoxyribonucleic acid diploid ploidy had 5 and 10-year rates free of disease of 85 per cent. In contrast, patients with tumors with abnormal deoxyribonucleic acid ploidy patterns had 5 and 10-year rates of 20 and 0 per cent, respectively (p less than 0.001). Determination of deoxyribonucleic acid ploidy pattern by flow cytometry provides important prognostic information for male patients with primary squamous cell carcinoma of the urethra.