European Association of Urology Guidelines on Primary Urethral Carcinoma-2020 Update

Definitive treatment for primary urethral cancer: A single institution's experience with organ-preserving brachytherapy

BACKGROUND

Radical urethectomy ± cystectomy has long represented the standard of care for rare primary urethral cancer (PUC). With our analysis, we want to demonstrate the efficacy and safety of brachytherapy (BT) of urethra for organ preservation.

MATERIALS AND METHODS

We analyzed treatment procedures and results of 3 patients with PUC, which have been treated in our department between 2011 and 2020 with brachytherapy. One male patient underwent brachytherapy with chemoradiotherapy after transurethral resection (TUR). Brachytherapy has been performed as high-dose-rate (HDR) boost with a cumulative dose of 8 Gy (9.3 Gy EQD2-α/β = 10 Gy). The 2 further female patients have been treated with sole pulsed-dose-rate (PDR) brachytherapy with a total dose of 49.9 Gy (50.3 Gy EQD2-α/β = 10 Gy) and 62.2 Gy (64.6 Gy EQD2-α/β = 10 Gy).

RESULTS

Median follow-up was 103 months (41-153). No local recurrence occurred and all patients are still alive. For the male patient we documented Grade 3 cystitis. As late side effects the pre-existing Grade 2 incontinence worsened to Grade 3. Among female patients one developed Grade 3 vaginal synechiae. There was no Grade ≥4 toxicity.

CONCLUSION

Brachytherapy in PUC is a feasible and promising option with high local control rate and tolerable toxicity. It provides a good alternative to surgery for organ preservation in selected patients.

Mullerian Duct-Type Clear Cell Adenocarcinoma of the Urethra in a Woman Presenting As Groin Swelling

Primary Mullerian duct-type clear cell adenocarcinoma of the urethra is a rare clinical entity with a varied clinical presentation. This can be diagnosed only with a high index of suspicion. Clinical examination, biopsy, and immunohistochemistry are essential for diagnosis. Management will need a multimodal approach with a combination of chemotherapy and surgical excision.

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.

Ultrasonographic features of female urethral caruncle: a retrospective study of 20 patients

Female urethral caruncle is the most common urethral mass in postmenopausal women, yet there is a lack of studies on its imaging. The aim of this study was to provide a summary of the clinical and ultrasound features as well as the precise location of female urethral caruncle. This study reviewed the clinical and ultrasonographic records of 20 consecutive women with pathologically confirmed urethral caruncle. Data on patient demographics, symptoms, and transperineal and transrectal ultrasound imaging features, including location, shape, margin, size, blood flow, and inner echo of the caruncle, were extracted. Each patient presented with only one mass at the urethral meatus. Most caruncles were located on the posterior lip (75%) of the urethra, presenting as oval (80%), mixed-echoic (50%), or hypo-echoic (40%) nodules with abundant linear (40%) or dendritic (60%) blood flow. The average distance between the bladder neck and the cranial end of the masses was 28 mm. Hyper-echogenic spots, cystic echo areas, and macrocalcifications were detected in thirteen caruncles (70%). This study shows that transperineal combined with transrectal ultrasound can be used to assess female urethral caruncle, and its relative location to the urethra can be accurately described, which is helpful for surgeons making preoperative localization and conversations.

Primary urethral carcinoma: Recommendations of the oncology committee of the French Urology Association

Primary urethral carcinoma (PUC) is defined as a tumor process arising within the urethra, with no history of other urinary tract localization or synchronous tumor of the urinary tract. The most common histological types are urothelial carcinoma (UC), squamous cell carcinoma (SCC) and adenocarcinoma (AC). In men, UC predominates, while AC is rare. In women, AC affects around one in two patients, while EC and UC are equally divided between the remaining cases. Diagnosis is often delayed, and requires endoscopic examination with biopsies. MRI is the gold standard for local staging. FDG-PET scan can help in cases of doubt about regional or distant extension. The prognosis remains unfavorable despite aggressive surgical treatment. Multimodal management combining surgery, radiotherapy and chemotherapy appears to improve prognosis in severe forms.

Contemporary conditional cancer-specific survival rates in surgically treated nonmetastatic primary urethral carcinoma

BACKGROUND

We examined the effect of disease-free interval (DFI) duration on cancer-specific mortality (CSM)-free survival, otherwise known as the effect of conditional survival, in radical urethrectomy nonmetastatic primary urethral carcinoma (PUC) patients.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database 2000-2020, patient (age, sex, race/ethnicity, and marital status) and tumor (stage and histology) characteristics, as well as systemic therapy exposure status of nonmetastatic PUC patients were tabulated. Conditional survival estimates at 5-year were assessed based on DFI duration and according to stage at presentation (T1 -2N0 vs. T3-4N0-2).

RESULTS

Of all 512 radical urethrectomy PUC patients, 278 (54%) harbored T1-2N0 stage versus 234 (46%) harbored T3-4N0-2 stage. In 512 PUC patients, 5-year CSM-free survival at initial diagnosis was 61.8%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 85.6%. In 278 T1-2N0 PUC patients, 5-year CSM-free survival at initial diagnosis was 68.4%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 86.9%. In 234 T3-4N0-2 PUC patients, 5-year CSM-free survival at initial diagnosis was 53.8%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 83.6%.

CONCLUSIONS

Although intuitively, clinicians and patients are well aware of the concept that increasing DFI duration improves survival probability, only a few clinicians can accurately estimate the magnitude of survival improvement, as was done within the current study. Such information is crucial to survivors, especially in those diagnosed with rare malignancies, where the survival estimation according to DFI duration is even more challenging.

Disitamab Vedotin plus anti-PD-1 antibody show good efficacy in refractory primary urethral cancer with low HER2 expression: a case report

Primary urethral carcinoma (PUC) has a low incidence, but with high aggressiveness. Most of the patients are found in late stage, with poor prognosis. At present, chemotherapy is still the main treatment for metastatic PUC, but it has limited effect. Here, we report a case of metastatic PUC with low HER2 expression that developed disease progression after multiline therapy including chemotherapy, programmed death-1 (PD-1) inhibitors and multi-targeted receptor tyrosine kinase (RTK) inhibitor. After receiving Disitamab Vedotin(a novel antibody drug conjugate, ADC) and toripalimab (a PD-1 inhibitor), the patient achieved persistent PR, and the PFS exceeded 12 months up to now. Our report indicates that, despite the patient of metastatic PUC has low expression of HER2, it is still possible to benefit from Disitamab Vedotin combined with PD-1 inhibitor, which may reverse the drug resistance of PD-1 inhibitor and chemotherapy to a certain extent. But larger sample studies are needed to determine the efficacy of this treatment strategy and its impact on survival.

Role of inguinal and pelvic lymph node dissection for primary urethral carcinoma: a systematic review

PURPOSE OF REVIEW

Primary urethral carcinoma (PUC) is a rare urologic tumor. There is limited evidence on this entity. This review summarizes the existing evidence on lymph node dissection (LND) in patients with PUC.

RECENT FINDINGS

We performed a systematic search of the PubMed, EMBASE, and Web of Science databases to evaluate the impact of inguinal and pelvic LND on the oncological outcomes of PUC and to identify indications for this procedure.

RESULTS

Three studies met the inclusion criteria. The cancer detection rate in clinically nonpalpable inguinal lymph node (cN0) was 9% in men and 25% in women. In clinically palpable lymph node (cN+), the malignancy rate was 84% and 50% in men and women, respectively. Overall cancer detection rate in pelvic lymph nodes in patients with cN0 was 29%. Based on tumor stage, the detection rate was 11% in cT1-2 N0 and 37% in cT3-4 N0. Nodal disease was associated with higher recurrence and worse survival. Pelvic LND seems to improve overall survival for patients with LND regardless of the location or stage of lymph nodes. Inguinal LND improved overall survival only in patients with palpable lymph nodes. Inguinal LND had no survival benefit in patients with nonpalpable lymph nodes.

SUMMARY

The available, albeit scarce, data suggest that inguinal LND derives the highest benefit in women and in patients with palpable inguinal nodes, whereas the benefit of pelvic LND seems to be more pronounced across all stages of invasive PUC. Prospective studies are urgently needed to further address the prognostic benefit of locoregional LND in PUC.

Reprint of: Female Urethral Carcinoma: A contemporary review of the clinicopathologic features, with emphasis on the histo-anatomic landmarks and potential staging issues

Primary female urethral carcinoma (PUC-F) accounts for less than 1% of all genitourinary malignancies and comprises a histologically diverse group of tumors that are usually associated with poor prognosis. The carcinomas documented at this site include adenocarcinoma (clear cell adenocarcinoma, columnar cell carcinoma, and Skene gland adenocarcinoma), urothelial carcinoma (UCa), and squamous cell carcinoma (SCC). Recent studies have shown adenocarcinomas to be the most common type of primary urethral carcinoma in females. As most of the urethral carcinomas morphologically resemble carcinomas arising from surrounding pelvic organs or metastases, these should be ruled out before making the diagnosis of PUC-F. These tumors are currently staged according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. However, the AJCC system has limitations, including the staging of tumors involving the anterior wall of the urethra. Staging systems like the recently proposed histology-based female urethral carcinoma staging system (UCS) takes into account the unique histological landmarks of the female urethra to better stratify pT2 and pT3 tumors into prognostic groups, that correlate with clinical outcomes including recurrence rates, disease-specific survival and overall survival. Further larger multi-institutional cohorts are however required to validate the results of this staging system. There is very limited information regarding the molecular profiling of PUC-F. Thirty-one percent of clear cell adenocarcinomas have been reported to show PIK3CA alterations, whereas 15% of adenocarcinomas show PTEN mutations. Higher tumor mutational burden and PD-L1 staining have been reported in UCa and SCC. Although multimodality treatment is usually recommended in locally advanced and metastatic disease, the role of immunotherapy and targeted therapy is promising in select PUC-F cases.

Serum organic acid metabolites can be used as potential biomarkers to identify prostatitis, benign prostatic hyperplasia, and prostate cancer

Background

Noninvasive methods for the early identify diagnosis of prostatitis, benign prostatic hyperplasia (BPH), and prostate cancer (PCa) are current clinical challenges.

Methods

The serum metabolites of 20 healthy individuals and patients with prostatitis, BPH, or PCa were identified using untargeted liquid chromatography-mass spectrometry (LC-MS). In addition, targeted LC-MS was used to verify the organic acid metabolites in the serum of a validation cohort.

Results

Organic acid metabolites had good sensitivity and specificity in differentiating prostatitis, BPH, and PCa. Three diagnostic models identified patients with PROSTATITIS: phenyllactic acid (area under the curve [AUC]=0.773), pyroglutamic acid (AUC=0.725), and pantothenic acid (AUC=0.721). Three diagnostic models identified BPH: citric acid (AUC=0.859), malic acid (AUC=0.820), and D-glucuronic acid (AUC=0.810). Four diagnostic models identified PCa: 3-hydroxy-3-methylglutaric acid (AUC=0.804), citric acid (AUC=0.918), malic acid (AUC=0.862), and phenyllactic acid (AUC=0.713). Two diagnostic models distinguished BPH from PCa: phenyllactic acid (AUC=0.769) and pyroglutamic acid (AUC=0.761). Three diagnostic models distinguished benign BPH from PROSTATITIS: citric acid (AUC=0.842), ethylmalonic acid (AUC=0.814), and hippuric acid (AUC=0.733). Six diagnostic models distinguished BPH from prostatitis: citric acid (AUC=0.926), pyroglutamic acid (AUC=0.864), phenyllactic acid (AUC=0.850), ethylmalonic acid (AUC=0.843), 3-hydroxy-3-methylglutaric acid (AUC=0.817), and hippuric acid (AUC=0.791). Three diagnostic models distinguished PCa patients with PROSTATITISA < 4.0 ng/mL from those with PSA > 4.0 ng/mL: 5-hydromethyl-2-furoic acid (AUC=0.749), ethylmalonic acid (AUC=0.750), and pyroglutamic acid (AUC=0.929). Conclusions: These results suggest that serum organic acid metabolites can be used as biomarkers to differentiate prostatitis, BPH, and PCa.

Management of Primary Female Urethral Adenocarcinoma: Two Rare Case Reports and Literature Review

Primary urethral adenocarcinoma in females is an extremely rare malignancy with unclear origin and only a few retrospective cases have been reported. The controversy continues to exist over the origin of primary urethral adenocarcinoma from periurethral glands (which include the Skene's glands), urethritis glandularis or intestinal metaplasia. Herein, we report one case of a 49-year-old female with distal urethral adenocarcinoma who presented with obstructive voiding. Abdominal and pelvic CT scans and chest radiology were unremarkable. Biopsy of the mass confirmed urethral adenocarcinoma. The patient underwent partial ureterectomy and was disease-free at the 2-years follow-up period. We also present another extremely rare case of primary urethral adenocarcinoma with mucinous features in a 58-year-old female who initially complained of external urethral orifice itching with painless urethral bleeding and was treated with local excision. The patient has not received any neoadjuvant or adjuvant therapy, and experienced tumor recurrence, inguinal lymph nodes metastasis, and even local iliopsoas metastasis during over 10-years follow-up. In conclusion, our current study emphasizes the importance of imaging studies and biopsy in making an accurate preoperative diagnosis of this rare disease, and further highlights the role of multimodal therapy. A combination of radiotherapy, chemotherapy and surgery is recommended for the optimal local and distant disease control. Moreover, better medical compliance and regular follow-up are required in these patients.

Granular cell tumors of the urethra

Granular cell tumors (GCTs) are a rare type of mesenchymal tumors that are histologically derived by Schwann cells and rise within soft tissues such as skin and mucosal surfaces. Differentiation between benign and malignant GCTs is often difficult and relies on their biological behavior and metastatic potential. While there are no standard guidelines for management, upfront surgical resection, whenever feasible, is key as a definitive measure. Systemic therapy is often limited by poor chemosensitivity of these tumors; however, accumulating knowledge of their underlying genomic landscape has opened some opportunities for targeted approaches, for example, the vascular endothelial growth factor tyrosine kinase inhibitor pazopanib, which is already in clinical use for the treatment of many types of advanced soft tissue sarcomas.

Pedicled dorsal penile skin tube as neourethra in total penectomy for primary male urethral carcinoma

Background:

The aim of this article is to present our experience of pedicled dorsal penile skin tube as neourethra after radical penectomy due to invasive primary male carcinoma of anterior urethra.

Methods:

This is an observational descriptive study including seven men with primary urethral carcinoma who underwent radical penectomy between 2018 and 2021. Instead of urinary derivation with suprapubic catheter, perineal urethrostomy, or bladder orthotopic/heterotopic reconstruction, patients underwent reconstruction of the anterior urethra with a pedicled dorsal penile skin tube. In brief, before corpora amputation and radical urethrectomy, the dorsal penile skin is preserved to reconstruct the neourethra. The distal end of the skin is anastomosed with the proximal urethral stump (usually membranous urethra) to assure continuity of the urinary tract, without jeopardising urinary continence. Finally, the flap is tubularized with two layers of watertight running sutures.

Results:

Median age was 50 (35–70) years. Histology revealed squamous cell carcinoma in all patients. Almost 100% of patients presented locally advanced (pT3–4, G3) disease and received perioperative chemotherapy (MVAC). The median follow-up was 10 (5–24) months. Median operative time was 230 min (190–315). There were not severe (Clavien–Dindo III–IV) perioperative complications. All patients were able to void in standing position through the reconstructed neourethra. No patients reported post-operative incontinence. Two patients died after 8 and 11 months from surgery.

Conclusion:

This new technique of using the dartos-based dorsal penile skin tube urethroplasty offers the possibility to void in standing position after radical penectomy with no need of urinary derivations.

Level of evidence:

Not applicable.

Female urethral carcinoma: a contemporary review of the clinicopathologic features, with emphasis on the histoanatomic landmarks and potential staging issues

Primary female urethral carcinoma (PUC-F) accounts for less than 1% of all genitourinary malignancies and comprises a histologically diverse group of tumors that are usually associated with poor prognosis. The carcinomas documented at this site include adenocarcinoma (clear cell adenocarcinoma, columnar cell carcinoma, and Skene gland adenocarcinoma), urothelial carcinoma (UCa), and squamous cell carcinoma (SCC). Recent studies have shown adenocarcinomas to be the most common type of primary urethral carcinoma in females. As most of the urethral carcinomas morphologically resemble carcinomas arising from surrounding pelvic organs or metastases, these should be ruled out before making the diagnosis of PUC-F. These tumors are currently staged according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. However, the AJCC system has limitations, including the staging of tumors involving the anterior wall of the urethra. Staging systems like the recently proposed histology-based female urethral carcinoma staging system (UCS) takes into account the unique histological landmarks of the female urethra to better stratify pT2 and pT3 tumors into prognostic groups, that correlate with clinical outcomes including recurrence rates, disease-specific and overall survival. Further larger multi-institutional cohorts are however required to validate the results of this staging system. There is very limited information regarding the molecular profiling of PUC-F. Thirty-one percent of clear cell adenocarcinomas have been reported to show PIK3CA alterations, whereas 15% of adenocarcinomas show PTEN mutations. Higher tumor mutational burden and PD-L1 staining have been reported in UCa and SCC. Although multimodality treatment is usually recommended in locally advanced and metastatic disease, the role of immunotherapy and targeted therapy is promising in select PUC-F cases.

[Gender-associated differences in bladder cancer]

BACKGROUND AND OBJECTIVES

Although the incidence of bladder cancer among women is lower, they tend to more often have advanced disease at presentation with a more aggressive course. It is still unclear which factors are responsible for the poorer prognosis of bladder cancer in women.

MATERIALS AND METHODS

Original papers and reviews from 2004 until 2022 were identified in a PubMed search and evaluated.

RESULTS

Multiple factors are likely responsible for the different courses of bladder cancer in women versus men. In the literature, epidemiologic and clinical aspects are discussed. Furthermore, genetic and hormonal causes and the role of the urobiome have been the focus of discussion more recently.

CONCLUSIONS

Earlier diagnosis and better surgical treatment could lead to a more favorable course of bladder cancer in women. Further analyses of genetic, hormonal, und microbiological factors could open new perspectives in the prevention, diagnosis, and treatment of bladder cancer.

Adenosquamous Carcinoma of Skene’s Gland: A Case Report and Literature Review

Skene’s gland is homologous to the male prostate and can secrete prostate fluid. However, Skene’s gland carcinoma is extremely rare, with only 20 cases reported in the literature thus far. We report the first case of adenosquamous carcinoma of Skene’s gland. The patient was a 54-year-old woman who was admitted to our hospital due to vaginal bleeding and a vaginal mass, accompanied by multiple lymph nodes and vulvar metastases. She had a history of dysuria and episodic hematuria for 2 years. Contrast-enhanced pelvic MRI showed a mass in the right labia majora and swelling of the right inguinal lymph nodes. In addition, a mass in the anterior vaginal wall surrounded the urethra and grew in a semi-encircled manner. After receiving neoadjuvant chemotherapy, MRI revealed that the mass surrounding the urethra had shrunk, and the nodular shadow of the right labia majora was larger than before. The patient underwent elective surgery. Surgical pathology showed adenosquamous carcinoma, and immunohistochemistry suggested intestinal differentiation. Forty-six days after surgery, the patient subsequently died of tumor consumption and organ insufficiency due to cerebral infarction, recurrence, and multiple metastases. This paper describes the clinical, radiological, and histopathologic features as well as the prognosis of the rare disease adenosquamous carcinoma of Skene’s gland. In addition, we briefly review the published literature.

Primary urothelial carcinoma of the male anterior urethra; A case report

Introduction

and importance: Urethral cancer is a rare condition. It represents less than 1% of all cancers and the clinical signs are not very specific and confusing, which explains the often-late diagnosis. The prognosis can be poor. The objective of our observation is to discuss, through a review of the literature, the diagnostic and therapeutic means of tumors of the male anterior urethra.

Case presentation

This is a 54-year-old patient, smoker, followed for urinary lithiasis. He initially consulted us for right nephritic colic, with an obstructive iliac ureteral stone on a CT scan. He had drainage by JJ stent followed by extracorporeal lithotripsy. After three months, it was decided to remove the JJ Stent. During urethrocystoscopy, a papillary tumor of the anterior urethra was found, measuring 0.5 cm on the long axis. Endoscopic resection of the tumor was performed. Pathological examination revealed a low-grade malignant urothelial carcinoma. No tumor recurrence was noted after one year of follow-up.

Discussion

Primary urethral cancer is a rare condition. Most series in the literature show a male predominance. The main risk factors are chronic inflammation, history of urethritis, and urethral stricture. The clinical signs of urethral cancer are usually discrete and not very specific. The reference examination for positive diagnosis remains urethroscopy, which allows a more precise diagnosis thanks to a direct view of the urethral mucosa. The management of tumors of the anterior urethra consisted of aggressive excisional surgery. The main goal was to achieve satisfactory local control. conservative treatment by resection, fulguration or laser vaporization is indicated for small lesions (<1 cm).

Conclusion

Tumors of the anterior urethra in men are often diagnosed late. More effort should be made to diagnose this disease earlier, especially in high-risk groups. Conservative treatment can be offered in patients with a small lesion.

•

Primary tumors of the male urethra are exceedingly rare.

•

More effort should be made to diagnose this disease earlier, especially in high-risk groups.

•

This cancer is associated with poor outcomes if not diagnosed and treated promptly.

•

Prognostic factors are important to be known.

Distal urethral carcinoma: Contemporary management with phallus preserving techniques

INTRODUCTION

Primary urethral carcinoma is a rare clinical entity with an incidence of 1 case per million in the United Kingdom. Cancers of the distal urethra are most commonly of squamous subtype and often associated with Human Papilloma Virus infection. Penile preserving techniques are recommended in tumours of the pendulous urethra with a number of surgical approaches described. Herein, we describe the surgical management of 7 patients presenting with primary urethral carcinoma.

METHODS

Seven patients diagnosed with primary urethral carcinoma of the distal urethra were identified using a prospectively maintained penile cancer database at our institution from May 2017 to November 2020.

RESULTS

The mean age at presentation was 56.5 (33-80) years. Presenting symptoms included visible lesion, LUTS and a groin mass. Three patients had lesions located within the glanular urethra and had a distal urethrectomy and primary closure. Two patients with lesions extending proximal to the glanular urethra and into or beyond the fossa navicularis had a distal urethrectomy with a hypospadic neomeatus formation. One patient with tumour extending into the glans penis underwent distal urethrectomy and partial glansectomy with split thickness skin graft. A partial penectomy was performed for one patient with urethral tumour invading the corporal heads. Mean follow-up was 23.4 (±17.0) months. There have been no disease recurrences to date.

CONCLUSION

Penile preserving techniques are feasible in patients with tumours of the pendulous urethra and do not appear to compromise local control.

A Case of Muscle-Invasive Bladder Cancer With Pelvic Lymph Node Involvement Treated With Pembrolizumab and Subsequent Radical Cystectomy and Maintained No Evidence of Disease After Surgery

A 67-year-old man was referred to our hospital with chief complaints of macrohematuria and anemia. He was diagnosed with muscle-invasive bladder cancer (MIBC) with right external iliac lymph node (LN) involvement and received two courses of gemcitabine and carboplatin. After chemotherapy, left external iliac LN involvement was identified as a new lesion, even though the bladder cancer (BCa) and right external iliac LN decreased in size. Therefore, pembrolizumab was administered as a second-line treatment. The bladder tumor and positive LNs subsequently shrunk. Open radical cystectomy and bilateral ureterocutaneostomy were also performed. The pathological examination of the surgical specimen indicated urothelial carcinoma, pathological stage Tis, and negative LN involvement. The patient was followed up for 30 months without evidence of local recurrence or distant metastasis.

Urethral Masses

Urethral and periurethral masses in women include both benign and malignant entities that can be difficult to clinically differentiate. Primary urethral carcinoma is rare and the optimal treatment modality may vary depending on the stage at presentation. Because cancer-free survival is poor, clinicians shouldhave a high index of suspicion when evaluating a urethral mass. Some benign-appearing urethral masses may be safely observed. Surgical resection is an effective option that should be used based on patient preference and symptoms, and for suspicious lesions.

Primary tumor surgery improves survival in non-metastatic primary urethral carcinoma patients: a large population-based investigation

Background

Primary urethral carcinoma (PUC) is a rare genitourinary malignancy with a relatively poor prognosis. The aim of this study was to examine the impact of surgery on survival of patients diagnosed with PUC.

Methods

A total of 1544 PUC patients diagnosed between 2004 and 2016 were identified based on the SEER database. The Kaplan-Meier estimate and the Fine and Gray competing risks analysis were performed to assess overall survival (OS) and cancer-specific mortality (CSM). The multivariate Cox regression model and competing risks regression model were used to identify independent risk factors of OS and cancer-specific survival (CSS).

Results

The 5-yr OS was significantly better in patients who received either local therapy (39.8%) or radical surgery (44.7%) compared to patients receiving no surgery of the primary site (21.5%) (p < 0.001). Both local therapy and radical surgery were each independently associated with decreased CSM, with predicted 5-yr cumulative incidence of 45.4 and 43.3%, respectively, compared to 64.7% for patients receiving no surgery of the primary site (p < 0.001). Multivariate analyses demonstrated that primary site surgery was independently associated with better OS (local therapy, p = 0.037; radical surgery, p < 0.001) and decreased CSM (p = 0.003). Similar results were noted regardless of age, sex, T stage, N stage, and AJCC prognostic groups based on subgroup analysis. However, patients with M1 disease who underwent primary site surgery did not exhibit any survival benefit.

Conclusion

Surgery for the primary tumor conferred a survival advantage in non-metastatic PUC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08603-z.

Systematic Review of the Role of BCG in the Treatment of Urothelial Carcinoma of the Prostatic Urethra

BACKGROUND

In patients with non-invasive urothelial carcinoma of the prostatic urethra (PUC), treatment with Bacillus Calmette-Guérin (BCG) could be beneficial.

OBJECTIVE

To assess the response rates to BCG in the different tumor stages, to describe the clinical impact of transurethral resection of the prostate (TURP) before BCG treatment, and to review the side effects of BCG treatment for PUC.

METHODS

A systematic search was conducted using the PubMed database to identify original studies between 1977 and 2019 reporting on PUC and BCG.

RESULTS

Of a total of 865 studies, ten were considered for evidence synthesis. An indication for BCG treatment was found in non-stromal invasive stages (Tis pu, Tis pd) and in stromal infiltrating cases (T1) of primary and secondary PUC when transitional cell carcinoma was the histology of origin. Studies including patients treated with TURP before BCG showed a better local response in the prostatic urethra with a higher disease free survival (DFS) (80-100% vs. 63-89%) and progression free survival (PFS) (90-100% vs. 75-94%) than patients in studies in which no TURP was performed. However, this difference in recurrence and progression in the prostate neither affected the total PFS (57-75% vs. 58-93%), nor the disease specific survival (70-100% vs. 66-100%).

CONCLUSIONS

The use of resection loop biopsies of the prostatic urethra in appropriate cases during the primary work-up for suspected PUC, as well as the use of the current TNM classification for PUC, need to be improved. BCG therapy for non-stromal invasive stages of PUC show a good local response. Local response is further improved by a TURP before BCG therapy, although the overall prognosis does not seem to be affected. Further evidence for BCG treatment in the rare cases of stromal invasive PUC is needed. Specific side effects of BCG treatment for PUC are not reported.