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Urethral cancer is a rare type of cancer affecting the male or female urethra that comprises approximately 1 to 2 percent of all urological cancers. To date, the number of persons diagnosed with this condition each year has remained stable. Although some people with urethral cancer do not complain of any symptoms, most do. What are these symptoms? How should this malignancy be treated? What is the chance of recovery? The following information should help answer these questions.
What happens under normal conditions? The urethra is a hollow tube that allows urine to pass from the bladder, the organ that stores urine until ready for release, to the outside of the body. In men the urethra is approximately eight inches long, and passes through the prostate and the penis before it opens to the outside at the end of the penis. In women the urethra is approximately one and a half inches long and opens to the outside just above the vaginal opening. A layer of cells called epithelium lines the urethra. In both men and women there are several glands located along the length of the urethra. A supportive network of connective tissue, elastic and muscle fibers and blood vessels surrounds the urethra. What causes urethral cancer? The exact cause of urethral cancer is not known. However, chronic inflammation and infection have been identified as factors that may increase the risk for developing this condition. Many men with urethral cancer have previously been treated for urethral stricture disease or sexually transmitted diseases (STDs). Many women with urethral cancer have previously been treated for urethral caruncle, urethral diverticulum or chronic urinary tract infection. In both men and women the presence of human papilloma virus (HPV) has been linked to urethral cancer. What are the symptoms of urethral cancer? In its early stages, there are usually few symptoms associated with urethral cancer. As the cancer grows, some patients may notice a lump or growth on the urethra. Others may notice pain or bleeding that accompanies urination. If the tumor grows so that it narrows the diameter of the urethra, patients may have difficulty urinating. How is urethral cancer diagnosed? The diagnostic investigation begins with a thorough medical history and physical examination. The urologist will ask the patient about medical conditions that may be associated with urethral cancer, such as urethral stricture, STDs, bladder cancer, urethral caruncle, urethral diverticulum and urinary tract infection. The urologist will examine the urethra, feeling for any abnormalities. An important diagnostic instrument that the urologist will use is the cystoscope, which is a thin, lighted scope that allows the urologist to view the inside of the urethra. Cystourethroscopy is most commonly performed as an office procedure under local anesthesia. If the urologist observes any abnormalities, the patient will require a biopsy. A tissue biopsy is essential to diagnose urethral cancer. It is difficult to perform this procedure under local anesthesia, so the patient is usually scheduled to return for biopsy. Under general anesthesia or regional anesthesia, the urologist will biopsy any suspicious areas identified. Certain patients may also require a biopsy technique that involves passing a needle through the skin or vagina into the urethral growth. The biopsy tissue is then sent to the pathologist for examination under a microscope to confirm the diagnosis. Before the patient awakens from anesthesia, the urologist will perform a thorough examination to determine the local extent of the tumor.
Once urethral cancer is found, the extent of disease is categorized (i.e. staged) based on how deeply the tumor has penetrated the tissues surrounding the urethra (Table 1). More tests will be performed to find out if cancer cells have spread to other parts of the body. A CT scan of the abdomen and pelvis may be performed in order to examine the lymph nodes that collect drainage from the urethra. An MRI may be performed in order to examine the local extent of the tumor. A chest X-ray is usually obtained to ensure that the tumor has not spread to the lungs, and select patients may require a bone scan to look for bony metastases. If the urethral cancer is classified as transitional cell carcinoma, the patient will undergo either excretory urography or retrograde pyelography to image the lining of the kidney and ureter to ensure there are no other sites of cancer. How is urethral cancer treated? There are treatment options for all patients diagnosed with urethral cancer. These options may be divided into three categories: surgery, radiation and chemotherapy. Surgery is the most common treatment for cancer of the urethra. There are several surgical techniques that may be used. The tumor may be removed endoscopically, meaning using an instrument such as a cystoscope or a resectoscope, which does not require a skin incision. Some patients may require conventional surgery to remove the affected area. Certain men with a tumor that involves only part of the urethra closest to the outside of the body (anterior urethra) may require removal of part of the penis that contains the tumor (partial penectomy) or even removal of the entire penis (penectomy). For patients with tumors that involve the part of the urethra that connects to the bladder (posterior urethra) more extensive surgery may be required. In men with this type of tumor the bladder and prostate, as well as the penis, may be removed. In women with this type of tumor surgery to remove the urethra, bladder and part of the vagina may be required. For the men and women undergoing these extensive surgeries lymph nodes in the pelvis are often removed as well. If the urethra is removed, the urologist will construct a new way for the urine to pass from the body, a procedure known as urinary diversion. Radiation therapy destroys cancer cells with high-energy radiation. Radiation therapy may be used alone or in conjunction with surgery or chemotherapy. Although radiation therapy may allow the patient to retain his or her urethra and surrounding organs, this method of treatment is not without complications. Chemotherapy kills cancer cells with drugs. Chemotherapy may be used alone in patients with metastatic tumors or in conjunction with surgery or radiation therapy in patients with locally advanced disease. Chemotherapy may kill cancer cells not just at the site of the tumor in the urethra, but also at sites where the tumor might have spread. What to expect after treatment? Despite aggressive therapy with chemotherapy, radiation therapy and surgery, recurrence of urethral cancer following treatment is not uncommon. For this reason, patients with this condition require life-long follow-up with a physician. Only with early recognition of recurrence and prompt initiation of appropriate therapy in such cases is prolonged survival possible. Frequently Asked Questions What determines if urethral cancer can be treated with local excision vs. a more radical surgical procedure? In general, urethral cancers that involve the anterior urethra (part of the urethra closest to the outside) are more often successfully treated with local surgery. Tumors that involve the posterior urethra (part of the urethra closest to the bladder) often require more radical surgery to ensure optimal outcome. What are the chances of urethral cancer coming back following treatment? The likelihood of urethral cancer recurring following treatment depends on both the stage and location of the initial tumor. For patients with low stage disease, the five-year disease specific survival rate approaches 90 percent; patients with high stage disease have a survival rate of 33 percent. For patients with tumor located in the anterior urethra regardless of stage, the five-year disease specific survival is 60 to 70 percent, whereas for patients with tumor located in the posterior urethra regardless of stage, the five-year survival rate is less than 25 percent. If my bladder was surgically removed due to bladder cancer, can I still develop urethral cancer? Yes, patients who undergo cystectomy for bladder cancer may still develop cancer of the urethra. For this reason, it is important for these patients to maintain close follow-up with their urologist. These patients will require periodic cytologic evaluation of urethral washings, and if cancerous cells are found in these washings a urethrectomy may be required. Table 1 - TNM Staging of Urethral Cancer Primary Tumor (T) Tx Primary tumor cannot be assessed T0 No evidence of primary tumor Ta Noninvasive papillary, polypoid or verrucous carcinoma Tis Carcinoma in situ T1 Tumor invades subepithelial connective tissue T2 Tumor invades corpus spongiosum, prostate or periurethral muscle T3 Tumor invades corpus cavernosum, beyond prostatic capsule, anterior vagina or bladder neck T4 Tumor invades other adjacent organs Regional Lymph Nodes (N) Nx Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastases in a single lymph node, 2 cm or less in greatest dimension N2 Metastases in a single node more than 2 cm in greatest dimension, or in multiple nodes Distant Metastases (M) Mx Distant metastases cannot be assessed M0 No distant metastases M1 Distant metastases
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