The Diagnosis and Investigation of Urethral Cancer

The management of urethral cancer depends on the anatomical location of the tumor and the staging of the primary lesion and the status of the inguinal lymph nodes. Examination of the penis may reveal a discrete nodular lump in the anterior urethra. More distal tumours progressively infiltrate the glans spongiosum and eventually extend out of the urethral meatus (Fig. 8.2). The physical examination should also include a bilateral inguinal examination in order to detect the presence of palpable lymphadenopathy. Cytological examination of the urine may detect the presence of malignant cells, although it is noted that voided urine cytology has a high sensitivity

Fig. 8.2 Distal urethral SCC presenting in a 62-year-old man who presented with urethral bleeding and a firm mass in the glans penis

Fig. 8.2 Distal urethral SCC presenting in a 62-year-old man who presented with urethral bleeding and a firm mass in the glans penis

in detecting high-grade (poorly differentiated) bladder TCC, there is a reduced sensitivity in detecting urethral SCC.16

Imaging of the primary tumor can be performed using a range of imaging techniques including ultrasound, penile MRI (see Chap. 4), and cross-sectional imaging in order to detect the presence of abnormal lymphadenopathy. Although ascending and descending urethrography has been used previously, these techniques have now been superseded by the use of penile MRI.

Cystourethroscopy and a biopsy of the lesion should be attempted before undertaking definitive treatment. In some patients with recurrent stricture disease, a biopsy may have been performed incidentally. It is important to ensure that the biopsy is of a sufficient size in order to allow a reliable histological analysis (Fig. 8.3). One study comparing the penile SCC biopsy specimens to the final post-penectomy specimens found a 30% discordance between the two sample types both in the grade and histological subtype of the tumor.17 In most cases, the biopsy was unable to determine the deepest point of invasion or the presence of lymphovascular invasion, both of which are important prognostic indicators.181917

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