The Role of Radiotherapy in the Management of Urethral Cancer

External beam radiotherapy (EBRT) and brachytherapy implants or a combination of both have been used in the management of urethral tumors. Historically EBRT has been used in the adjuvant setting following surgery for male urethral cancer but is often a primary treatment for urethral cancers in females. A number of studies have shown that the outcomes following radiotherapy alone are poor.3 3 However, these studies involve selected patients who may have presented with poor prognostic features or a poor performance status, hence prevented radical surgery being undertaken.

The EBRT technique follows a traditional 2-field pelvis treatment which also incorporates the common, internal and external iliac vessels and also the inguinal nodes if the anterior urethra is involved with tumour. Initial doses of 45 Gy are delivered in 25 fractions. Recently intensity-modulated radiation therapy (IMRT) has been used in treating other genitourinary malignancies and undoubtedly reduces the toxicity.

A survival rate of 67% has been reported for 140 patients with low-stage disease treated with radiotherapy alone from an analysis of a number of publications.

However, the nonuniformity of the patients and the treatments given in these studies does not lend itself to providing recommendations. Advanced urethral cancers fared worse with the survival rate declining to 34%.1,27

In locally advanced tumors the use of radiotherapy alone again shows poor results. There is some evidence to suggest that a combination of brachytherapy with EBRT with the aim of increasing the overall radiation dose may improve the overall outcome by decreasing the failure rates when compared to EBRT alone. However, the majority of these studies are related to female urethral cancers.28,29

The complication rates following radiotherapy range between 16% and 20%. Currently dose reduction without compromising tumor control appears to be the best way of reducing the morbidity associated with this treatment.914 The complications following radiotherapy include penile lymphoedema and urethral stricture disease for anterior lesions. For posterior urethral tumors there is a risk of fistula formation with the bladder or rectum.

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