The Surgical Management of Penile Urethral Carcinoma

The first description of male urethral cancer was by Thiaudierre in 1834.18 Subsequently McCrea and Furlong reported a survival rate of <10 months for patients who did not undergo any definitive treatment for the disease.19 Even as late as 1967 a published cohort of 46 men treated with palliation or no treatment resulted in a survival of only 3-15 months. In 1954, Hotchkiss and Amelar described radical surgical treatment in the form of penile amputation for five patients and radical cystectomy for two patients with posterior urethral tumors.20 Despite this report the surgical management only came to the fore when Farrer and

Squamous cell carcinoma

Benign urethra

Invasive squamous cell carcinoma

Squamous carcinoma-in situ

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Urethral Squamous Cell Carcinoma, H&E stain, x 40 magnification

Invasive squamous cell carcinoma

Urethral Squamous Cell Carcinoma, H&E stain, x 400 magnification

Fig. 8.3 (a, b) Histological specimens from the same 62-year-old man as in Fig. 8.2, presenting with an anterior urethral tumor. Comparison is made with normal urethral histology

Lupu reported an improved 5 year cancer specific survival rate of 30% compared to 3% in those who had undergone radical surgery compared to those who had not.21

Since then the literature has defined the radical nature of the exenteration required to treat these tumors, particularly posterior urethral tumors.22 This invariably has involved urinary diversion combined with anterior pelvic exenteration with inferior pubectomy. Although excellent local control has been reported, contemporary series have sought to identify the limits of such a resection which are compatible with good local control.23 This has been coupled with the role of neoadjuvant and adjuvant therapies without diminishing the pivotal role played by surgery in the successful management of urethral cancer.

In 1994 Dinney et al. reported on a series of 23 men from the MD Anderson Cancer Centre.5 This showed that the prognosis was dependent on the anatomical location of the tumor. For anterior urethral cancers the survival rate was better with a 60% cancer-specific survival at 4 years compared to below 30% at 31 months for posterior urethral tumors. The study proposed that tumors of the fossa navic-ularis and anterior urethra should be treated by performing a distal urethrec-tomy and penile amputation and that posterior urethral tumors required an en bloc resection of the penis, scrotum, prostate, bladder, and inferior pubic rami. Similar results were published in 1999 from the Memorial Sloan-Kettering Hospital which reported a 69% 5 year survival rate for anterior urethral tumors and 26% for posterior urethral tumors. Low-stage disease and an anterior location were significant prognostic factors. Of the 46 cases reported in this study 40 had surgery alone and 6 had preoperative radiotherapy. The latter presented with advanced disease and therefore had a worse prognosis.7

The observed and overall survival rates for patients with urethral cancer using data from the National Cancer Data Base shows that the survival rate for men is dependent on the stage of the disease (Fig. 8.4).

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