Urethral cancer is a malignant tumor of the urethra. In women, it is manifested by burning, pain, cuts, urethrorrhagia, urinary incontinence, contact bleeding. Men have difficulty urinating, hematuria, the presence of a palpable tumor, purulent discharge, erectile dysfunction. Diagnosis consists in urethroscopy, cystoscopy, neoplasm biopsy, urethrography, cystography, in men – cavernosography, prostatography. In women, the urethra, external genitals, part of the vagina, and bladder are removed; in men, transurethral resection of the tumor, partial penectomy, total amputation of the penis with prostatovesiculectomy and cystectomy can be undertaken.
Meaning
Urethral cancer is a malignant process of rare localization, occurring in practical oncourology in 1-2% of cases of all tumors of the urinary organs. It can develop in both sexes, but it is most common among postmenopausal women.
Cancer of the female urethra can be located in the distal or proximal part of the urethra, but more often occurs in the area of the external opening, in the area of the junction of the urothelium and the multilayer flat epithelium of the vulva. In men, the tumor usually develops in the bulbar-membranous part (59%), less often in the hanging (34%) or prostatic (7%) segment of the urethra. Melanoma is more often detected in the area of the navicular fossa.
Causes
The true causes of urethral cancer have not been clarified. It is believed that the main risk factors are chronic urethritis, including specific etiology. In the anamnesis, patients often have gonorrhea, mycoplasmosis, chlamydia, papillomavirus infection and other venous diseases. Other risk factors include permanent traumatization of the urethral mucosa, bladder cancer, prostate cancer, urethral diverticula. Leukoplakia is considered among facultative precancerous diseases.
Classification
The histological type of urethral cancer is due to the type of epithelium from which the tumor develops. Thus, in the distal part of the urethra, lined with squamous epithelium, squamous cell carcinoma develops; in the proximal part, covered with transitional epithelium, transitional cell carcinoma develops. Adenocarcinomas in men originate from the glandular tissue of the prostate; in women – from the paraurethral glands. Sarcomas and melanomas of the urethra are less common in oncourology. According to the TNM classification, the following stages of invasive cancer of the female and male urethra are distinguished:
- T1– invasion by a tumor of subepithelial connective tissue
- T2 – the tumor spreads to the periurethral muscles, spongy body, prostate
- T3 – spread of the tumor to the prostate, prostatic capsule, cavernous body, anterior vaginal wall, bladder neck T4 – tumor invasion of adjacent organs.
- N1 – single metastases in a regional lymph node less than 2 cm
- N2 – single or multiple metastases in lymph nodes more than 2 cm in maximum size
- M0 – absence of distant metastases
- M1 – the presence of distant metastases
According to the degree of differentiation (G), urethral cancer can be highly differentiated, moderately differentiated, low-differentiated or undifferentiated. According to the type of tumor growth, there are exophytic, polypous, ulcerative and infiltrative forms of neoplasia. Metastasis can occur by lymphogenic and hematogenic mechanism. In the first case, the iliac and inguinal lymph nodes are affected; in the second – the lungs, pleura, bones, liver, adrenal glands, salivary glands, brain, glans penis.
Symptoms
The manifestations of the tumor are variable and poorly specific. Cancer of the male urethra is characterized by difficulty urinating, up to its complete delay; the presence of a palpable seal in the urethra, pus-like secretions, microhematuria, urethrorrhagia. Later, pain in the urethra and perineum joins, the formation of periurethral abscesses and fistulas, enlarged inguinal lymph nodes, the development of swelling of the scrotum and penis. Cases of long-term painful erections (malignant priapism) are described. With melanoma, pigmented spots are found on the head of the penis.
In women, neoplasia is manifested by burning and pain in the urethra, pain during urination, pain during sexual intercourse, urethrorrhagia and contact bleeding, urinary incontinence, ulceration of the vulva mucosa. The transition of the tumor to the vaginal walls is accompanied by pain in the lower abdomen, vaginal bleeding, the formation of urethro-vaginal fistulas. When the neoplasm germinates into the bladder, macrohematuria becomes the defining symptom.
When the tumor is localized in the area of the external opening of the urethra, the volume formation is easily determined visually and palpationally. In the case of tumor thrombosis of lymphatic vessels, lymphostasis develops with swelling of the lower half of the trunk. Metastasis of neoplasia to parenchymal organs is accompanied by the development of appropriate symptoms.
Diagnostics
The primary diagnosis of urethral cancer includes anamnesis and physical examination. It turns out the presence in the past of urethritis, STDs, benign tumors of the urethra, bladder cancer, diverticula of the urethra. When questioned, attention is paid to the presence of hematuria, bloody discharge from the urethra (urethrorrhagia), difficulty urinating, narrowing and splashing of urine, painful erections in men.
A mandatory stage is a visual and palpatory examination of the external genitals and urethra. The oncourologist examines the external urethra, palpation of the perineum and urethra (in men along the lower surface of the penis and through the rectum; in women during vaginal examination).
Examination of the urethra throughout is carried out with the help of an endoscopic examination of the urethra – urethroscopy. Endoscopy allows you to examine the mucous membrane of the urethra, find out the location, type of growth, size and depth of tumor invasion. Urethral cancer is characterized by the density of the tumor node, light bleeding on contact, infiltration of the underlying tissues. The diagnosis is clarified by performing ascending urethrography and cystography.
The task of histological verification of the tumor is solved by biopsy and morphological examination of the altered tissues. A biopsy can be performed by puncture through a urethroscope or by transurethral resection of the formation. To assess the spread of cancer beyond the urethra, cystoscopy, cystography, cavernosography, prostatography are indicated. In the presence of fistulous passages, fistulography is necessary.
To exclude metastases, intravenous urography, lymphangioadenography, chest X-ray, osteoscintigraphy, abdominal ultrasound, pelvic ultrasound, MRI of various organs are resorted to. Pathology should be differentiated from urethral strictures, urethral stones; in men, additionally – from chronic prostatitis and urethritis, tuberculosis and prostate cancer; in women – from vulvar cancer, paraurethral cysts, prolapse of the urethral mucosa.
Treatment
In women with a superficial localized neoplasm (T0), transurethral resection, destruction by Nd:YAG or CO2 laser, fulguration of the tumor can be performed. If the tumor process is localized in the area of the external opening, circular resection of the urethra within healthy tissues can be undertaken.
Removal of the urethra, vulva and anterior vaginal wall is resorted to when cancer spreads to most of the urethra. In common forms (T3), removal of the urethra, vulva, bladder neck, anterior vaginal wall and the imposition of an epicystostomy is indicated. If a cystectomy is performed during an extended urethral resection, the ureters are transplanted into the skin or intestine to ensure urination.
Treatment options for neoplasia in men are also determined by the prevalence of the tumor process. At the T0-T1 stage, transurethral electroexcision of the tumor can be limited. Open resection of the urethra within the boundaries of healthy tissues is resorted to when the tumor is localized in the spongy part of the urethra at the stages of the T1-T2 process.
In the case of the spread of cancer of the anterior urethra to the cavernous bodies, partial amputation of the penis is indicated. With cancer of the posterior urethra, a total penectomy is indicated, which can be supplemented by prostatovesiculectomy and cystectomy. To urinate, perineal urethrocutaneostomy is performed – the formation of an external ureteral fistula. Any surgical interventions are combined with radiation therapy.
Prognosis and prevention
The average 5-year survival rate is 40%. The factors of a favorable prognosis are early detection of urethral cancer, non-invasive tumor growth, absence of metastases, and radical treatment. Preventive measures include timely therapy of urethritis, STIs, early access to a urologist for any symptoms of urinary tract problems.