Urethral Cancer Guidelines

Updated: Oct 13, 2021
  • Author: Shahrokh F Shariat, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Guidelines

Guidelines Summary

The following organizations have released guidelines for the management of urethral carcinomas:

  • National Comprehensive Cancer Network (NCCN) 
  • European Association of Urology (EAU)

Diagnosis

NCCN guidelines recommend referral to a specialized center and require the following for a diagnosis [22] :

  • Cystourethroscopy, including exam under anesthesia and transurethral resection or transvaginal biopsy
  • Chest CT (preferred) or PA and lateral chest x-ray
  • Consider abdominal CT or MRI in high-risk T1 disease or patients with ≥T2 disease
  • MRI of pelvis without and with intravenous contrast

If palpable inguinal lymph nodes are present, a chest/abdominal/pelvic CT scan and lymph node biopsy should be performed. [22]  

Similarly, the EAU recommends the following for diagnostic evaluation and staging [10] :

  • Urethrocystoscopy with biopsy and urinary cytology
  • CT of the thorax and abdomen/pelvis to assess for distant metastases 
  • Pelvic MRI to assess the local extent of urethral tumor and regional lymph node enlargement

Treatment

Tis, Ta, T1:

  • NCCN guidelines recommend repeat of transurethral resection followed by intraurethral bacillus Calmette-Guerin (BCG) therapy in selected cases. [22]

T2-Women:

  • NCCN guidelines recommend either chemoradiotherapy or urethrectomy and cystectomy or distal urethrectomy (depending on tumor location). [22]

T2-Men

NCCN treatment recommendations are summarized as follows [22] :

  • Pendulous urethra: Distal urethrectomy or partial penectomy; if positive margins are present, additional surgery, chemoradiotherapy (preferred), or RT
  • Bulbar urethra: Urethrectomy with or without cystoprostatectomy
  • pT3/pT4, pN1, pN2 disease: Chemotherapy or chemoradiotherapy

T3/T4

NCCN guidelines recommendations are summarized below. [22]

For patients with regional lymph nodes staged cN0, either:

  • Chemoradiotherapy (preferred) with or without consolidative surgery
  • Neoadjuvant chemotherapy and consolidation with surgery or RT
  • RT
  • Surgery alone for non-urothelial histology

For patients with regional lymph nodes staged cN1/cN2, either:

  • RT with chemotherapy (preferred for squamous cell carcinoma)
  • Systemic therapy with or without consolidative surgery
  • Chemoradiotherapy followed by consideration of consolidation with surgery

Localized primary urethral carcinoma in males

EAU recommendations are as follows [10] :

  • Offer distal urethrectomy as an alternative to penile amputation for distal urethral tumors, if surgical margins are negative.
  • Ensure complete circumferential assessment of the proximal urethral margin if penis-preserving surgery is intended.

Localized urethral carcinoma in females

EAU recommendations are as follows [10] :

  • Offer urethra-sparing surgery as an alternative to primary urethrectomy for distal urethral tumors, if negative surgical margins can be achieved intraoperatively. 
  • Offer local radiotherapy as an alternative to urethral surgery, but discuss local toxicity.      

Advanced urethral carcinoma in males and females              

EAU recommendations are as follows [10] :

  • Discuss the treatment of patients with locally advanced urethral carcinoma within a multidisciplinary team of urologists, radio-oncologists, and oncologists.             
  • In locally advanced urethral carcinoma, use cisplatin-based chemotherapeutic regimens with curative intent prior to surgery.  
  • In locally advanced squamous cell carcinoma of the urethra, offer the combination of curative RT with radiosensitizing chemotherapy for definitive treatment and genital preservation.  
  • Offer salvage surgery or RT to patients with urethral recurrence after primary treatment.
  • Offer inguinal lymph node dissection to patients with limited LN-positive urethral squamous cell carcinoma.

Distant metastasis

NCCN guidelines recommend systemic therapy (chemotherapy or checkpoint inhibitors as subsequent-line therapy). [22]