Prepubic urethrectomy during radical cystoprostatectomy

OBJECTIVES: In muscle-invasive bladder cancer, the risk of developing a urethral recurrence after cystectomy varies between 4% and 18%, especially when an ileal conduit is performed. For this reason, some authors advocate a urethrectomy in these indications. At our center, we developed the technique of prepubic urethrectomy. We assessed the feasibility and implications of this technique over 20 yr of use. PATIENTS AND METHODS: We retrospectively analyzed the medical files of 180 consecutive male patients who underwent a urethrectomy simultaneously with cystectomy for invasive bladder cancer between 1985 and 2005. We describe our technique step-by-step, and present possible technical difficulties and complications of urethrectomy. RESULTS: The mean increase in operative time with the prepubic urethrectomy over cystoprostatectomy alone was 17min (range: 15-25). Postoperative complications occurred in 10 (5.5%) patients. A subcutaneous penile haematoma was noted in four (2.2%) patients, two of whom needed a circumcision later on. A scrotal haematoma was seen in five (2.7%) patients; two needed a surgical drainage and three were treated conservatively. A prepubic collection was noted in one patient who was also treated conservatively. No thromboembolic or neurologic complications were encountered. CONCLUSIONS: When a urethrectomy is indicated, it can best be performed by using the prepubic approach, because it is easier and less time-consuming than the perineal approach, and has very limited and easily manageable complications.     

Complications of radical cysto-urethrectomy using modified Clavien grading system: prepubic versus perineal urethrectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? It is expected there will be added risks of morbidity for patients undergoing urethrectomy with radical cystectomy for bladder cancer. Two surgical approaches were described for doing simultaneous cysto‐urethrectomy: pre‐pubic and perineal. Comparative analysis of the outcome of the two approaches using standardized assessment tools revealed that the pre‐pubic approach has a lower incidence of serious complications with shorter operation duration and shorter hospital stay.

OBJECTIVES

? To assess the impact of both prepubic and perineal urethrectomy on the complication rate and grade when cysto‐urethrectomy is planned. ? To review the perioperative complications of radical cysto‐urethrectomy and grade them according to the modified Clavien classification system.

PATIENTS AND METHODS

? A total of 186 radical cysto‐urethrectomies were performed between 1984 and 2008 ? Patients’ charts were retrospectively reviewed, focusing on operation duration, hospital stay and complications arising. ? According to this new classification, perioperative complications were stratified into five grades.

RESULTS

? Prepubic urethrectomy was done in 71 patients (group I) while perineal urethrectomy was done in 115 patients (group II). ? The mean operation duration was significantly lower in group I than in group II (173.8 and 208.9 min in groups I and II, respectively; P= 0.003). ? There were a total of 46 perioperative complications in 186 (24.7%) patients, 21 (29.5%) in the prepubic group and 25 (21.1%) in the perineal group. ? There were 19 (90.5%) and 18 (72%) low‐grade (G1–3) complications in the prepubic and perineal groups, respectively, and two (9.5%) and seven (28%) high‐grade (G4–5) complications in the prepubic and perineal groups, respectively (P= 0.033). ? The mean hospital stay was significantly lower in group I than in group II (14.5 and 17.6 days in groups I and II, respectively; P= 0.047).

CONCLUSION

? The prepubic approach has a lower incidence of serious complications with shorter operation duration and shorter hospital stay.     

En bloc transpubic urethrectomy in conjunction with radical cystectomy for bladder carcinoma in males

A technique for en bloc transpubic urethrectomy and radical cystectomy in the male is described and compared with commonly employed means of urethrectomy. Although this technique has been performed in a limited number of cases, this report is warranted because of the following advantages: en bloc resection is achieved at one operation without compromised positioning or need to reposition; the risk of transecting tumor in the urethra or leaving tumor behind in the urethra is avoided; the contamination inherent with a perineal incision and the resulting increase in morbidity are avoided, yet the mobilization of the urethra and prostate is comparable to that achieved transperineally; the exposure with this technique equals or excels that achieved by other approaches; although thirty minutes are required to perform pubectomy and urethrectomy, this is comparable to the time required to expose and close the perineum; and usually time is saved because of the improved exposure.     

Indications and techniques in urethrectomy

The indications for urethrectomy during cystectomy for bladder cancer have substantially changed during the last years. Many years ago, prophylactic urethrectomy was performed in most patients undergoing cutaneous diversion. Today, transitional cell carcinoma at the level of the prostatic urethra or at the bladder neck is recognized to be the most important risk factor of urethral recurrence. Since the development of bladder substitutions, the indications for prophylactic urethrectomy have been dramatically reduced. Pre - and intra operative evaluation of the prostatic urethra in men and that of the bladder neck in women is the major determinant in the appropriate treatment strategy for the urethra in patients with bladder cancer.     

The accuracy of antimicrobial disk sensitivity testing in urinary tract infections

Carcinoma in situ of the urethral margin was demonstrated in 12 men who underwent radical cystectomy for bladder cancer. Six of the 7 patients who underwent simultaneous urethrectomy are free of the tumor but 4 of the 5 who did not undergo urethrectomy died of the disease. This dismal survival rate for patients with carcinoma in situ in the retained urethra indicates the necessity for clear-cut guide lines for the performance of urethrectomy. Frozen section of the urethral margin, as well as of both distal ureters, should be obtained at the time of operation, and urethrectomy, either simultaneous or during the same hospitalization, should be considered strongly for those with carcinoma in situ of the bladder neck or of the urethra.     

Transitional cell carcinoma of the urethra in men after radical cystectomy for bladder cancer. Is prophylactic urethrectomy indicated?

A retrospective study of the incidence and clinical course of transitional cell carcinoma of the urethra is reported. Of 110 consecutive male patients who underwent cystectomy during a 9-year period, 9 had or developed a urethral tumour. Five patients undergoing radical cystectomy had known or suspected urethral involvement which was confirmed at urethrectomy. All 5 had deeply invasive (T3 or T4) transitional cell carcinomas of the bladder and subsequently died of metastatic disease. Four patients underwent urethrectomy because of signs or symptoms of urethral recurrence at an average interval of 2.5 years after cystectomy. There were two deaths in this group, neither of which appeared to be due to urethral recurrence. Six additional patients had undergone prophylactic urethrectomy because of prostatic urethral involvement or diffuse carcinoma in situ in the cystectomy specimen, and none had identifiable tumour in the anterior urethra. The residual urethra is a potential focus for recurrent tumour and this necessitates careful follow-up with serial cytology, but the low incidence of urethral recurrence (3.5% in this series) does not appear to warrant routine urethrectomy at the time of cystectomy.     

Congenital prepubic sinus: an epispadiac variant of urethral duplication: case report and review of literature

Urethral duplication is rare; the duplicated urethra is almost always dorsal to the normal urethra, which contains the sphincteric mechanism. It is very rare to present as a prepubic sinus. Urethral duplication does not represent a uniform entity making it difficult to find an unequivocul and comprehensive classification. A case of epispadiac variant of urethral duplication is reported in which the duplicated urethra presents as a prepubic sinus, with complete cure and normal urinary and sexual functions after maturity.     

原发性女性尿道癌（附21例报告）

为探讨女性尿道癌的发病趋势及临床过程，治疗及预后，总结３０年来收治原发性女性尿道癌患者２１例，平均年龄４８．５岁。主要临床表现有尿道出血，尿道口新生物等。手术行尿道部分切除术，尿道全切膀胱肌瓣代尿道等。病理结果：腺癌１０例（４７．６％），鳞癌９例（４２．８％），移行细胞癌２例（９．５％）。提出肿瘤位置，侵犯范围，组织学特点和有无远处转移四点决定肿瘤治疗方案和预后。     

Inflatable penile prostheses in patients undergoing cystoprostatectomy with urethrectomy

When urethrectomy is indicated in the male patient in combination with cystoprostatectomy for diffuse transitional cell carcinoma, an additional challenge to reconstruction and sexual rehabilitation will be encountered. Inflatable penile prostheses were implanted in 19 patients who had undergone cystoprostatectomy with prophylactic urethrectomy. Of the patients 13 underwent cystoprostatectomy with en bloc urethrectomy and delayed placement of an inflatable penile prosthesis. The remaining 6 patients required urethrectomy and simultaneous implantation of an inflatable penile prosthesis 6 to 12 weeks after radical cystectomy. All 19 patients healed appropriately and had an adequate functioning prosthesis. However, results in patients in whom the glandular urethra could be preserved safely were far superior to those in patients requiring total urethrectomy. This was so because of easier and improved cylinder placement with better support to the glans, increased glandular sensation and a more acceptable penile appearance. The inflatable penile prosthesis can be used successfully in the cystourethrectomy patient with gratifying results, especially when the glandular urethra remains intact.     

A clinical study on urethral recurrence observed after cystectomy

A clinical study was made on 108 male patients who underwent cystectomy. The posterior urethra and partial anterior urethra were removed in 47 cases, half of the perpendicular urethra was removed in 13 cases and the anterior urethra up to the fossa navicularis was removed in 48 cases. Out of 60 cases without urethrectomy, urethral recurrence was observed in 13 cases (21.7%), while no recurrence was observed in the cases treated with urethrectomy. The average period of time from cystectomy to urethral recurrence was 24.7 months (11-39 months). Urethral cancer of such early stages as pIa and pIb were found in 3 and 6 cases, respectively. Stage pT2 was found in 4 cases. Grade 1 cancer was found in 3 cases, grade 2, in 5 cases, and 3 in 5 cases. The proximal end of the perpendicular urethra was found to be the most frequent site for recurrence with 11 cases exhibiting recurrence at this location and 2 cases at the mid-portion of the perpendicular urethra. Many cases exhibited multiple recurrence of tumor of visually grayish, velvety and non-papillary type which was histologically all transitional cell carcinoma. Bladder tumor with higher grade tended to cause urethral cancer recurrence with higher grade. Bladder tumors at multiple locations from the trigone to the lateral and posterior walls tended to cause recurrence in the urethra (p less than 0.05). Of all the cases, 10 cases underwent urethrectomy and 2 cases penectomy. 12 cases received chemotherapy and 5 cases radiation therapy as postoperative adjuvant treatments.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of the urethra in patients undergoing radical cystectomy for bladder carcinoma

Urethral carcinoma recurrence after radical cystectomy for bladder carcinoma is a rare but devastating condition. Among 140 male patients submitted to radical cystectomy, urethral carcinoma recurrence occurred in 11. Nine of whom died. Nine other patients underwent urethrectomy at the time of cystectomy or shortly afterwards. Five are alive with no evidence of disease, 4 died of local recurrence or distant metastasis. Prophylactic urethrectomy should be performed in the presence of carcinoma in situ in the prostatic urethra or involvement of the prostatic urethra from the bladder tumor. These criteria should be considered as an absolute contraindication for substitution enteroplasty.     

Recurrence of sigmoid colon carcinoma in the residual urethra after cystectomy

INTRODUCTION: We report a case of recurrence of sigmoid colon cancer in the residual urethra after cysto-prostato-sigmoidectomy. METHODS/RESULTS: The patient successfully underwent urethrectomy and is currently tumor-free. To our knowledge, this is the first case of recurrence of a non-urothelial malignant tumor in the residual urethra.     

Distal urethral carcinoma: Contemporary management with phallus preserving techniques

IntroductionPrimary urethral carcinoma is a rare clinical entity with an incidence of 1 case per million in the United Kingdom. Cancers of the distal urethra are most commonly of squamous subtype and often associated with Human Papilloma Virus infection. Penile preserving techniques are recommended in tumours of the pendulous urethra with a number of surgical approaches described. Herein, we describe the surgical management of 7 patients presenting with primary urethral carcinoma.MethodsSeven patients diagnosed with primary urethral carcinoma of the distal urethra were identified using a prospectively maintained penile cancer database at our institution from May 2017 to November 2020.ResultsThe mean age at presentation was 56.5 (33-80) years. Presenting symptoms included visible lesion, LUTS and a groin mass. Three patients had lesions located within the glanular urethra and had a distal urethrectomy and primary closure. Two patients with lesions extending proximal to the glanular urethra and into or beyond the fossa navicularis had a distal urethrectomy with a hypospadic neomeatus formation. One patient with tumour extending into the glans penis underwent distal urethrectomy and partial glansectomy with split thickness skin graft. A partial penectomy was performed for one patient with urethral tumour invading the corporal heads. Mean follow-up was 23.4 (±17.0) months. There have been no disease recurrences to date.ConclusionPenile preserving techniques are feasible in patients with tumours of the pendulous urethra and do not appear to compromise local control.     

Urethrectomy is harmful for preserving potency after radical cystectomy

Twenty-three patients who underwent conventional total cystectomy were examined regarding postoperative potency. Two patients who were subjected to simple cystectomy and whose partial prostate and whole seminal vesicles were left showed full erection and normal ejaculation 1-2 months after surgery, thus giving 100% potency after simple cystectomy. In contrast, of 12 patients who underwent radical cystectomy alone, only 3 (25%) regained potency postoperatively, and the strength and duration of erection were not satisfactory for 1 of the 3 patients. Nine patients who received radical cystectomy and urethrectomy did not show signs of potency postoperatively. The sum total postoperative potency rate in the 21 patients subjected to radical cystectomy was 14.3% (3/21). The facts may indicate that urethrectomy is harmful for postoperative potency because damage of the cavernous nerves probably takes place during surgery. To avoid nerve damage, the urethra should be left intact during radical cystectomy employing the nerve-sparing technique developed by Walsh and Donker unless the posterior urethra is invaded by bladder carcinoma. In addition, it was demonstrated that pelvic irradiation might cause impotency as neither pelvic lymph node dissection nor cisplatin administration had any influence on postoperative potency.     

膀胱移行细胞癌行膀胱全切术后尿道再发肿瘤的原因及处理

目的 研究膀胱移行细胞癌行膀胱全切术后尿道再发肿瘤的原因及处理方法，进行提出预防及治疗措施，以降低尿道再发肿瘤的可能性。方法 回顾分析1978～1998年膀胱全切后尿道再发肿瘤19例。结果 尿道再发肿瘤占9%，均为男性。18例发生于后尿道，1例发生于前尿道，主要症状为尿道溢血。结论 再发原因除移行上皮肿瘤的多中心发生因素外，膀胱肿瘤已侵及前列腺及前列腺尿道的主要原因。“膀胱全切除”范围不够，残留前列腺及前列腺尿道以及膀胱切除时对肿瘤的挤压也是不容忽视的原因。少数病例也可经血行转移至前尿道。尿道全切术有替代后尿道切除术的趋势。     

Sexual function in men after radical cystectomy with or without urethrectomy.

Sexual function was evaluated in 21 patients with bladder carcinoma who had undergone radical cystectomy either with (n = 9) or without (n = 12) excision of the urethra. All patients received preoperative radiotherapy, and the cystectomy was done by a nerve-sparing surgical technique. At follow-up all patients reported normal sexual desire and tactile sexual activity. Eight of the 12 patients in whom the urethra was preserved could achieve penile erection and orgasm to tactile stimulation, and five of them had sufficient strength and duration of erection for sexual intercourse. Two of the nine patients in whom the urethra was removed-had weak erections insufficient for intercourse; three could experience orgasm. These results show that when cystectomy is done by a nerve-sparing technique and without urethrectomy there is more chance of preserving sexual function than when simultaneous urethrectomy is done.     

Urethrectomy in men with transitional cell carcinoma of bladder

Data on a selected group of 90 male patients who had total cystectomy for diffuse transitional cell carcinoma in situ, multiple bladder neoplasms involving the trigone, or transitional cell carcinoma encroaching on the bladder neck and/or involving the prostatic urethra were studied in relation to the incidence of urethral involvement. Of the 59 patients who had only total cystectomy, 8 (13.5 per cent) required a subsequent therapeutic urethrectomy for clinical anterior urethral carcinoma. Of the remaining 31 patients who underwent simultaneous prophylactic urethrectomy at the time of cystectomy, 2 (6.4 per cent) had transitional cell carcinoma and 1 had moderate mucosal atypia of the anterior urethra. Although the remaining urethra constitutes a potential hazard for further tumor formation, only l of 10 patients with urethral carcinoma possibly died of urethral tumor recurrence. Therefore, the urologist has a choice either to follow the patient closely with cytologic urethral wash or to do a prophylactic urethrectomy, especially in patients who are difficult to follow-up closely.     

EN BLOC RADICAL CYSTOPROSTATOURETHRECTOMY WITH PRESERVATION OF SEXUAL FUNCTION

Background:
Recent understanding of the precise anatomy of the cavernous nerves to the penis allows us to preserve potency in men undergoing radical prostatectomy or radical cysto-prostatectomy. A technique of urethrectomy that preserves potency has been also developed. To date, however, delayed urethrectomy has been recommended to preserve potency. We have applied a nerve-sparing technique to en bloc cystoprostatourethrectomy.
Methods:
Seven patients have undergone simultaneous urethrectomy with the radical cystoprostatectomy by the nerve-sparing technique. Patient age ranged from 52 to 69 years (mean age, 61.3 years). All patients were potent preoperatively. Meticulous and complete dissection of the membranous urethra from the pelvis is the key to preservation of potency at urethrectomy.
Results:
The patients were followed for 7 to 64 months (mean, 27.3 months). Four (57%) of the patients regained potency postoperatively. Two patients were able to have erections postoperatively but are still impotent.
Conclusions:
Our clinical results show that it is possible to perform simultaneous urethrectomy and preserve potency.     

Urethral tumor recurrences after radical cystoprostatectomy: the case for primary cystoprostatourethrectomy?

Of 273 male patients who underwent radical cystoprostatectomy between 1967 and 1987, 22 were regarded as at risk for urethral recurrence. These patients underwent simultaneous primary urethrectomy or urethrectomy shortly after cystectomy because of the histology of the cystectomy specimen. Of the remaining 251 patients a urethral recurrence was observed in 23 (9.2%). A patient with a urethral recurrence originally had undergone an operation at another hospital. The first urethral tumor recurrence was observed in 1977 but between October 1987 and May 1988, 7 patients were treated for an initial or secondary urethral recurrence. This finding suggests that the rate of urethral recurrence increases with improved survival rates after cystoprostatectomy and longer followup of these patients. Of the 24 patients who had urethral recurrence 21 showed multifocal tumor growth in the primary cystectomy specimen and 2 had unifocal tumors. The original histological status in the patient treated elsewhere is not known. The data suggest that primary simultaneous urethrectomy should be performed in all patients undergoing cystoprostatectomy for multifocal bladder tumors. Patients who retain the urethra require regular and life-long washout cytology studies of the urethra for early diagnosis of recurrent urethral tumor.     

女性尿道原发性恶性黑色素瘤3例报告

目的：探讨女性尿道原发性恶性黑色素瘤的临床特征及治疗手段。方法：对3例女性原发性尿道恶性黑色素瘤进行临床病理分析及随访观察。结果：3例均以尿道外口包块就诊。2例因术前诊断不清，仅局部切除，其中1例术后半年死于肿瘤复发。1例正在随访中；1例行全尿道切除，双侧腹股沟淋巴结清扫及永久性膀胱造瘘。结论：女性尿道原发性恶性黑色素瘤恶性度高，临床易误诊，早期确诊的主要依据是病理学检查，及时规范手术是提高患者生存率的主要手段。