PAPILLOMA, CANCER OF URETHRA
Urethral warts (papillomas) are benign,
sexually trans- mitted lesions that occur at the urethral meatus, in the fossa
navicularis, along the penile urethra, and as far proximal as the prostatic
urethra. However, 90% of lesions are observed in the distal urethra. Bladder
involvement is rare. These are generally HPV-positive lesions, similar to
condyloma acuminata (see Plate 2-27). Indeed, urethral
papillomas are observed in 15% of men with condyloma of the external genitalia.
The usual presentation is a mass protruding from the urethra, blood per
urethra, hematuria, dysuria, or urethral dis- charge. Risk factors include
multiple sexual partners and unprotected intercourse. Urethroscopy is important
to determine the full extent of intraurethral lesions. Urethral meatal lesions
can be treated by local excision, often accompanied by meatoplasty to improve
access. The base of the lesion is generally fulgurated after excision. Deeper
urethral lesions are treated cystoscopically with heat diathermy or CO2
laser fulguration or cold cup excision. Recurrences are common after a single
treatment and therefore multiple treatments may be needed. The use of 5%
5-fluorouracil cream, although irritating, may help prevent recurrence.
True
urethral polyps are rare, nonsexually transmitted, and occur almost exclusively
in boys. They are characterized by benign urothelial-lined masses attached to a
fibrovascular stalk and generally arise from the verumontanum. This location
suggests that they may represent the embryologic persistence of müllerian
structures. They may cause urinary urgency, dysuria and frequency, hematuria,
urinary tract infection, or occasionally urinary retention, especially if
situated in the posterior urethra. They are visualized by cystoscopy and are
removed by simple fulguration.
Primary
urethral carcinoma of the urethra is rare but deadly. The most common type of
urethral malignancy is squamous cell cancer (78% of cases) in the penile and
bulbar urethra but transitional cell carcinoma is also observed (15% of cases)
in the prostatic urethra (see Plate 2-12). Occasionally,
papillary adenocarcinoma of the urethra can originate from the glands of Littré
or Cowper. Urethral cancer is more common in whites than in blacks, and it is
the only urologic malignancy that is more common in females than in males. No
formal risk factors have been identified, although cancer is thought to develop
from chronic inflammation, infection, or irritation of the urethra. Patients
with a history of bladder cancer have an increased risk of urethral cancer.
The onset
of urethral cancer is insidious, and early symptoms are nonspecific. Because of
this, the interval between symptom onset and formal diagnosis may be 3 years.
Approximately one-half of patients give a history of urethral stricture and
about 20% give a history of urethral discharge, often inviting treatment for a
sexually transmitted disease. As the lesion progresses, urinary symptoms such
as weak stream, postvoid dribbling, and dysuria as well as sexual symptoms such
as painful erections may occur. Some degree of urinary retention is observed in
25% of patients, and in 40% of patients a palpable indurated penile mass may be
detected.
The
diagnosis is made by cystoscopy, urethral biopsy, and cytologic washings.
Tumors at the urethral meatus can simply be excised, although the entire
urethra requires inspection. Noninvasive lesions may be managed expectantly,
with repeat endoscopic incision for recurrences. Invasive lesions require more
extensive surgery with wide urethral margins, often necessitating urethrectomy
with penectomy. Depending on the location of the primary tumor in the urethra,
metastases most commonly involve the inguinal lymph nodes, followed by lungs,
liver, pleura, bones, and other distant organs. Surgery is the main curative
treatment for urethral cancer, although multimodality treatment with
chemotherapy and radiotherapy may also provide benefit. Four levels of surgical management are used
for urethral cancer: (1) conservative therapy or local excision, (2) partial
penectomy, (3) radical penectomy, and (4) pelvic lymphadenectomy and en bloc resection,
including penectomy and cystoprostatectomy with removal of the anterior pubic
bone (anterior exenteration) and urinary diversion. The 5-year survival rates
are 60% for distal urethral tu ors and less than 50% for proximal urethral
cancers.
