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.