​Published August 2002

1. Diagnosis

Diagnostic Pathology

1. History and physical
2. Urethroscopy, cystoscopy, examination under anesthesia
3. IVP
4. CT scan pelvis
5. TUR biopsy is preferable to open biopsy
6. Excisional biopsy or needle biopsy of inguinal lymph node metastases

2. Staging

Classification Criteria

T - Primary Tumour

• TX: Primary tumour cannot be assessed
• T0: No evidence of primary tumour

Urethra (male and female)

• Tis: Carcinoma in situ
• Ta: Non-invasive papillary, polypoid or verrucous carcinoma
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades any of the following: corpus spongiosum, prostate, periurethral muscle
• T3: Tumour invades any of the following: corpus cavernosum, beyond prostatic capsule, anterior vagina, bladder neck
• T4: Tumour invades other adjacent organs

Transitional cell carcinoma of prostate (prostatic urethra)

• Tis pu: Carcinoma in situ, involvement of prostatic urethra
• Tis pd: Carcinoma in situ, involvement prostatic ducts
• T1: Tumour invades subepithelial connective tissue
• T2: Tumour invades any of the following: prostatic stroma, corpus spongiosum, periurethral muscle
• T3: Tumour invades any of the following: corpus cavernosum, beyond prostatic capsule, bladder neck (extra-prostatic extension)
• T4: Tumour invades other adjacent organs (invasion of the bladder)

N - Regional Lymph Nodes

Regional nodes: inguinal and pelvic irrespective or laterality.

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single node 2 cm or less in greatest dimension
• N2: Metastasis in a single node more than 2 cm in greatest dimension, or multiple lymph nodes

M - Distant Metastasis

• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

Staging Diagram

3. Management

Tumours of the male urethra are very rare and their treatment is complex and controversial. Multi-disciplinary assessment is needed before commencement of treatment.

1. Anterior tumours that can be widely excised by total or partial penectomy can usually be controlled locally
2. Periurethral infiltration in posterior tumours accounts for high incidence of local recurrence after their excision
3. One third of posterior tumours have invaded pubic rami
4. Inferior pubic rami must be excised to prevent otherwise virtual certainty of local recurrence
5. Radiation alone does not control posterior tumours
6. For one half of posterior tumours only palliative treatment possible

Specific recommendations according to anatomic location

Anterior tumours

1. Partial penectomy when residual urethra long enough to direct urinary stream
2. Total penectomy and perineal urethrostomy when partial penectomy not applicable
3. Staged therapeutic groin dissections when inguinal lymph node metastases clinically present

Posterior tumours

Options include:

1. Radical radiotherapy
2. Radical cystectomy, penectomy, partial scrotectomy (+ bilateral orchiectomy), with en bloc excision of inferior pubic rami and bilateral pelvic lymphadenectomy with or without preoperative radiation
3. Staged therapeutic groin dissection for inguinal lymph node metastases
4. Palliative therapy : Surgery or radiation as indicated

4. Follow-up

Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy.

Follow up will be primarily by the urologist and will include urethrocystoscopy where relevant:

• Year 1 = q 3 months
• Year 2 = q 4 months
• Year 3-4 = q 6 months
• Year 5+ =annually

Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g. symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request.

Notification is requested in the event of any of the following:

1. Local recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy)
2. Metastasis at regional or distant sites
3. Complications of therapy especially if acute requiring hospitalization, or chronic and symptomatic
4. Death with primary cause and whether cancer or treatment contributed

The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BC Cancer Agency.