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Surgical Management of Urethral Carcinoma Occurring After Cystectomy
Vol. 103, Mar. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright@ 1970 by The Williams & Wilkins Co.
SURGICAL MANAGElVIENT OF URETHRAL CARCINOMA OCCURRING AFTER CYSTECTO.:\![Y DOUGLAS E. JOHNSON
AND
GENE A. GUINN
From the Department of Surgery, Section of Urology, The University of Texas M. D. Anderson Hospital and Tumor Institute at H01,ston, Houston, Texas
It is not unusual for urethral carcinoma to develop in men who have undergone prostatocystectomy and urinary diversion because of malignant disease of the bladder. Cordonnier and Spjnt reviewed the records of 17 4 male patients on whom cystectomy had been performed for carcinoma of the bladder and discovered 7 men (4.02 per cent) subsequently had recurrent carcinoma in the urethra.I Ashworth reviewed case reports of 1,307 patients with epithelial tumors of the bladder and found 54 with urethral papillomas (4.1 per cent). 2 Other investigators have reported an occasional case of carcinoma developing after cystectomy for cancer of the bladder. 3- 8 lVIanagement of this condition has varied, partially reflecting the unfamiliarity of the natural history of the neoplastic proce~s. Although lymphatic spread from the primary tumor or implantation of exfoliated cells onto the urethral epithelial surface has been incriminated in isolated instances most cases appear to result from the multicentric origin of urothelial tumors. In support of this latter oncogenetic theory Gowing demonstrated carcinoma in situ in 8 per cent of the male urethras in a series of 33 patients Accepted for publication April 21, 1969. 1 Cordonnier, J. J. and Spjut, H. J.: Urethral occurrence of bladder carcinoma following cystectomy. J. Urol., 87: 398, 1962. 2 Ashworth, A.: Papillomatosis of the urethra. Brit. J. Urol., 28: 163, 1956. 3 Baird, S. S., Bush, L. and Livingstone, A.G.: Urethrectomy subsequent to total cystectomy for papillary carcinoma of the bladder: case reports. J. Urol., 74: 621, 1955. 4 Deming, C. L. and Lindsskog, G. E.: Papillomatosis of bladder and entire urethra. J. Urol., 52: 309, 1944. 5 Gowing, N. F.: Urethral carcinoma associated with cancer of the bladder. Brit. J. Urol., 32: 428, 1960. 6 Howe, G. E., Prentiss, R. J., Mullenix, R. B. and Feeney, M. J.: Carcinoma of the urethra: diagnosis and treatment. J. Urol., 89: 232, 1963. 7 Riches, E.W. and Cullen, T. H.: Carcinoma of the urethra. Brit. J. Urol., 23: 209, 1951. 8 Zaslow, ,T. and Priestley, J. T.: Primary carcinoma of the male urethra. J. Urol., 58: 207, 1947.
on whom cystectomy had been performed for malignant disease. 5 In addition careful scrutiny of the urethras which had been removed for recurrent urethral disease after cystectomy has usually shown multiple lesions scattered over wide areas of the surface epithelium. Occasionally carcinoma has developed in the fossa navicularis or external meatus when incomplete excision has been performed.I, 4 Therefore it would appear that to insure complete removal of all neoplastic foci total extirpation of the urethra is required. However, detailed accounts for performing urethrectomy are noticeably absent from the literature. Our recent experience in surgically treating 4 male patients in whom urethral recurrences developed after cystectomy and urinary diversion emphasizes the necessity for early diagnosis of this condition. A review of the operative procedure might enable the inexperienced surgeon to perform a more adequate and less troublesome resection. OPERA'l'IVE TECHNIQUE
With the patient in the exaggerated lithotomy position, a 3 to 4 cm. median-ventral incision is mabe at the penoscrotal junction, exposing the corpus spongiosum (fig. 1, A). A metal sound in the urethra facilitates the initial exposure. The corpus spongiosum is freed circumferentially from its facial investments, proceeding in a distal direction until it is attached only at the external meatus (fig. 1, B). The elasticity of the penile skin allows dissection of the anterior portion of the urethra to be performed through the initial incision. However, care must be exercised to avoid entering the corpora cavernosa. The external urethral meatus is then widely circumscribed and the glandular urethra is freed of its investments with the use of blunt and sharp dissection (fig. 1, C). The urethra is drawn proximally through the glans penis and dissection proceeds toward the urogenital diaphragm (fig. 1, D). 314
URE'l'HRAL CARCINOMA OCCURRING AFTER CYSTECTONIY
;315
F'm. 1. A, initial incision at penoscrotaJ junction exposing corpus spongiosum B, corpus spongiosmn dissected distally to its attachments within glans penis, external urethral meatus is widely circumscribed, D, external urethral meatus freed from its within glans penis,
,·,n--·-_.· . _.i" ·
I
i
_
_,---
·· ,·. '
~ j
A
Fro. 2. Bulbo-membranous urethra 1s exposed with inverted V perinea! incision.
On occasion the body habitus of the patient and the elasticity of the scrotum will allow completio11 of the dissection through the initial incision. However, a second incision is necessary in most cases. Although Baird and associates recommended bivalvi11g the scrotum to facilitate ex-
FIG. 3. Surgical specimen
posure of the bulbous urethra we prefer to make an inverted V perineal incision (fig. 2) .3 The incision is carried through the skin and fascia by sharp dissection and then deepened on each side by blunt dissection in the ischiorectal fossa. The central tendon is exposed and incised. The bulbous urethra and remainder of the membranous urethra are dissected free from attachments to the urogenital diaphragm and the specimen is removed intact to prevent wound seeding (fig. 3). Bleeding is usually minimal and hemosta~is has
316
JOHNSON AND GUINN
posed no particular problem. A Penrose drain is left in the depths of the perineal wound and brought out through the lateral margin of the incision. The perineal wound is closed in layers in routine fashion. The incision in the glans is approximated with several interrupted absorbable sutures. The ventral penile incision is approximated in 2 layers with interrupted absorbable sutures. A perineal dressing is applied and left in place for 48 hours. DISCUSSION
Some investigators have recommended that urethrectomy be included as a prophylactic procedure in all male patients in whom cystectomy is performed for carcinoma of the bladder.1• 3 Others withhold the procedure for those patients in whom the bladder tumor encroaches upon the vesical neck or directly invades the prostatic urethra. We argue against the necessity of urethrectomy in this situation. Cystectomy and urinary diversion performed together or in stages are sufficiently long and difficult procedures to negate adding an additional hour of
operative time for a prophylactic procedure. Instead emphasis should be focused on carefully following postoperatively the status of the remaining lower urothelial tract. All male patients in whom cystectomy has been performed for malignant disease of the bladder should undergo routine periodic urethroscopic examinations with cytologic examinations of the urethral washings. Patients with persistent urethral discharge or vague perineal or penile symptoms warrant more frequent examinations. Urethral bleeding remains the sine qua non for recurrent urethral disease and demands prompt and thorough evaluation. SUMMARY
A detailed description for performing urethrectomy is presented. Its use in managing urethral carcinoma occurring after cystectomy is discussed. A plea is made for careful periodic postoperative evaluation of the lower urothelial tract in all patients in whom cystectomy has been performed for malignant disease of the bladder.
THE JOURNAL OF UROLOGY
Copyright@ 1970 by The Williams & Wilkins Co.
SURGICAL MANAGElVIENT OF URETHRAL CARCINOMA OCCURRING AFTER CYSTECTO.:\![Y DOUGLAS E. JOHNSON
AND
GENE A. GUINN
From the Department of Surgery, Section of Urology, The University of Texas M. D. Anderson Hospital and Tumor Institute at H01,ston, Houston, Texas
It is not unusual for urethral carcinoma to develop in men who have undergone prostatocystectomy and urinary diversion because of malignant disease of the bladder. Cordonnier and Spjnt reviewed the records of 17 4 male patients on whom cystectomy had been performed for carcinoma of the bladder and discovered 7 men (4.02 per cent) subsequently had recurrent carcinoma in the urethra.I Ashworth reviewed case reports of 1,307 patients with epithelial tumors of the bladder and found 54 with urethral papillomas (4.1 per cent). 2 Other investigators have reported an occasional case of carcinoma developing after cystectomy for cancer of the bladder. 3- 8 lVIanagement of this condition has varied, partially reflecting the unfamiliarity of the natural history of the neoplastic proce~s. Although lymphatic spread from the primary tumor or implantation of exfoliated cells onto the urethral epithelial surface has been incriminated in isolated instances most cases appear to result from the multicentric origin of urothelial tumors. In support of this latter oncogenetic theory Gowing demonstrated carcinoma in situ in 8 per cent of the male urethras in a series of 33 patients Accepted for publication April 21, 1969. 1 Cordonnier, J. J. and Spjut, H. J.: Urethral occurrence of bladder carcinoma following cystectomy. J. Urol., 87: 398, 1962. 2 Ashworth, A.: Papillomatosis of the urethra. Brit. J. Urol., 28: 163, 1956. 3 Baird, S. S., Bush, L. and Livingstone, A.G.: Urethrectomy subsequent to total cystectomy for papillary carcinoma of the bladder: case reports. J. Urol., 74: 621, 1955. 4 Deming, C. L. and Lindsskog, G. E.: Papillomatosis of bladder and entire urethra. J. Urol., 52: 309, 1944. 5 Gowing, N. F.: Urethral carcinoma associated with cancer of the bladder. Brit. J. Urol., 32: 428, 1960. 6 Howe, G. E., Prentiss, R. J., Mullenix, R. B. and Feeney, M. J.: Carcinoma of the urethra: diagnosis and treatment. J. Urol., 89: 232, 1963. 7 Riches, E.W. and Cullen, T. H.: Carcinoma of the urethra. Brit. J. Urol., 23: 209, 1951. 8 Zaslow, ,T. and Priestley, J. T.: Primary carcinoma of the male urethra. J. Urol., 58: 207, 1947.
on whom cystectomy had been performed for malignant disease. 5 In addition careful scrutiny of the urethras which had been removed for recurrent urethral disease after cystectomy has usually shown multiple lesions scattered over wide areas of the surface epithelium. Occasionally carcinoma has developed in the fossa navicularis or external meatus when incomplete excision has been performed.I, 4 Therefore it would appear that to insure complete removal of all neoplastic foci total extirpation of the urethra is required. However, detailed accounts for performing urethrectomy are noticeably absent from the literature. Our recent experience in surgically treating 4 male patients in whom urethral recurrences developed after cystectomy and urinary diversion emphasizes the necessity for early diagnosis of this condition. A review of the operative procedure might enable the inexperienced surgeon to perform a more adequate and less troublesome resection. OPERA'l'IVE TECHNIQUE
With the patient in the exaggerated lithotomy position, a 3 to 4 cm. median-ventral incision is mabe at the penoscrotal junction, exposing the corpus spongiosum (fig. 1, A). A metal sound in the urethra facilitates the initial exposure. The corpus spongiosum is freed circumferentially from its facial investments, proceeding in a distal direction until it is attached only at the external meatus (fig. 1, B). The elasticity of the penile skin allows dissection of the anterior portion of the urethra to be performed through the initial incision. However, care must be exercised to avoid entering the corpora cavernosa. The external urethral meatus is then widely circumscribed and the glandular urethra is freed of its investments with the use of blunt and sharp dissection (fig. 1, C). The urethra is drawn proximally through the glans penis and dissection proceeds toward the urogenital diaphragm (fig. 1, D). 314
URE'l'HRAL CARCINOMA OCCURRING AFTER CYSTECTONIY
;315
F'm. 1. A, initial incision at penoscrotaJ junction exposing corpus spongiosum B, corpus spongiosmn dissected distally to its attachments within glans penis, external urethral meatus is widely circumscribed, D, external urethral meatus freed from its within glans penis,
,·,n--·-_.· . _.i" ·
I
i
_
_,---
·· ,·. '
~ j
A
Fro. 2. Bulbo-membranous urethra 1s exposed with inverted V perinea! incision.
On occasion the body habitus of the patient and the elasticity of the scrotum will allow completio11 of the dissection through the initial incision. However, a second incision is necessary in most cases. Although Baird and associates recommended bivalvi11g the scrotum to facilitate ex-
FIG. 3. Surgical specimen
posure of the bulbous urethra we prefer to make an inverted V perineal incision (fig. 2) .3 The incision is carried through the skin and fascia by sharp dissection and then deepened on each side by blunt dissection in the ischiorectal fossa. The central tendon is exposed and incised. The bulbous urethra and remainder of the membranous urethra are dissected free from attachments to the urogenital diaphragm and the specimen is removed intact to prevent wound seeding (fig. 3). Bleeding is usually minimal and hemosta~is has
316
JOHNSON AND GUINN
posed no particular problem. A Penrose drain is left in the depths of the perineal wound and brought out through the lateral margin of the incision. The perineal wound is closed in layers in routine fashion. The incision in the glans is approximated with several interrupted absorbable sutures. The ventral penile incision is approximated in 2 layers with interrupted absorbable sutures. A perineal dressing is applied and left in place for 48 hours. DISCUSSION
Some investigators have recommended that urethrectomy be included as a prophylactic procedure in all male patients in whom cystectomy is performed for carcinoma of the bladder.1• 3 Others withhold the procedure for those patients in whom the bladder tumor encroaches upon the vesical neck or directly invades the prostatic urethra. We argue against the necessity of urethrectomy in this situation. Cystectomy and urinary diversion performed together or in stages are sufficiently long and difficult procedures to negate adding an additional hour of
operative time for a prophylactic procedure. Instead emphasis should be focused on carefully following postoperatively the status of the remaining lower urothelial tract. All male patients in whom cystectomy has been performed for malignant disease of the bladder should undergo routine periodic urethroscopic examinations with cytologic examinations of the urethral washings. Patients with persistent urethral discharge or vague perineal or penile symptoms warrant more frequent examinations. Urethral bleeding remains the sine qua non for recurrent urethral disease and demands prompt and thorough evaluation. SUMMARY
A detailed description for performing urethrectomy is presented. Its use in managing urethral carcinoma occurring after cystectomy is discussed. A plea is made for careful periodic postoperative evaluation of the lower urothelial tract in all patients in whom cystectomy has been performed for malignant disease of the bladder.