Indications for urethrectomy

This review article addresses the pertinent issues regarding management of the urethra in the setting of transitional cell carcinoma of the bladder. This topic is often a subject of considerable confusion among urologic surgeons and is timely in this era of routine orthotopic diversion. The risk of urethral recurrence in the retained urethra is approximately 10%. Of the potential risk factors that may predispose the retained anterior urethra to metachronous transitional cell carcinoma, involvement of the prostatic urethra, glands, or stroma is the most significant. In this circumstance, if a cutaneous diversion is performed, urethrectomy is indicated. Conversely, for orthotopic diversion, involvement of the prostatic urethra with transitional cell carcinoma is not a contraindication to proceeding. Orthotopic diversion should be aborted, and cutaneous diversion and urethrectomy should be performed, only if intraoperative frozen section of the prostatic urethra margin is positive. In a woman, en bloc urethrectomy should be included with cystectomy if cutaneous diversion is planned. Although tumor involvement of the female bladder neck is a risk factor for urethral disease, prospective studies suggest that intraoperative frozen section evaluation of the proximal urethra is more accurate and can be used to exclude orthotopic diversion at cystectomy. Using these and other guidelines, management of the urethra should be straightforward and less concerning for the urologic surgeon.