Management of the male urethra after cystectomy for bladder cancer

All patients with locally advanced transitional-cell carcinoma of the bladder should undergo thorough precystectomy assessment of the prostatic urothelium for evidence of malignancy. Those with carcinoma or carcinoma in situ should not be considered candidates for orthotopic continent diversion, and urethrectomy should be recommended. Regardless of risk status, all patients with a urethral remnant after cystectomy should have semiannual urethral washings performed for cytologic analysis. Any positive result should be followed by urethrectomy. By identifying and modifying the treatment plan for those patients who are clearly at increased risk of developing a urethral recurrence, it should be possible to reduce the morbidity and anxiety that urethral recurrence can entail. More importantly, the risk of noncompliance in follow-up with disastrous results is reduced, and both the patient and the physician can be assured that the best management for urothelial malignancy has been offered, not simply isolated treatment of the primary bladder carcinoma.