Indications for urethrectomy in an era of continent urinary diversion

Interest in performing a continent urinary diversion and in preserving sexual potency after radical cystectomy for transitional cell carcinoma of the bladder has emphasized the need to identify accurately those men who are at high risk for urethral recurrences. We reviewed the records of 200 men who underwent radical cystectomy between 1969 and 1976. In 76 men urethrectomy and cystectomy were combined. Of these patients 6 had known urethral tumors and the incidence of unsuspected urethral malignancy was 2.9%. A total of 124 men had initial cystectomy only and were monitored up to 16 years (mean 67 months). Of these patients 6 (4.8%) underwent subsequent urethrectomy for malignant disease 6 to 40 months (median 23.5 months) after cystoprostatectomy. This group included 1 of 69 patients (1.5%) who presented with a solitary tumor not encroaching on the bladder neck, 1 of 22 (4.5%) with either carcinoma in situ or multifocal tumors not involving the prostate and none of the 9 with tumor at the bladder neck alone, which suggests that these patients may be satisfactory candidates for continent urinary diversion and may avoid the added risk to potency associated with urethrectomy. However, urethral recurrences were found in 4 of 24 patients (17%) who presented with disease extending into the prostate, including 3 of 10 (30%) with stromal invasion. These results emphasize the importance of assessing the prostatic urethra and ducts carefully before deciding to eliminate urethrectomy.