Indications for urethrectomy in men undergoing single stage radical cystectomy for bladder cancer

During a 10-year period 174 consecutive male patients underwent radical cystectomy with pelvic lymph node dissection for transitional cell cancer of the bladder. Urethrectomy, either performed en bloc with the cystectomy or secondarily, was required in 23 patients. Of these 23 patients 9 died of metastatic disease and 4 deaths were believed to be directly related to development of tumor in the urethra. A careful review of our data suggests that patient selection is possible so that urethrectomy in all patients undergoing cystectomy may be avoided, while maintaining the ability to treat those at risk for carcinoma in the retained urethra before invasion occurs. We recommend the following indications for urethrectomy: 1) en bloc cystourethrectomy for clinically overt involvement of the anterior urethra with carcinoma or tumor extending into the prostatic urethra, 2) immediate or delayed total urethrectomy either during the initial hospitalization or within 2 months of cystectomy for all patients with pathological evidence of invasion of the prostate (P4) or carcinoma in situ of the prostatic urethra, 3) indefinite close followup of all patients whose bladder specimens demonstrate carcinoma in situ (urethral cytology within 4 months of cystectomy and every year thereafter, and immediate total urethrectomy for any urethral cytology positive for malignant cells), and 4) immediate total urethrectomy for any patient experiencing bloody urethral discharge.