Rare urological malignancy · KIMS Secunderabad
Urethral Cancer — A Rare Malignancy Requiring Early Diagnosis and Specialist Treatment
Urethral cancer is the rarest of the urological cancers — accounting for less than 1% of all genitourinary malignancies. Despite its rarity, it is clinically important because delayed diagnosis (which is common, given how rarely it is considered) allows a potentially curable early-stage cancer to progress to locally advanced disease. Urethral cancer occurs in both men and women — and is actually more common per capita in women than men, though men have a slightly higher absolute incidence. The most common histological types: squamous cell carcinoma (SCC — the most common, arising from the distal urethral mucosa), transitional cell carcinoma (TCC — arising from the proximal urethra closer to the bladder), and adenocarcinoma (arising from the periurethral glands — Cowper's glands in men, Skene's glands in women).
Risk factors
Recognised risk factors for urethral cancer
Urethral stricture — chronic inflammation from urethral stricture predisposes to SCC in the area of chronic irritation and metaplasia. Urethral cancer arising in a strictured urethra is a recognised association.
Recurrent urinary tract infections and sexually transmitted infections — chronic urethral inflammation.
HPV infection — HPV 16 and 18 are associated with urethral SCC, particularly in the anterior urethra.
Prior bladder cancer — the urothelium-lined proximal urethra is a site of field change in patients with a history of bladder cancer. Urethral recurrence after cystectomy is a specific risk.
Urethral diverticula in women — the mucosa of a urethral diverticulum has an increased risk of adenocarcinoma.
Clinical features
Symptoms and signs of urethral cancer
Haematuria or urethral bleeding — blood at the urethral meatus, not associated with voiding, is the most specific symptom of urethral cancer. Any urethral bleeding in an adult should prompt urethroscopy.
Urethral discharge — persistent, blood-stained or purulent discharge from the meatus.
Obstructive symptoms — reduced urinary stream, hesitancy, and incomplete emptying from the tumour narrowing the urethral lumen.
Palpable mass — a palpable firm mass along the penile urethra or in the perineum (bulbar urethra) or anterior vaginal wall (in women with urethral cancer).
Inguinal lymphadenopathy — lymph node metastasis from the distal urethra (which drains to the inguinal nodes).
Diagnosis and staging at KIMS
Urethroscopy with biopsy
The essential diagnostic procedure. Direct visualisation of the urethral mucosa with a flexible or rigid urethroscope. Any suspicious lesion — irregular mucosa, ulceration, papillary growth, or mass — is biopsied. Urethroscopy can be performed in the KIMS urology outpatient clinic under local anaesthesia (flexible) or in theatre under general anaesthesia (rigid). Any urethral stricture with associated mucosal irregularity must be biopsied — not assumed to be benign.
MRI pelvis — local staging
MRI provides the most accurate assessment of tumour extent — depth of invasion into the urethral wall, involvement of the corpus spongiosum (in men), anterior vaginal wall (in women), prostate, or bladder. The local extent determines surgical approach and resectability.
CT of the chest, abdomen, and pelvis — systemic staging
Identifies lymph node involvement (inguinal nodes for distal urethral tumours; pelvic nodes for proximal urethral tumours) and distant metastases.
Treatment
Distal urethral cancer
(Anterior urethra, meatal, or pendulous urethra in men; distal one-third of the urethra in women.) Wide local excision with clear margins — often achieving cure for small, localised tumours. Distal urethrectomy — removal of the distal urethra with perineal urethrostomy for urinary diversion — for larger tumours. Radiotherapy as an alternative to surgery in selected cases (preserving urethral function).
Proximal urethral cancer
(Bulbar, membranous, or prostatic urethra in men; proximal two-thirds in women.) Radical surgery is required — anterior exenteration (removal of the urethra, bladder, and in women the vaginal anterior wall, uterus, and ovaries) with urinary diversion (ileal conduit). Neoadjuvant chemotherapy (platinum-based) for locally advanced disease. Prognosis is significantly worse for proximal urethral tumours.
Lymph node management
Inguinal lymph node dissection (bilateral) for clinically node-positive distal urethral tumours. Pelvic lymph node dissection for proximal urethral tumours. Radiotherapy to the inguinal and pelvic nodes for high-risk cases not suitable for surgical dissection.
Any persistent urethral bleeding — blood at the urethral meatus not associated with voiding — should be evaluated by urethroscopy within 2 to 4 weeks. Urethral cancer presenting at an early stage (confined to the urethral mucosa) has excellent prognosis after surgery. Delayed presentation with corpus spongiosum invasion or lymph node involvement dramatically reduces survival. Call KIMS on 040-4488-5000 for an urgent urology appointment.
Book an Urgent Urology Assessment for Urethral Bleeding at KIMS
Frequently Asked Questions — Urethral Cancer
The most specific symptom is blood at the urethral meatus — distinct from haematuria (blood in the urine during voiding). Urethral cancer may bleed from the tumour surface independently of voiding. Other symptoms: persistent urethral discharge, a change in the urinary stream (reduced flow, split stream, spraying), a palpable lump along the urethra or in the perineum, and inguinal lymph node enlargement in advanced disease. These symptoms are often attributed to other conditions (urethral stricture, prostatitis, STI) before urethral cancer is considered — which is why delayed diagnosis is common. Urethroscopy with biopsy is mandatory for any unexplained urethral symptom persisting beyond 4 to 6 weeks.
Urethral cancer has an unusual epidemiology among urological cancers — it is more common per capita in women than men (women have a 4 to 1 higher per capita incidence despite the longer male urethra providing more mucosal surface). This is because in women, the short urethra is surrounded by HPV-susceptible squamous and transitional epithelium, and adenocarcinoma from the Skene's glands is a recognised entity. In absolute numbers, given the larger male population, male urethral cancer cases slightly outnumber female cases in India. Both sexes benefit from early urethroscopic diagnosis.
Long-standing urethral stricture is a recognised risk factor for urethral SCC — the chronic inflammation and epithelial metaplasia at the site of the stricture predispose to carcinogenesis. The latency between stricture formation and SCC development is typically 10 to 25 years. Any patient with a long-standing urethral stricture who develops urethral bleeding, a change in the character of the stream beyond what is explained by the stricture alone, or a palpable mass at the stricture site should have urethroscopy and biopsy — not simply urethroplasty for the stricture.
Urethral cancer has widely varying survival depending on stage and location. Distal urethral tumours confined to the mucosa — 5-year survival above 70 to 80% with surgery. Proximal urethral tumours with corpus spongiosum invasion — 5-year survival 20 to 40%. Tumours with lymph node or distant metastases — 5-year survival below 20%. The distal location is favourable because excision is technically simpler and lymphatic drainage is to the inguinal nodes (which are surgically accessible). Proximal urethral tumours require radical pelvic surgery and have a worse prognosis from both the disease and the surgical morbidity.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology KEM Mumbai, Member SIU), urethroscopy and biopsy, MRI pelvis local staging, CT for systemic staging, distal urethrectomy and wide local excision, radical surgery with anterior exenteration and urinary diversion for proximal urethral cancer, inguinal and pelvic lymph node dissection, chemotherapy coordination. MDT tumour board review of every urethral cancer case. NABH and NABL accredited. Call 040-4488-5000.