Urethral cancer in India

A cancer occurs when cells in any part of the body starts dividing uncontrollably. A cancer that affects the urethra is called as urethral cancer. Urethra is tube that connects the urinary bladder to the outside. In men the urethra opens to the penis. In women it opens to the urinary meatus located above the vagina. In men the urethra is about eight inches long. It extends from the urinary bladder and passes through the prostate and ends up in the penis. In women it is about one and a half inches long.

A cancer of the urethra affects the proper outflow of urine. Urethral cancer is one of the less common cancers of the urinary system. Men are much more commonly affected by the disease than women. In men a urethral cancer may occur in the proximal or distal portions of the urethra. The main treatment for urethral cancer is surgery. Chemotherapy and radiation may be used in certain situations along with surgery.

Urethral cancer is a type of cancer that occurs in the urethra of males and females. Urethra is the duct that transports urine from the urinary bladder to the outside through the external urethral orifice.

 In males the urethra is about 20 cm long and in females it is about 4 cm long. The external urethral orifice is located in the tip of the penis in males and just above the vaginal opening in females.

The symptoms of urethral cancer are usually present only during the advanced stages of the disease. This is especially so, for proximal urethral cancers that are located close to the urinary bladder and the prostate.

Most of the problems of urethral cancers are linked to problems with urination. Since these symptoms are very common to various other urinary problems it is difficult to diagnose urethral cancer symptomatically.

The most common symptoms of urethral cancer are  

·       Presence of blood in the urine or haematuria

·       Trouble starting urination

·       Diminished flow of urine 

·       Having to strain to void

·       Increased frequency of urination

·       Increased frequency of urination in the night or nocturia

·       Hardening of tissues in the perineum and labia in females and the penis in males

·       Itching sensation during urination

·       Incontinence or uncontrolled flow of urine

·       Pain during or after sexual intercourse or dyspareunia

·       Pain during urination or dysuria

·       Recurrent episodes of urinary tract infection (UTI)

As already said, the above mentioned symptoms are common to various other urinary problems. Urethral strictures, urethritis, an enlarged prostate as in benign prostatic hyperplasia, prostate cancers etc can also create the above-mentioned symptoms.

Urethral cancer causes

The exact cause of urethral cancer is still not clear. Certain changes in certain cells make them multiply uncontrollably causing the cancer.

 Certain factors increase the risk of developing urethral cancer. They include

•       Previous history of urethral cancer

•       History of urinary bladder cancer

•       History of sexually transmitted diseases

•       Age above sixty

Urethral cancer diagnosis

 A diagnosis of urethral cancer is done through various tests. They include

•       Physical examination: A physical examination checks for unusual signs of  a disease, 

•      Pelvic examination: In this the inside of the pelvis is examined through the vagina

•       Digital rectal examination: The rectum is examined using gloved fingers to look for any abnormal growths

•       Urine analysis: The urine is analysed for any abnormal findings. Presence of any abnormal cells is also looked into. 

•       Blood tests: To look for any abnormal blood findings 

•       CT scans: Provides detailed images of the urethra and adjoining structures. This helps to assess the extent and spread of the disease.

•     Ureteroscopy: This procedure uses an instrument called ureteroscope to examine the urethra, urinary bladder etc. The ureteroscope has a camera that beams images to a monitor.

•       Biopsy: Is done as a confirmatory test if other tests indicate a cancer.

The outcome of urethral cancer treatment varies, depending on the location of the tumour and which stage the cancer is in. Cancer that is only ureter may be cured with surgery. Cancer that has spread to other organs is usually not curable.

Types of urethral cancer

There are three main types of urethral cancer. Most of the urethral cancers occur in the portion of urethra that extends to the penis. Cancers may also occur in the portion of the urethra that passes through the prostate and close to the bladder. Distal urethral cancers occur in the part of the urethra in the penis. Proximal urethral cancers occur in the portion close to the bladder. Proximal cancers spread wide while distal urethral cancers are confined to a particular space.

Squamous cell carcinoma is the most common form of urethral cancer and usually occurs in the penis part of urethra. Transitional cell carcinoma occurs in the portion of the urethra that passes through the prostate. Adenocarcinoma of the urethra is commonly seen in the portion of the urethra close to the bladder.

Urethral cancer staging

Urethral cancer is staged in a scale of one to four. In stage one the cancer is confined to a particular part of the urethra without any lymph node involvement. In stage four, the cancer has spread to other organs of the body. Stages two and three denote the extent of cancer and the involvement of lymph nodes. The stage of the cancer plays an important role in the framing of treatment.

Urethral cancer treatment

The most common choice of treatment is surgery followed by radiation therapy and chemotherapy. Radiation therapy may be done before or after surgery. The aim of radiation therapy is to shrink the tumour or to destroy the remnants of cancer after surgery. Chemotherapy is administered if the cancer had spread to other organs of the body. 

Surgery for urethral cancer

Surgery is one of the most preferred methods of treating urinary cancer. The aim of the surgery is to remove the tumour along with a margin of healthy tissue. Various surgical techniques are used to treat urethral cancer. The choice of the technique depends on the stage of the disease.

The surgical removal of cancer affected lymph nodes may also be necessary in certain cases. At times the urinary bladder and a part of the penis or vagina may also be removed along with the urethra. In situations where the penis is removed the surgeon may create a stoma or opening in the abdomen. The urine from the bladder is then directed to the stoma for evacuation.

Various types of surgeries are performed for urethral cancer. They include

·       Open excision surgery:  This is most conventional technique followed for urethral cancer surgery. In this surgery the cancer along with a 2 cm margin of healthy tissue is removed. The surgery is usually done under general anaesthesia. Spinal anaesthesia may be used in certain cases.

·     Mohs surgery:  This is a conservative and tissue-sparing type of surgery. The surgery aims to remove cancerous tissues in small layers to retain as much of normal tissue as possible. This is effective only in primary stage tumours that involve only the superficial layers of the urethra.

·      Transurethral resection (TUR): This is a minimally invasive surgery. Surgery is done through a catheter that is inserted through the urethra. The catheter contains an instrument called a cystoscope that provides a detailed picture of the urethra and urinary bladder. Another instrument called a resectoscope is used to cut the cancer cells and there by removing the entire cancer mass.

·       Electro-resection with fulguration: This is a minimally invasive surgery. The surgery is done with the help of instruments that are inserted through the urethra. A small loop of wire that is heated with the help of electric current is used to burn away the cancerous tissues.

·       Laser surgery:  In this minimally invasive surgery, a precise beam of laser, is used to destroy the cancerous tissue. The surgery is a bloodless one and something akin to a radiation therapy.

The type of surgery depends on the location, size, depth, involvement of other structures close to the urethra, invasiveness etc.

Cysto-urethrectomy: This surgery is done for distal urethral cancers that also involves the urinary bladder. In this surgery the urinary bladder is also surgically removed along with the urethra.

Cysto-prostatectomy: In this surgery, the urinary bladder and the prostate gland is removed along with the urethra.

Anterior exenteration: This is a type of urethral cancer surgery in women invasive cancer. During the surgery, the urethra, the urinary bladder, and whole or part of the vagina is surgically removed. Plastic surgery can help rebuild the vagina.

Partial penectomy: This is usually done in distal urethral cancers that originate in the penile portion of the urethra. In this surgery the part of the urethra affected by cancer is removed along with a part of the penis surrounding the cancer. Plastic surgery may be done afterwards to restore the shape of the penis if necessary.

Radical penectomy: This surgery is done for urethral cancers that have extended along the length of the penis. The urethra and the whole of the penis is removed during the surgery. Plastic surgery is an option to rebuild the penis.

Lymph node dissection: The surgery involves the removal of lymph nodes to which the cancers have spread. In the case of urethral cancer, the commonly affected lymph nodes are those of the pelvis and the groin.

Chemotherapy for urethral cancer
Chemotherapy may be used in treating urethral cancer along with surgery. Chemotherapy may be done before the surgery to shrink the tumour and after the surgery to destroy any remnants of the tumour. Chemotherapy before surgery is called as neo-adjuvant chemotherapy and after surgery is called adjuvant chemotherapy.

Radiation therapy for urethral cancer

Radiation therapy may be done either along with surgery or as a palliative measure in advanced urethral cancers, that involve neighbouring structures.

External beam radiation therapy or brachytherapy may be used according to the stage and anatomic location of the cancer.

Urethral cancer treatment is available in all major hospitals in India. The surgeries for urethral cancer require a hospitalisation period of about a week. Further time will have to be spent in the hospital if one has to undergo a plastic surgery. Urethral cancer treatment cost will depend on the type of surgery and period of hospitalisation. Generally, one needs to spend about two weeks in India for treatment.

Surgery costs depends on the type of surgery to be performed and the hospital where it will be performed.

Here’s a quick breakdown of other treatment costs:

Cost of evaluation – Approx. 1,500 USD

Chemotherapy – Approx. 1,300 to 1,500 USD per cycle

Pre-operative investigations - 2500 USD

Apart from these, patients will also need to factor in additional costs such as travel fares, hotel stay costs for themselves and their travelling partner(s), medicines, food expenses etc.

Urethral cancer is a type of cancer that originates in the urethra, the duct that carries urine stored in the urinary bladder to the outside. Urethra is anatomically different in males and females. A male urethra is about 20 cm long in males, while in females it is about 4 cm long.

A five-year survival rate for primary proximal urethral cancer that is treated with surgery and radiotherapy is more than sixty percent. For invasive cancers of the urethra the average recurrence rate in five years is more than fifty percent.   

One of the most important factors of urethral cancer is that it is under-detected or even undetected till an advanced stage. This is essentially because urethral cancer is a very rare type of cancer. The symptoms of urethral cancers resemble that of various other common types of urinary problems. By the time doctors rule out other similar conditions and start suspecting a urethral cancer, the disease will be in an advanced stage.

An early diagnosis and early treatment for urethral cancer can increase the survival rate to a great extent. The response to treatment of urethral cancers hinges on many factors. The most common among them are:

Anatomical location of the tumour- A superficial urethral tumour located in the distal part of the urethra is more easily treatable. The chances of it involving adjacent structures are very less. Tumours in the proximal parts may involve the urinary bladder and the prostate in males and the vagina in females. This makes treatments less effective.

Size of the tumour -A primary urethral cancer that is smaller in size can be better treated than a cancer that involves the deeper layers.

Type of tumour- In men squamous cell carcinomas are more difficult to treat than adenocarcinomas. But in women adenocarcinomas have the worst survival outlook.

Involvement of the lymph nodes- The spread of the cancer to the adjacent and distant lymph nodes signifies the spread of the disease. There will be chances of spread to other organs in the body as well.

There are various treatments for urethral cancer like surgery, radiotherapy and chemotherapy. Apart from superficial tumours in the distal urethra, that responds to surgery, all other types of urethral cancers are better treated with a multi-modal approach. Surgery along with radiotherapy or chemotherapy is best suited for advanced stage urethral cancers.

Late stage urethral cancers may require the surgical removal of the urinary bladder, the prostate gland, the penis or vagina along with the urethra. From a physical and psychological point of view, organ preserving surgical modality will be an elective choice.  This is mainly because of the preservation of urinary and sexual functions. Organ preserving surgeries should only be done if there is total confidence that cancer has not affected the preserved structures.