Squamous Cell Carcinoma In Situ in a Female Urethral Diverticulum

A prospective cohort trial evaluating sexual function after urethral diverticulectomy

OBJECTIVE

Dyspareunia is a main symptom of urethral diverticulum in the female population, reported up to 60% of patients. Pain may cease after diverticulectomy as published in previous retrospective studies. To date scarce or no data exists on the postoperative outcome in terms of sexual function. The present study wants to quantify sexual function and evaluate lower urinary tract symptoms in sexually active patients after resection of urethral diverticulum.

STUDY DESIGN

In this prospective cohort trial at a tertiary referral center, we evaluated 40 female patients who presented with symptomatic urethral diverticulum and were sexually active. All of them underwent a standardized surgical procedure with inverted U-shape colpotomy between 2008 and 2018. The patients completed the Female Sexual Function Index (FSFI), which is determined by the mean score of the different domains, and underwent urodynamic assessment both at baseline examination before surgery and 12 months postoperatively. For statistical analysis, we conducted a paired Wilcoxon rank sum test analyzing the non-normally distributed non-parametric variables of the female sexual function index.

RESULTS

In two patients a malignancy was found in postoperative histology and received a different therapeutical approach. They have been excluded from statistical analysis. Sexual function improved in all domains (n = 38): total score (Z = -5.4, P < 0.000), satisfaction (Z = -5.3, P < 0.000), pain (Z = -5.4, P < 0.000), arousal (Z = -2.6, P = 0.010), lubrication (Z = -2.4, P = 0.020), desire (Z = -2.6, P = 0.009) and orgasm (Z = -2.2, P = 0.029). Maximum urethral closure pressure deteriorated from 39 to 36 cmH2O (P = 0.0008) and residual urine increased from 10 ml to 20 ml after surgery (P = 0.0019). No statistical significance is found for bladder capacity and free urinary flow.

CONCLUSIONS

All domains of the female sexual function index improved. Patients' bothersome symptoms, mainly pain may cease and sexual satisfaction increases, which is reassuring concerning patients' preoperative consent. We should be aware that occasionally an unexpected malignancy may be detected and it is mandatory to examine all excised tissue histologically. Lower urinary tract function remains clinically unchanged, although maximum urethral closure pressure deteriorated and postvoid residual increased though not being clinically significant.

Urethral diverticulum carcinoma in females-a case series and review of the English and Japanese literature

The aims of our study were to describe our case series of three urethral diverticulum carcinomas (UDC) in women and to review the literature on UDC in females to determine patient characteristics, presenting symptoms and outcomes along with optimal investigations and treatment modalities. A literature search was performed utilizing Medline, EMBASE and the Cochrane library for all papers including case reports on UDC in women published to date. The results along with those of our three cases are detailed. A total of 126 cases of UDC in women have been reported; 75% adenocarcinoma (Adenoca), 15% transitional cell carcinoma (TCC) and 10% squamous cell carcinoma (SCC). Median age at presentation was 53 years (range, 14-81 years). The commonest presenting symptoms were bleeding and retention. Cystoscopy, MRI and trans-urethral biopsy were the commonest methods of diagnosis. Treatment was radiotherapy +/- chemotherapy alone in 21%, local excision +/- radiotherapy in 44%, urethrectomy in 3% and anterior exenteration +/- radiotherapy in 32%. At last follow-up 63% were alive and well, 10% were alive with recurrent cancer and 25% had died from their disease. UDC is rare in women. It is predominantly adenocarcinoma. There is no established treatment and survival is at best moderate. An international registry and consensus on management is needed if this is to be improved.

Primary clear cell adenocarcinoma of a urethral diverticulum treated with multidisciplinary robotic anterior pelvic exenteration

Primary urethral carcinoma is extremely rare and is marked by a variety of clinical symptoms. Primary carcinoma of a urethral diverticulum is still rarer and clear cell adenocarcinoma of the urethra is particularly uncommon (Swartz et al., 2006). Such infrequency has led to inadequate management guidance in the literature for a disease that is often late in presentation and carries substantial morbidity and mortality. This treatable but grave disease deserves definitive curative treatment. We present the first published instance in which it was treated with robotic anterior exenteration. In our case, a 47-year-old female was referred to the urology service for investigation of recurring urinary tract infections. During the workup, the patient was found to have an advanced clear cell urethral adenocarcinoma originating in a urethral diverticulum. We discuss the natural history of this condition, its consequences, and the first instance of its treatment using robotic anterior pelvic exenteration.

Surgery for urethral cancer

Primary urethral cancers represent less than 1% of genitourinary malignancy. Given this is an uncommon disease, there are limited data to guide diagnostic and treatment strategies. Surgical extirpation remains the standard for most patients, with the addition of chemotherapy and radiation therapy in select patients. The surgical approach to urethral cancer depends largely on the location and extent of the tumor.