Actitud con la uretra antes y durante la cistectomía en el varón: de la uretrectomía profiláctica a la biopsia por congelación del margen uretral

Abstract

Context Decision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. Objective To analyze the changes produced in the management of the urethra from the beginning of the cystectomy up to the present moment. Evidence acquisition Analysis of original articles and reviews obtained through a search in PubMed, related with the risk factors of urethral recurrence (UR) and with the management of the urethra in patients subjected to radical cystectomy. Evidence synthesis At first, many authors recommended urethrectomy simultaneously with cystectomy. The identification of risk factors of the bladder tumor related with the appearance of UR limited the indication of prophylactic urethrectomy in patients with multifocal disease and with prostate tumor involvement. The development of orthotopic bladder substitutes (OBS) complicated the situation. The involvement the prostatic urethral tumor was maintained as the principal risk factor for UR, which then gave importance to its pre-cystectomy staging. Series of OBS observed a lower incidence of UR regarding patients with skin derivations, even in cases with prostatic urethral involvement. Prostatic urethral involvement stopped being a contraindication for OBS when the frozen section biopsy of the urethral margin was negative. Conclusions Currently, most authors agree that the intraoperative frozen section biopsy of the urethral margin will determine whether an OBS or urethrectomy should be performed. In spite of this, we have very few series in which this approach has been systematically used and with sufficient follow-up.