Management of the male urethra before and after cystectomy: From the prophylactic urethrectomy to the intraoperative frozen section biopsy of the urethral margin

Abstract

ContextDecision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. ObjectiveTo analyze the changes produced in the management of the urethra from the beginning of the cystectomy up to the present moment. Evidence acquisitionAnalysis 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 synthesisAt 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. ConclusionsCurrently, 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.