Urethral Surveillance after Radical Cystectomy

Abstract

Introduction Radical cystectomy (RC) is commonly performed with curative intent for primary or recurrent high-risk non-muscle-invasive and muscle-invasive bladder cancers. Urethral recurrence (UR) within the residual urethra, often proximally where the epithelial lining comprises urothelial cells, is a rare but well-described occurrence associated with adverse clinical outcomes. Current national guidelines therefore suggest that male patients with a defunctioned urethra should undergo annual endoscopic or urethral washing surveillance for 5 years following RC, to identify UR early, where local disease management (e.g., urethrectomy) may still be possible. Anecdotally, however, urethroscopy and urethral washing cytology appear to be infrequently performed. Our regional trainee-led research collaborative evaluated the frequency and timing of urethral surveillance in the West Midlands in comparison to National Institute for Health and Care Excellence (NICE) guidelines. Patients and methods Our 10-year cross-sectional retrospective regional analysis included 495 patients from 2008–2018. Clinical and demographic data were collected alongside cross-sectional staging and imaging, and timings and frequency of urethral endoscopic surveillance or urethral washing cytology. Results Overall, 159 (35.2%) patients received one (or more) surveillance urethroscopy. A minority of surveillance urethroscopies were annual, with hugely variable frequency or intervals ranging from every 4–50 months. Only 81 (19.6%) patients had urethral surveillance in keeping with the frequency suggested by NICE guidelines. At 10 years, disease-specific mortality was 42.0%, and overall or all-cause mortality was 44.7%. The overall UR rate (as detected by staging CT and/or urethroscopy) was 1.0% (n = 4); all four cases of UR were found in patients with positive urethral margins after RC who did not undergo immediate urethrectomy. Conclusions Our regional urethral surveillance practice following RC is heterogeneous and suboptimal in comparison to NICE guidelines. Our UR rate was so low that we are unable to assert whether early detection has any clinical benefit, and therefore we cannot advocate routine urethral surveillance, but suggest that patients with positive urethral margins should be offered immediate urethrectomy post RC. In addition, we encourage collaborative urological research and data collection to generate higher volume series, more representative and generalisable data, and more meaningful conclusions.