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Complex strictures - Urethral Cancer

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Squamous cell carcinoma of the urethra is rare. I have seen only five patients of Squamous carcinoma in last twenty years of my practice and all patients had Lichen sclerosus as a precancerous disease. All patients presented with lump in the perineum. In two patients the lumps were incised thinking that they were periurethral abscesses. Two patients were referred after first stage of Johansson’s urethroplasty for non healing of the wound. One patient was diagnosed on endoscopy.

Traditional  treatment for penile urethral cancer will be decided by the local extent of the disease and may vary from wide local excision to partial or total amputation of the penis. For bulbar urethral cancer depending upon the local invasion wide local excision and or total amputation of penis may be required.  For large bulbar urethral cancers and posterior urethral cancers traditional treatment involves total amputation of penis with cystoprostato urethrectomy and lymph node dissection and the patient needs diversion may be ileal conduit. The local recurrence rate after such a major operation is very high, five year survival is less than 20% so 80% patients may die because of local recurrence and its problems. So in two patients, I have utilized a new technique of wide local excision followed by neo urethra formation with the dorsal penile skin. Under anesthesia a circumcision incision is made the dorsal penile skin far away from the side of the cancer is preserved with the its fascia. Total amputation of the penis with bilateral orchidectomy is performed in the traditional way.  As the patient may have a perineal incision for urethroplasty or biopsy or drainage in (thinking it is a periurethral abscess) perineal skin use may not be possible.  In one patient the prostate also was removed. Biopsies from the bladder neck were normal. For prostate removal inferior pubectomy was useful to control the dorsal vein complex. The bladder neck was preserved and was competed. If I introduced a forceps inside the bladder neck urine flowed out freely but as soon as I removed the forceps urine leak stopped immediately. Now the dorsal penile skin was turned into a tube with skin as its lining and was anastomozed to the bladder neck. The patient voided well and was cotenant. In second patient, we had taken biopsies from the prostatic urethra and they were normal so we could preserve the prostate and anastomose the new urethra to the apex of the prostatic urethra. One patient died within six months due to local recurrence but one patient has survived for more than a year and is still free from recurrence. This new technique of wide local excision and neo urethra allows the patient to void perineally and is continent it also prevents supra major surgery with ileal conduit as described above.

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