Risk factors and outcomes of urethral recurrence following radical cystectomy

Background: Conflicting data exist regarding predictors of urethral recurrence (UR) following radical cystectomy (RC) as well as variables associated with survival in patients who experience UR.

Objective: To evaluate the incidence, risk factors, and outcomes of patients with UR.

Design, setting, and participants: We reviewed 1506 patients who underwent RC to identify patients with UR. Median follow-up after RC was 13.5 yr (interquartile range [IQR]: 10.5-18.4).

Intervention: Urethrectomy.

Measurements: Cox proportional hazard regression models were used to analyze predictors of UR and evaluate factors associated with death from urothelial carcinoma (UC) in patients who experienced UR. Cancer-specific survival (CSS) for patients with UR, stratified according to the mode of diagnosis (abnormal urethral cytology vs symptoms), was estimated using the Kaplan-Meier method and compared with the log-rank test.

Results and limitations: UR was identified in 85 patients (5.6%) at a median of 13.3 mo (IQR: 6.1-23.2) after RC, including 80 of 1243 (6.4%) who underwent cutaneous urinary diversion and 5 of 242 (2.1%) who received an orthotopic neobladder (p=0.002). On multivariate analysis, prostate involvement with UC (hazard ratio [HR]: 4.89; p<0.0001), bladder tumor multifocality (HR: 2.34; p=0.001), and orthotopic diversion (HR: 0.34; p=0.02) were significantly associated with the risk of UR. The 5-yr CSS after UR diagnosed by cytology was 80% versus 41% for patients who presented with symptoms (p<0.0001). Patients with symptomatic UR were noted to have significantly higher stage disease at urethrectomy (p=0.04) and tended toward an increased risk of death from UC (HR: 1.94; p=0.08). Limitations included retrospective study design.

Conclusions: Prostate involvement with UC, tumor multifocality, and type of urinary diversion are significantly associated with UR following RC. Although UR is relatively uncommon, the detection of asymptomatic UR was associated with significantly lower stage disease and improved patient survival, suggesting the importance of continued postoperative evaluation of the urethra.