This review article addresses the pertinent issues regarding management of the urethra in the setting of
transitional cell carcinoma of the bladder. This topic is often a subject of considerable
confusion among urologic surgeons and is timely in this era of routine orthotopic diversion. The risk of urethral recurrence in the retained urethra is approximately 10%. Of the potential risk factors that may predispose the retained anterior urethra to metachronous
transitional cell carcinoma, involvement of the prostatic urethra, glands, or stroma is the most significant. In this circumstance, if a cutaneous diversion is performed, urethrectomy is indicated. Conversely, for orthotopic diversion, involvement of the prostatic urethra with
transitional cell carcinoma is not a
contraindication to proceeding. Orthotopic diversion should be aborted, and cutaneous diversion and urethrectomy should be performed, only if intraoperative frozen section of the prostatic urethra margin is positive. In a woman, en bloc urethrectomy should be included with
cystectomy if cutaneous diversion is planned. Although
tumor involvement of the female bladder neck is a risk factor for
urethral disease, prospective studies suggest that intraoperative frozen section evaluation of the proximal urethra is more accurate and can be used to exclude orthotopic diversion at
cystectomy. Using these and other guidelines, management of the urethra should be straightforward and less concerning for the urologic surgeon.