Female urethral cancer

　　First, etiology

　　The etiology of urethral cancer is unknown, and the possible causes are as follows:

　　1. Long-term chronic inflammation stimulation, such as chronic urethritis;

　　2. Related to birth injury, sexual life injury factors;

　　3. Urethral chemotherapy perfusion secondary or associated with urethral cancer;

　　4. Related to human papillomavirus (HPV), with research showing that 59% of urethral tumors are HPV positive;

　　5. Related to the malignant transformation of urethral proliferative lesions, such as urethral caruncle, papilloma. It has been reported that in a group of female bladder cancer patients who underwent total cystectomy, 6% to 13% developed urethral cancer, mostly involving the proximal urethra. The causes are as follows: (1) Multicentric and homologous origin of urethral epithelial cells: the entire urinary system is covered with transitional epithelium, which is homologous, and the incidence of urethral tumors in multiple organs is 46.2%, and the order of occurrence is in the direction of urine flow; (2) Lymphatic metastasis of urinary system tumors, such as rectal cancer, vaginal cancer, etc., metastasizing to the urethra; (3) Compression during surgery, urethral manipulation, or urination implantation. With the increasing number of transurethral endoscopic treatments for bladder cancer, it should be considered that the tumor tissue cells that have fallen off may implant in the urethra.

　　Second, pathogenesis

　　Urethral cancer is divided into distal and proximal cancers, the former with the cancer focus located in the urethral orifice to the anterior 1/3 segment of the urethra, which can also gradually extend to the entire urethra or involve the vulva; the latter with the cancer focus located in the remaining 2/3 of the urethra, which is more likely to侵犯 the entire urethra.

　　Primary urethral cancer is most commonly squamous cell carcinoma, followed by adenocarcinoma and transitional cell carcinoma, etc. The routes of metastasis include hematogenous, lymphatic, and local infiltration, among which lymphatic metastasis and local infiltration are the main ones. Distant urethral cancer can metastasize to deep and superficial inguinal lymph nodes, while proximal urethral cancer can metastasize to pelvic lymph nodes and internal and external iliac and obturator lymph nodes.

　　Squamous cell carcinoma originates from the distal squamous epithelium or transitional epithelium, which undergoes squamous metaplasia due to repeated stimulation by inflammation. The degree of differentiation varies, with well-differentiated cases showing cancer pearls and intercellular bridges, while poorly differentiated cases show obvious atypicality and a large number of nuclear division figures.

　　Urethral cancer often presents as localized and persistent growth. Delela reported that 50% of patients have localized lesions when they seek medical attention, which can grow to the bladder and vulva at both ends of the urethra, or infiltrate into the vagina.

　　The commonly used staging method for female urethral cancer is the Grabstald staging.

　　O stage: in situ cancer, the lesion is limited to the mucosal layer.

　　A stage: the lesion reaches the submucosal layer.

　　B stage: infiltration of the muscle layer of the urethra.

　　C stage: infiltration of the surrounding organs of the urethra.

　　C1 stage: infiltration of the muscle layer of the vaginal wall.

　　C2 stage: infiltration of the muscle layer and mucosa of the vaginal wall.

　　C3 stage: infiltration of adjacent organs such as bladder, labia, and clitoris.

　　D stage: distant metastasis occurs.

　　D1 stage: metastasis of inguinal lymph nodes.

　　D2 stage: metastasis of pelvic lymph nodes.

　　D3 stage: metastasis of lymph nodes above the bifurcation of the abdominal aorta.

　　D4 stage: metastasis to distant organs.

　　Urethral cancer can lead to the following complications:

　　1, Obstructing the urethra:It can cause difficulty in urination, but urinary retention occurs very rarely.

　　2, Infection:It can penetrate the urethral corpus spongiosum, causing perineal urethritis or leading to perineal abscess; or it can spread to the scrotum, perineum, and form perineal urethral fistula. At the same time, the disease can locally spread and infiltrate surrounding normal tissues, or directly transfer to the distal end to form metastatic tumors.

　　Urethral cancer in women is more common in elderly women, with 3/4 occurring in women over 50 years old. Common symptoms include urethral bleeding and hematuria, other symptoms include frequent urination, dysuria, burning sensation during urination, difficulty in urination, pain, itching, or sexual dissatisfaction. Locally, tumors, necrosis, ulcers, and infections can be seen, with yellow or bloody, smelly secretions exuding from the urethra or vagina. In the late stage, symptoms include weight loss, pelvic pain, perineal abscess, urinary incontinence, urethrovaginal fistula, or urinary retention. A few patients have no symptoms at all and the tumor is discovered during physical examination for other reasons.

　　Tumors located at the distal part of the urethra can be seen early as papillary masses or superficial small ulcers, which gradually develop into cauliflower-like tumors, protruding from the urethral orifice. The hardness of the tumor varies, with ulcers and bleeding on the surface. Local swelling, hardness, and tenderness can be felt in the proximal urethral tumor. Vaginal palpation can estimate the extent of the lesion. Tumors located in the proximal urethra may sometimes manifest as diffuse infiltration of the urethra. Biopsy of living tissue can confirm the diagnosis.

　　It is generally believed that female urethral cancer originates from periurethral glands, immunohistochemistry shows positive staining of PSA, the serum PSA level of patients increases, and it rapidly decreases after surgical resection of the tumor, so serum PSA monitoring before and after surgery is helpful for diagnosis and judgment of efficacy.

　　Staging of female urethral cancer: Stage 0: In situ cancer, Stage A: Invasive submucosal layer, Stage B: Invasive urethral surrounding muscle, Stage C: Periurethral (C1 vaginal muscle layer, C2 vaginal muscle and mucosa, C3 adjacent structures such as bladder, labia, clitoris), Stage D: Metastasis (D1 inguinal lymph nodes, D2 pelvic lymph nodes below the aortic bifurcation, D3 lymph nodes above the aortic bifurcation, D4 distant metastasis).

　　Early symptoms are often asymptomatic, easy to ignore, and once symptoms appear, they include frequent urination, urgency, and difficulty urinating, even leading to urinary retention. There is often urethral bleeding or bloodstains on the underwear, gross hematuria is rare, and sometimes there is an increase in vaginal discharge, urinary incontinence, and difficulty in sexual intercourse. In the late stage, cauliflower-like masses appear at the urethral orifice, and there is a foul smell when complications such as infection occur.

　　Any urethral orifice exostosis should be vigilant of the possibility of urethral cancer, and a biopsy should be performed if necessary to confirm the diagnosis. Vaginal palpation can feel urethral masses.

　　The distal two-thirds of the female urethra is covered by squamous epithelium, the proximal one-third is covered by transitional epithelium, and occasionally, the entire urethra is covered by squamous epithelium. Periurethral glands are commonly found near the urethral orifice, occasionally in the middle segment of the urethra, and a few glands are found near the internal orifice of the urethra. Urethral cancer originates from different sites and presents different pathological types. Among 73 patients from 11 groups in China, the pathological types were squamous cell carcinoma in 34 cases, adenocarcinoma in 28 cases, transitional cell carcinoma in 4 cases, mixed squamous and adenocarcinoma in 4 cases, undifferentiated cancer in 2 cases, and malignant melanoma in 1 case. Clinically, it is generally divided into distal and proximal urethral cancer: segmental urethral cancer occurs in the distal one-third of the urethra, and the tumor can develop into total urethral cancer; tumors located in the middle or proximal segment of the urethra are difficult to exclude the involvement of other parts of the urethra, especially when the tumor is large and involves adjacent structures, it should be considered as total urethral tumor. Urethral cancer sometimes occurs in urethral diverticula.

　　The malignancy of urethral cancer is generally classified into 3 grades, with grade III being the highest. The grade of distal urethral cancer is usually lower, while that of total urethral cancer is higher.

　　The etiology of urethral cancer is unknown, and there may be no association between urethral hemangioma and the occurrence of cancer. However, urethral cancer in the early stage resembles urethral hemangioma, polyp, or papilloma, and needs to be differentiated. Urethral leukoplakia may be a precancerous lesion.

　　The spread of urethral cancer is often direct extension, with invasion of the bladder neck proximally, and the vestibule, labia, and vagina distally, eventually forming a urethrovaginal fistula. Urethral cancer invades deep tissue rapidly. Advanced urethral cancer is difficult to differentiate from vulvar cancer in appearance. Urethral cancer mainly spreads through lymphatic channels: distal urethral cancer to inguinal lymph nodes, some lymphatic vessels can ascend to above the pubic symphysis, enter the pelvis between the ischiorectal muscles, and reach the external iliac lymph nodes. Proximal urethral cancer to obturator and external, internal iliac lymph nodes. In the initial diagnosis, 20% to 57% of patients have enlarged inguinal lymph nodes, of which 20% to 80% are metastases. The lymphatic metastasis rate of total urethral cancer is higher than that of distal urethral cancer. Most patients with distant metastasis have regional lymphatic metastasis. Common sites of distant metastasis are lung, liver, bone, and brain.

　　Prognosis: This disease is rare. According to clinical symptoms, biopsy should be performed as soon as possible to clarify the diagnosis. Literature reports that the survival rate of surgery combined with radiotherapy is higher than that of radiotherapy alone. The comprehensive application of radiotherapy and chemotherapy can strive to preserve the urethra, which can reduce the physical and psychological impact on the patient. The prognosis is mainly related to pathological stage, pathological type, and treatment method, while age and course of disease have little impact on prognosis. Therefore, early diagnosis and early treatment are still effective means to improve survival rate. There is a high risk of distant metastasis within 2 years after treatment, so attention should be paid to follow-up observation.

　　1. X-ray examination

　　The proximal urethral cancer can directly invade the pubic bone, causing bone destruction.

　　2. CT and MRI examination

　　It is helpful to examine pelvic lymph nodes, judge the stage, and understand whether there is metastasis of pelvic lymph nodes.

　　3. Lymphangiography

　　It is helpful for diagnosing pelvic lymph node metastasis.

　　4. Endoscopic examination

　　Urethral cystoscopy can observe the lesion and take a biopsy.

　　5. Pathological examination

　　1. If any urethral verruca is suspicious of urethral cancer, a biopsy should be performed directly.

　　2. Urine swab deep into the urethra for smearing and then perform cytological examination.

　　3. Urinary secretion, urine sediment, urethral lavage or brushing material can be examined by cytology or FCM analysis to detect urethral tumor cells.

　　1. Food therapy for female urethral cancer

　　After patients with malignant tumors receive surgery, radiotherapy, and chemotherapy, they often suffer significant damage to their original vitality, have an extremely weak physique, and a decreased ability to resist disease. At this time, if food therapy is used to assist, it will be beneficial to the recovery of the body.

　　1. American Ginseng and Ejiao Soup: 12 grams of American ginseng, and 30 grams of Ejiao. Boil the American ginseng into a decoction, grind the Ejiao into powder, take 10 grams each time, and take with the ginseng decoction. Take one dose per day, divided into three doses (American ginseng is chewed). This formula is suitable for people with deficiency of both Qi and blood after radiotherapy and chemotherapy, those with weak bodies, hair loss, and decreased white blood cells.

　　2. Lily and Dendrobium Pork Soup: 30 grams of lily, 15 grams of dendrobium, and 150-200 grams of lean pork. The above three ingredients are placed in a pot, with an appropriate amount of water added, and simmered until tender. Drink the soup, eat the meat, and consume the lily. Take one dose per day. This formula can be used as a food therapy during radiotherapy and chemotherapy for lung cancer, esophageal cancer, and gastric cancer patients.

　　3. Shenqi Gaojia Decoction: 12 grams of ginseng, 60 grams of raw Astragalus, 30 grams of Chinese wolfberry, and 100 grams of turtle. The Astragalus slices are packaged separately. The above four ingredients are placed in a pot, with an appropriate amount of water added, and simmered over low heat. Eat the ginseng, Chinese wolfberry, and turtle, and drink the soup. Take one dose per day. This formula is suitable for people with deficiency of both Qi and Yin after radiotherapy and chemotherapy, and those with extremely weak physique.

　　4. Pear juice honey seabuckthorn syrup: 1 part winter pear juice, 3 parts honey, 1 part seabuckthorn juice, mix the three juices and blend well for drinking. This recipe is suitable for symptoms such as thirst, dry throat, dry lips, low fever, irritability, constipation, and jaundice during radiotherapy and chemotherapy.

　　5. Dogwood and chrysanthemum dew drink: 15 grams of dogwood, 30 grams of white chrysanthemum, 6 grams of licorice, cut into thin slices, put into a teapot, pour boiling water, cover for 5-10 minutes, and drink as tea. Take one dose a day. This recipe is suitable for symptoms such as dizziness, tinnitus, thirst, irritability, and insomnia during radiotherapy and chemotherapy for various cancer patients.

　　6. Sweet potato porridge: 500 grams of sweet potato (cleaned, unpeeled), cut into small pieces, 250 grams of glutinous rice, cook together into a thin gruel, finish in one day. This recipe can be used as postoperative food therapy for patients with esophageal cancer, gastric cancer, and colon cancer, and has a certain effect on preventing cancer metastasis.

　　Secondly, Foods that are good for women with urethral cancer

　　1. Eat more foods with anti-bladder and urethral tumor effects, such as toads, frogs, snails, kelp, seaweed, tortoise shell, turtle, sea cucumber, water snake, Job's tears, water chestnut, walnut, goat kidney, pork kidney, dolichos, sand worm, perch, mackerel, and so on.

　　2. For urethral obstruction, eat kelp, wakame, seaweed, and green crab.

　　3. For infection, eat yellowfish bladder, shark fin, water snake, pigeon, jellyfish, lotus starch, buckwheat, malan head, earth ear, turnip, olive, eggplant, fig, mung bean sprouts, soy milk, amaranth, seaweed, eel, and so on.

　　4. For bleeding, eat celery, chrysanthemum, leek, winter melon, black plum, dried persimmon, sesame, lotus seeds, sea cucumber, and mouse meat.

　　Thirdly, Foods that women with urethral cancer should not eat

　　1. Avoid smoking, alcohol, coffee, and cocoa.

　　2. Avoid spicy, hot, and blood-moving foods.

　　3. Avoid moldy, fried, and greasy foods.

　　Firstly, Prevention

　　There are no special effective preventive measures for this disease. Changing bad lifestyles and paying attention to personal hygiene are the key to prevention.

　　Secondly, Preoperative Preparation

　　1. Start semi-liquid diet 2-3 days before surgery.

　　2. Oral intestinal antibiotic drugs 5 days before surgery.

　　3. Oral laxatives 24 hours before surgery.

　　4. Clean enema before surgery on the night before and on the day of surgery.