Distal urethral carcinoma: Contemporary management with phallus preserving techniques

IntroductionPrimary urethral carcinoma is a rare clinical entity with an incidence of 1 case per million in the United Kingdom. Cancers of the distal urethra are most commonly of squamous subtype and often associated with Human Papilloma Virus infection. Penile preserving techniques are recommended in tumours of the pendulous urethra with a number of surgical approaches described. Herein, we describe the surgical management of 7 patients presenting with primary urethral carcinoma.MethodsSeven patients diagnosed with primary urethral carcinoma of the distal urethra were identified using a prospectively maintained penile cancer database at our institution from May 2017 to November 2020.ResultsThe mean age at presentation was 56.5 (33-80) years. Presenting symptoms included visible lesion, LUTS and a groin mass. Three patients had lesions located within the glanular urethra and had a distal urethrectomy and primary closure. Two patients with lesions extending proximal to the glanular urethra and into or beyond the fossa navicularis had a distal urethrectomy with a hypospadic neomeatus formation. One patient with tumour extending into the glans penis underwent distal urethrectomy and partial glansectomy with split thickness skin graft. A partial penectomy was performed for one patient with urethral tumour invading the corporal heads. Mean follow-up was 23.4 (±17.0) months. There have been no disease recurrences to date.ConclusionPenile preserving techniques are feasible in patients with tumours of the pendulous urethra and do not appear to compromise local control.     

Urethral steinstrasse with urethrocutaneous fistula

A middle-age man presented with acute urinary retention and a history of passage of urine and stones through a fistula at the root of the penis of 7 years' duration. Computed tomography of the soft tissue penis revealed multiple calculi in the urethra. After an initial suprapubic cystostomy, he underwent Johanson's Stage I urethroplasty with excision of the fistulous tract and retrieval of the urethral stones. Intraoperatively, dense stricture of the distal penile urethra was found, with complete obliteration in places. A urethral stricture, if not promptly managed, can lead to devastating complications necessitating complex surgical management.     

Urethraduplikatur beim männlichen Kind

Urethral duplication is a rare deformity which can present in various forms, commonly together with other congenital malformations. The embryological genesis is unknown. The isolated deformity is most often found in young males, while for young females it is very rare. We report the case of a 1.5 year old male child having a duplicate urethra with penopubic epispadias and dorsal penis deviation. The child, with known penopubic epispadias grade II and dorsal penis deviation, presented for pediatric urological consultation involving additional diagnostics and therapy. Examination revealed a penopubic epispadias with an external urethral exit at the base of the penis. A preoperative micturating cystogram led to the diagnosis of an accessory central as well as an epispadic urethra. We then carried out urethral reconstruction with the surgical combination of both urethras into a single functioning unit. The penis deviation was corrected after Ransley in the same operation. The postoperative course and aftercare showed normal micturition with a normotopic urethral entry as well as a good urine stream without evidence of a stricture or residual urine. An duplicate urethra is an uncommon malformation which is, however, found more often in male patients. Surgery is based on the individual and must be planned dependent on the morphology present. In all cases, both functional and cosmetic aspects must be taken into account.     

Multiple hypoplastic duplicated urethral hydrodistension and simple end-to-end anastomosis to penoscrotal hypospadias: a novel technique

Complete urethral duplication is a rare congenital genitourinary anomaly with various symptoms. Since anatomical place of urethra greatly varies between cases, surgical management of the patients is personalized according to the type of the duplication and requires a careful workup before planning for any intervention. In this case report, a 4-year-old boy with finding of complete proximal hypospadiac urethral duplication is presented with double-stream voiding. He was passing a normal stream of urine through the hypospadiac tract, while a thin stream came out from the normal meatal site. Examination revealed a hypoplastic orthotopic urethra with an accessory penoscrotal hypospadiac urethra. The patient was successfully managed with hydrodistension technique which was used to resolve the stricture of hypoplastic dorsal urethra followed by end-to-end anastomosis to penoscrotal hypospadias. This approach gives an insight that the technique could be possibly considered as a simple alternative to avoid proximal hypospadias repair which is comparatively a challenging surgical task.     

Prospective Pathologic Analysis of Female Cystectomy Specimens: Risk Factors for Orthotopic Diversion in Women

Objectives. To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion.Methods. Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra).Results. Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. Conclusions. We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.     

Primary carcinoma of male urethra

Carcinoma of the male urethra is infrequent. To date approximately 600 cases have been reported. We reviewed 16 cases of carcinoma of the male urethra seen at the University of Tennessee and the Memphis Veterans Administration Hospital. The mean patient age was sixty-three years (range 38 to 84). The most common presentation was a palpable mass followed by symptoms of urinary obstruction. Five urethral carcinomas arose distal to the suspensory ligament of the penis while 11 were of bulbar or bulbomembranous origin. The histology was squamous cell carcinoma in 8 patients (50%), mixed squamous and transitional cell carcinoma in 5 (31%), transitional cell carcinoma in 2 (13%), and adenocarcinoma in 1 (6%). The mean patient survival was fifteen months following diagnosis of a proximal urethral tumor and seventy-seven months for tumors arising distally. Neoplasms of the distal urethra can be surgically managed successfully even if regional lymph nodes are involved. The prognosis for proximal urethra tumors remains poor and is best treated by a combination of surgery and radiotherapy.     

Leiomyoma of the female urethra with upper tract dilation and treatment with transurethral resection: a case report and literature review

Leiomyoma of the female urethra is a rare condition. It is a benign mesenchymal tumor that commonly presents with recurrent urinary tract infections and various lower urinary tract symptoms. We report a case of urethral leiomyoma and review the literature. A 44-year-old woman presented with severe irritative voiding symptoms without urinary tract infection and bilateral upper urinary tract dilation. Ultrasound and cystoscopy revealed a smooth mass arising from the urethra and projecting into the bladder. Transurethral resection of the mass was performed and 32 g of tissue was removed. There were no complications and the symptoms resolved completely, indicating this to be a safe approach. Histopathology showed the tumor to be leiomyoma.     

尿道下裂手术方式的选择

尿道下裂手术以达到：阴茎下曲完全纠正、阴茎头呈圆锥状、尿道外口位于或接近阴茎头、外观满意，能站立排尿，能进行正常性生活为目的。力求下曲矫直和尿道成形一次完成。尽管手术方式多达300余种，但各种尿道成形效果都不尽满意。保留尿道板能提高尿道成形成功率、减少并发症。尿道成形可取材自身移植物，而更多取材于阴茎包皮，要不烦于精细，提高手术技巧。作者推荐远端尿道下裂首选TIP术式，近端尿道下裂应当选择Duckett术式或OIF术式。     

Hypospadias and associated penile anomalies: a histopathological study and a reconstruction of the pathogenesis.

Hypospadias is considered to be the result of inadequate fusion of urethral folds and, possibly, of canalization of a glandar epithelial cord during the formation of the spongy urethra. This theory had to be reconsidered because a recent study in normal human embryos has exposed such fusion and invagination as misconceptions. Autopsy specimens of five penises with hypospadias from foetuses and neonates were studied histologically. The findings complemented with data from the literature were correlated to the normal developmental process to reconstruct the pathogenesis of the disorder. Histopathological analysis revealed that the hypospadic orifice was the proximal part of a mucosal delta which revealed the structure of the roof and meatus of a flattened distal urethra. Branches of the raphe bordering the delta and terminating in prominent 'dog ears' had the characteristics of the transient urethral labia (folds). Associated curvature and torsion could be related to structural abnormalities of vascular structures, notably the distal corpus spongiosum, and fasciae predominantly proximal to the hypospadic orifice. Correlation with normal development indicated that hypospadias and associated anomalies are not caused by disturbed fusion or glandar invagination but by maldevelopment of a complex of primordial fascial and vascular tissue proximal to the urethral orifice which normally form the venter side of the penis by disproportionately strong proliferation and make the urethral orifice shift distalward. Insufficient growth may disturb that shift with the degree of deficiency determining the precise position of the urethral orifice, size of the urethral delta and defect of the prepuce. Shortage and/or poor organisation of these tissues explain curvature and, if asymmetrical, torsion, both of which can occur also with minimal urethral deformity or as congenital ventral curvature and torsion without hypospadias.     

A case of clear cell adenocarcinoma arising from a female urethral diverticulum

A 49-year-old female was followed up at the gynecology clinic after conization for cervical cancer and underwent routine cervical smear, which revealed a cluster of adenocarcinoma cells. Positron emission tomography-computed tomography (PET-CT) showed increased FDG uptake around the proximal urethra. Urethroscopy showed a tumor arising from the urethral diverticulum, and it was revealed to be clear cell adenocarcinoma by cold-cup biopsy. Then, she was referred to our hospital for the treatment of the urethral cancer arising from the urethral diverticulum. MRI showed the urethral diverticulum at circumference of the urethra and a tumor projecting into its lumen. The patient underwent urethrectomy together with resection of the diverticulum tumor and cutaneous vesicostomy. Pathological examination demonstrated pT2, clear cell adenocarcinoma of the urethra. The patient had no local recurrence or metastasis 5 months after the surgery.     

Two cases of benign papilloma of the male urethra

Two cases of benign papilloma in the male urethra are reported herein. The first case was a 27-year-old man who complained of miction pain. A pea-sized papillary tumor was found in his external urethral meatus. Urethrocystogram revealed no abnormal findings. He was treated with simple excision and electrofulguration of the tumor and experienced no recurrence of the tumor up to now. The other case was a 24-year-old man who complained of tumor-formation in his distal urethra. Three papillary tumors as large as a grain of rice or a pea were found in his fossa navicularis, besides on panendoscopic examination, a small papillary tumor was found on the bulbous urethra. After he was treated with simple excision and electrofulguration of the tumors on the distal urethra, no tumors were found in his whole urethra on panendoscopy. He also experienced no recurrences of tumor to date. Histologic examinations of both cases revealed squamous papilloma of the urethra. There are a few reports of benign tumors of the male urethra in the Japanese literature. Of them, 48 cases of urethral papilloma in male were collected and are reviewed herein.     

Concomitant urethral triplication, bladder, and colon duplication

The concomitant presence of urethral triplication and caudal duplication is extremely rare with no previous reported cases. We report a case of urethral triplication associated with bladder, sigmoid, and rectum duplication. The patient was initially referred with a history of fecaluria and recurrent urinary tract infection. Physical examination revealed 2 meatal opening on the glans penis. Further investigation revealed three distinct urinary streams, two terminating on the glans penis, and one in the rectum in voiding cystourethrography and retrograde urethrography. Computed tomography demonstrated the bladder divided into two compartments by a complete sagittal septum. The patient was managed by the excision of the rectal ending urethra and removal of the bladder sagittal septum during which, two sigmoidal and rectal segments (the right one filled with fecal) were revealed. The right sigmoid and rectum was resected. The two ventral urethras were kept intact. The postoperative course was uneventful. At his 4 month readmission for colostomy closure, the patient reported good urethral voiding with no complication and recurrence of urinary tract infection and the colostomy was closed with no major complication.     

Urethral disruption treated by echo guided endoscopic management: a case report

We report a case of 63-years-old man with a chief complaint of urinary retention and urethral meatal bleeding due to straddle injury. Urological examination revealed proximal bulbous urethral disruption with 1 cm gap, and then cystostomy was placed. Afterwards, urethral disruption was treated by echo guided endoscopic urethroplasty. Transurethral resection of scar tissue was performed twice for postoperative urethral stricture. Postoperative voiding cystourethrography revealed no urethral stricture. The patient voids well without urinary incontinence and erectile dysfunction. Recently, endoscopic urethroplasty, which is easy, minimally invasive, and repeatable in comparison with open urethral reconstruction, has been frequently performed for urethral disruption as endoscopic instruments functionally develop. Echo guided image in the present case is so useful that proximal and distal end of urethral disruption can be shown in same plane, indicating that primary urethral tract can be reconstructed without injury of rectum and urethra.     

Three cases report on the epispadiac urethral duplication in male

A case of complete type and two cases of incomplete type of epispadiac urethral duplication are reported. In the complete one, the accessory urethra (14 cm in length) opened 1.5 cm proximal to the dorsum of the penis. In two cases of incomplete type, the epispadiac openings located at the base of the penis or higher. The sinuses were lined with transitional epithelium proximally, and with squamous cells on the distal half of the accessory urethra, which suggests a developmental origin. We conclude that these sinuses may etiologically represent the identical origin without regard to complete type or incomplete type.     

A case of malignant melanoma of the penis

An 83-year-old male presented in October, 1988, with pigmented tumor lesions on the penis. The main tumor mass accompanied with necrotic bleeding, measuring 5 cm in diameter was located on the fore skin and glans penis. On the proximal shaft of the penis, there were three other black tumors, measuring from 0.5 to 3 cm in diameter. The distal urethra of the penis was clinically involved in the tumor mass and bilateral inguinal lymph nodes were palpable. Chest X-ray and liver scan both revealed multiple metastases. Tumor biopsy confirmed malignant melanoma. Phallectomy and bilateral inguinal lymph node biopsies were performed in October, 1988. Pathological findings revealed that a malignant melanoma had developed from the fore skin and glans penis, extended into the penile urethra and metastasized to bilateral inguinal lymph nodes. The patient gradually deteriorated in general condition and died of cancer 28 days later. The prognosis of malignant melanoma of the penis seems to be extremely poor.     

Penile urethral obstruction in a subject with spinal cord injury

STUDY DESIGN: Single case report. OBJECTIVE: To report a case of urethral obstruction because of calculus in a subject with spinal cord injury (SCI). SETTING: Bangalore, India. CASE REPORT: A 25-year-old man sustained complete SCI at C(6) level following a road traffic accident. After 14 months, while on self-intermittent catheterization he noticed difficulty in introducing catheter and acute retention of urine. X-ray examination revealed a calculus in the penile urethra at the level of the glans penis. CONCLUSION: Impaction of calculi in penile urethra, although rare, can manifest with acute painless urinary retention in patients with SCI.     

Venous hemangioma of the urethra: a case report

A case of urethral hemangioma in a 61-year-old female is reported. She had the complaint of urethral bleeding and difficulty on urination since November 2, 1986. Physical examination revealed a reddish colored, thumb-head sized tumor at the external urethral meatus. All laboratory tests revealed normal findings. At cystoscopy reddish mucosa was found at the distal urethra. With the preoperative diagnosis of urethral tumor, the tumor was removed en masse under spinal anesthesia. The tumor mass was 2.0 x 1.7 x 1.2 cm. The specimen was pathologically diagnosed as venous hemangioma of the urethra. The patient remains symptomless for 2 months after the operation. Six cases of urethral hemangioma including this case have been reported in the Japanese literature and are reviewed briefly.     

Effects of selective autonomic and pudendal denervation on the urethral function and development of retention in female dogs

PURPOSE: This trial is an experimental approach to the possible causes of continence and voiding problems after urethra sparing radical cystectomy and orthotopic bladder substitution in women. MATERIALS AND METHODS: Between January 1996 and January 1999 we included 24 mongrel female dogs in this 4-phase study of 6 dogs each. The effects of autonomic denervation of the urethra (phase 1) and urethral transection just distal to the bladder neck (phase 2) on the urethral pressure profile were recorded. In phase 3 the effects of autonomic denervation, urethral transection and pharmacological manipulation of the denervated transected urethra on the urethral pressure profile were studied in succession. In phase 4 the effects of pudendal nerve transection and pharmacological blockade were recorded. In the 12 phases 2 and 3 dogs the transected urethra was re-anastomosed to the bladder neck. Acute experiments were repeated after 2 and 6 months, urethrocystoscopy was done and post-void residual urine was estimated. Two of the latter dogs were sacrificed 6 months after the acute experiment and the urethras were histopathologically examined. RESULTS: Autonomic denervation resulted in a 46% to 48% decrease in mean maximal pressure in the proximal urethra in phases 1 and 3 (p <0.001) with no significant effect on the distal urethra. Urethral transection in phase 2 did not affect the urethral pressure profile. Phentolamine injection after urethral denervation and transection in phase 3 produced a further reduction of 11.3% and 46.3% in mean resting pressure in the proximal and distal urethra, respectively, while succinyl choline produced a 38.1% further decrease in the distal urethra. Unilateral and bilateral pudendal denervation reduced pressure in the distal urethra significantly but not in the proximal urethra. When phentolamine was given thereafter, a further decrease of 38% and 2.4% resulted in resting pressure values in the proximal and distal urethra, respectively. The change in distal urethral pressure was marginally significant after succinyl choline injection (p = 0.05). Results were reproducible after 2 and 6 months. The proximal urethra remained patent with no post-void residual urine after autonomic denervation. There was no significant urethral fibrosis after realignment of the transected urethra in the 2 sacrificed phases 2 and 3 dogs. CONCLUSIONS: From this study we concluded that autonomic denervation reduced pressure in the proximal urethra by less than 50%. Continuity of the urethra with the bladder is not necessary for proper urethral function. After autonomic denervation the proximal urethra remained patent with no subsequent fibrosis. In addition, no post-void residual urine was noted. Bilateral pudendal denervation did not completely block activity of the distal urethra. The nonneuromuscular components had a small role in the creation of urethral closure function.     

Primary carcinoma of fossa navicularis.

A case of primary carcinoma of the fossa navicularis of the male urethra is discussed. The lesion presented as an ulcerative process that circumferentially involved the external urinary meatus in a sixty-three-year-old man. Initially, the lesion was confused with a superficial carcinoma of the penis, since results of urethroscopic examination were normal. Following midshaft penectomy, despite normal gross appearance of the distal urethra, histologic examination indicated poorly differentiated epidermoid carcinoma along the mucosa of the distal urethra up to the line of surgical resection. Subsequent total penectomy showed only a small area of residual tumor at the line of previous resection. Lymphadenectomy was not performed. The patient remains alive without evidence of residual disease five years later.