Carcinoma of the Urethra in Male Patients

Carcinoma of the Urethra in Male Patients

THE JOURNAL OF UROLOGY Vol. 91, No. 5 May 1964 Copyright © 1964 by The Williams & Wilkins Co. Printed in U.S.A. CARCINOMA OF THE URETHRA IN MALE PAT...

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THE JOURNAL OF UROLOGY

Vol. 91, No. 5 May 1964 Copyright © 1964 by The Williams & Wilkins Co. Printed in U.S.A.

CARCINOMA OF THE URETHRA IN MALE PATIENTS LOWELL R. KING* From the James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland

In an effort to determine the best means of establishing an early diagnosis of carcinoma of the urethra in the male patient and to define the best treatment, the case histories, x-ray diagnostic studies, urinary cytology and histopathology of the local lesion were reviewed in 12 patients admitted to the Johns Hopkins Hospital between August 1952 and April 1961. These tumors are classified according to location to permit evaluation of the therapeutic surgical procedures. Special attention was given to incidents in the patient's past history thought possibly to have some relation to the development of the carcinoma. The earliest sign or symptom is also recorded. RESULTS

Table 1 lists the patients in this series, together with their age when a diagnosis of carcinoma of the urethra was made, and some of the pertinent facts in their individual clinical history. Each patient was operated upon. Treatment depended upon the site and extent of the tumor. In all instances (four), squamous or mixed squamous and basal cell carcinomas of the pendulous urethra were treated by amputation of the penis at the level of the penoscrotal junction, with diversion of the urinary stream via permanent perineal urethrostomy. In one patient who had a large, 6 cm. local tumor, bilateral radical groin dissection was carried out concomitant with penile an1putation. This patient, and one other, later had distant metastases; thus, in two of 4 instances partial penile amputation failed to result in a cure of carcinoma thought to be limited to the pendulous urethra at the time of surgery. One transitional cell tumor, a malignant polyp, occurring 1 cm. proximal to the urethral meatus was removed by simple excision and has not recurred. Five patients had squamous cell carcinomas arising in the bulbous urethra. In 3 instances, Accepted for publication November 8, 1963. * Current address: The Children's Memorial Hospital, 707 Fullerton Avenue, Chicago, Illinois.

treatment consisted of excision of the penis, perineum, and part or all of the scrotum., with preservation in 2 patients of a urethral stump which functioned as a perineal urethrostomy. These 2 patients had subsequent local turn.or recurrences in the urethral stump. In the third patient an attempt was made to close the transected prostatic urethra. A suprapubic cystostomy was utilized, but urinary leakage througl1 the transected prostatic urethra resulted in overwhelming sepsis and the patient died in the immediate postoperative period. Another patient with extensive carcinoma in the bulbous urethra was treated by an excision of the bladder, prostate, perineum, penis and scrotum. Urinary diversion via ureterosigmoid anastomosis was performed. This patient has not suffered a recurrence. The fifth patient with carcinoma arising in the perineal portion of the urethra was found to have liver metastases at laparotomy. Urinary diversion via ureteroileocutaneous anastomosis was contemplated prior to extensive tumor resection. This was not performed because of the presence of metastases. The 2 patients with transitional cell carcinomas limited to the prostatic and membranous portion of the urethra presented a therapeutic dilemma. One was treated by transurethral resection and orchiectomy, but died with lung metastases. The other had local implantation of radon seeds and also radical perinea} prostatectomy, preserving the external urethral sphincter. A local recurrence which has since developed has responded to external irradiation. DISCUSSION

The tumors have been classified as: 1) squamous cell carcinoma and 2) transitional cell carcinoma. In 9 patients in whom squamous cell carcinoma was present, eight had a remote history of gonorrhea. Six of these 8 patients had been undergoing occasional or periodic dilatations of urethral strictures secondary to the gonorrhea for 2 to 18 years prior to the diagnosis of carcmoma of the urethra. The ninth patient had 555

TABLE

1. Carcinoma of the urethra in male patients

A

Patient

C.D., J.H.H. 158674

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I,

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First Sign or Symptom

History of Gonorhea

Known Urethral Stricture

Location of Tumor

Type of Operation

Survival

Mass in pendulous urethra

Yes; Positive STS

No

Pendulous urethra

Amputation of penis. Died 1½ yrs. postoperatively; meBilateral groin dissection tastases; local recurrence

Cell Type

Squamous and basal cell (mixed tumor)

--

°'~

M.G., J.H.H. 773904

64

Decreased urinary stream

No

No

Prostatic urethra

Transurethral resection; orchiectomy

Died 1 yr. postoperatively; metastases

Transitional cell carcinoma

J.B., J.H.H. 834621

43

Perineal mass

Yes

No. Fell astride, periurethral abscess 13 yrs. previously

Bulbous thra

ure-

Excision of bladder, prostate, perineum and penis. Ureter- osigmoidostomy

Surviving without evidence of tumor 10 yrs. after operation

Squamous cell carcinoma

Perforation of ure- No thra during dilatation of known stricture

Yes, secondary to TUR 19 yrs. previously

Bulbous thra

ure-

Block excision of penis, perineum and scrotum; perineal urethrostomy

Local recurrence in 8 months. Died with metastases

Squamous cell carcinoma

Marked hemorrhage following dilatation

Yes (x3)

Yes

Proximal pendulous urethra

Amputation of penis

Survived 4 yrs. No recurrence of tumor

Squamous cell carcinoma

Gross hematuria

No

No

Open transurethral resection of polyp

No recurrence at 4 yrs.

Transitional cell polyp. No muscle invasion

Periurethral abscess

Yes

Yes

------G.C., J.J.H. 75 542732

S.H., J.H.H. 519670

69

--------- --------

--------W.N., J.H.H. 859184

74

-B.B., J.H.H. 560072

68

c

Distal pendulous urethra

-------- ----------- ----------Bulbous urethra

Block excision of penis, scrotum, and perineum. Perineal urethrostomy

Local recurrence 2 yrs later; died with metastases

Squamous cell carcinoma

'

---~-------

J.P., J.H.H. 865376

"" ""--I

57

Yellow discharge Yes Yes Pendulous ure- Amputation of penis Died 1 yr. postopera- Squamous and from penis; penile thra tively; metastases basal cell swelling and spon(mixed tumor) taneous urethrocutaneous fistula ------- -- ----------- ----- --------- -------- ----------- ----------- --------E.C., 65 Pain in penis. Mass Yes Pendulous ure- Amputation of penis Yes Surviving 5½ yrs. Squamous cell behind glans penis thra carcinoma after operation. No recurrence - - - - - - - -·- - - - - - - - - - - - ------ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - M.P., J.H.H. 44 Gross hematuria No Membranous No Radical perinea! pros- Local recurrence Transitional cell 750692 and prostatic tatectomy and racarcinoma treated by external urethra don seed implantairradiation. Alive tion 5 yrs. after tissue diagnosis ------- -- ----------- ----- --------- -------- ----------- ----------- --------S.B., J.H.H. 46 Perforation of ure- Yes Yes Bulbous Amputation of penis, Died of retroperi to- Squamous cell thra during dilatascrotum, testes and carcinoma neal infection and tion of known stricprostatic apex en sepsis 1 wk after ture bloc with peritooperation neum; suprapubic cystostomy --------- - - ----------- - - - - - --------- -------- ----------- ----------- --------J.S. 50 Periurethral abscess Yes Yes Bulbous ure- Laparotomy revealed Died 4 wks. after op- Squamous cell carcinoma thra liver metastases; eration suprapubic cystostomy

558

KING

never had symptoms of gonorrhea, but he had a urethral stricture which required dilatation subsequent to a transurethral resection of the prostate that had been performed 19 years previously. Early signs and symptoms of urethral carcinoma, such as diminished urinary stream or bleeding with urethral dilatation, were thus attributed for a time to stricture. All patients with squamous cell carcinoma of the urethra had a history of inflammatory disease of that organ. The first signs or symptoms with which the individual patient presented varied considerably, depending upon where in the urethra the bulk of the tumor lay. Thus, tumors arising in the pendulous urethra were apt to produce a palpable mass before urinary symptoms were noted. Cancers arising in the bulbous portion of the urethra generally went unnoticed until a large solid mass developed or until the tumor eroded through the corpus spongiosum and a painful periurethral abscess resulted, as happened in two instances. The abscess necessitated drainage and forced medical re-evaluation. In two patients undergoing periodic urethral dilatations for stricture, extravasation inadvertently occurred when a sound was passed through the soft friable tumor, unsuspected in the perineal urethra, into periurethral structures. This happenstance resulted in detection of the tumor in both instances. Excessive bleeding following periodic urethral dilatation was an early presenting sign in one case. It may reasonably be assumed that need to increase the frequency of periodic urethral dilatations of a known stricture is a relatively early sign also, although documentation was difficult. The patients with transitional cell cancers of the prostatic urethra presented with diminished urinary stream and with hematuria. They had no past history of urethral inflammatory disease or instrumentation, and the diagnosis of prostatic cancer was initially suspected because that organ was indurated at rectal examination. Diagnosis of urethral carcinoma was generally confirmed by the appearance of the urethra at cystoscopy and on cystourethrography, where an irregular mass can be seen as a filling defect in the urethra. Papanicolaou smears of the sediment in fresh voided urine, made in 4 instances, substantiated the diagnosis in each patient. In retrospect, it appears that the best way to make the diagnosis of urethral carcinoma early in the course of the disease is to perform peri-

odic Papanicolaou examinations of the cellular sediment of fresh voided urine of patients who have a history of urethral inflammatory disease. Those who exhibit a need for more frequent periodic urethral dilatations, excessive bleeding (usually distal to the external sphincter) after dilatation, or periurethral abscess should, in addition, undergo cystoscopy and cystourethrography. The latter study was especially valuable in estimating the extent of tumor spread along the urethra. In those cases of urethral carcinoma from which no distant metastases could be demonstrated prior to operation, excepting the single postoperative death, six of 10 patients had recurrence and died of tumor. Five of these six had inadequate local excision as evidenced by the fact that local recurrences as well as distant metastases developed. Local recurrences appear to be primarily due to the attempt to preserve a portion of the urethra for use as a perinea! urethrostomy in patients with cancer of the bulbous urethra. Total cystectomy and prostatectomy, with excision of the overlying perineum, resulted in cure in 1 patient with a carcinoma of the bulbous portion of the urethra. In most instances, this greater margin of healthy tissue can be removed with relative safety and with little further cosmetic damage. Thus, in patients with carcinoma of the pendulous urethra, removal of the penis save for enough corpus spongiosum to use as a perineal urethrostomy is superior to simple penile amputation and will reduce the rate of local recurrences. Cancer of the perinea! urethra is best treated by removal of the penis, scrotum, perineum, prostate and bladder subsequent to urinary diversion by ureteroileocutaneous anastomosis. In one patient in this series, urinary diversion was provided by ureterosigmoidostomy. The patient has remained free of tumor. If the bladder is preserved, cystostomy and vesical neck closure should be securely accomplished before removal of prostate and penis with the tumor, as leakage through the bladder neck after attempted closure was the cause of sepsis and resulted in the death of 1 patient in this series. SUMMARY

Twelve cases of carcinoma of the urethra in male patients are reviewed. Early signs and symptoms are described and the relationship between urethral inflammatory disease and

CARCINOMA OF URETHRA IN MALE PATIENTS

squamous carcinoma of the urethra is demonstrated. The best means of a correct diagnosis is an investigator alert to the possibility of cancer of the urethra, aided by periodic examination of the Papanicolaou smear of the urinary sediment of patients with urethml stricture. Cystoscopy and cystourethrography are useful in substantiating the diagnosis. Surgical treatment, which depends upon the site and extent of the tumor, is discussed. A plea is made for more extensive surgical therapy. REFERENCES EWERT, E. E.: Treatment of carcinoma of the male urethra. In Treatment of Cancer and Allied Diseases, edited by Pack and Ariel, vol. 7,

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The Male Genitalia and the Urinary System. New York: Harper and Row, chap. 9, pp. 138143, 1962. FLOCKS, R. H.: Treatment of urethral tumors, J. Urol., 75: 514-526, 1956. HOTCHKISS, R. S. AND AMELAR, R. D.: Primary carcinoma of the male urethra. J. Ural., 72: 1181-1191, 1954. KAUFMAN, J. J. AND GOODWIN, W. E.: Carcinoma of the male urethra. One stage surgical treatment by radical perineal excision and rectal transplantation of the divided trigone. Surg,, Gynec. & Obst., 97: 627-632, 1953. MARSHALL, V. F.: Radical excision of locally extensive carcinoma of the deep male urethra. J. Urol., 78: 252-264, 1957. RICHES, E.W. AND CULLEN, T. H.: Carcinoma of the male urethra. Brit. J, Urol., 23: 209-221, 1951. UHLE, C. A. W, AND HoLFELNER, E, D.: Treatment of carcinoma of the male urethra by radical surgical infrapubic removal. J. UroL, 68: 302-310, 1952.