Primary Carcinoma of the Male Urethra

Primary Carcinoma of the Male Urethra

PRIMARY CARCINOMA OF THE MALE URETHRA JERRY ZASLOW Fellow in Surgery, Mayo Foundation AND JAMES T. PRIESTLEY Division of Surgery, Mayo Clinic, Roches...

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PRIMARY CARCINOMA OF THE MALE URETHRA JERRY ZASLOW Fellow in Surgery, Mayo Foundation AND

JAMES T. PRIESTLEY Division of Surgery, Mayo Clinic, Rochester, Minnesota

Fortunately, primary carcinoma of the male urethra is a relatively uncommon lesion. In 1939 Kreutzmann and Colloff reviewed the literature, collected data on 148 cases reported to that time and added 2 of their own. In 44 per cent of these cases the lesion was in the penile portion of the urethra and in the remainder it was located in the bulbomembranous or prostatic urethra. In 1945 Perez Castro collected data on 28 cases from the literature in which the growth was confined to the region of the fossa na vicularis and reported 1 case from his personal experience. A recent review of the literature revealed 33 cases in addition to those reported by Kreutzmann and Colloff. Of these additional cases, in 5 not mentioned by Perez Castro the lesion was reported as arising in the fossa navicularis. The present report was stimulated by a white man 74 years of age who presented an epithelioma, grade 2 (Broders' method), situated in the fossa navicularis and for which a partial amputation of the penis was performed (figs. 1 and 2). Inasmuch as there have been few reports in the literature during recent years of any appreciable number of cases of this type, it seemed worth while to review the records at the Mayo Clinic for the purpose of making a clinical study of these lesions. In this review it was found that 25 cases of primary urethral neoplasm have been encountered from 1910 to 1945, inclusive. The diagnosis was established by microscopic examination in all but 3 of these cases. In all cases studied histologically the diagnosis was epithelioma. Presumably an adenocarcinoma of the glands of Littre might be classified as a urethral neoplasm but no such lesion has been encountered. Cases of adenocarcinoma in the posterior urethra have not been included, as it is virtually impossible to prove that such lesions do not originate in the prostate or other glandular structures. CLINICAL CHARACTERISTICS

The classification offered by Kreutzmann and Colloff is practical and useful in discussing urethral carcinoma. These authors considered all growths in the penile urethra as "anterior" and all others as "posterior." From a therapeutic point of view, treatment frequently varies depending on the location of the lesion. In the present series of cases the growth was situated anteriorly in 10 cases and posteriorly in 14, and in 1 case both the anterior and posterior urethra were involved, a proportion in accord with reports in the literature. So far as symptoms and clinical characteristics are concerned there was little difference regardless of the location of the growth; however, the most common initial symptom for an anterior lesion was difficulty in micturition, whereas for a posterior lesion hema207

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turia was most often the presenting symptom. If a growth is of appreciable size it can be palpated, especially if it is located in the anterior urethra. Six of the 25 patients presented a history of urethral stricture prior to the onset of symptoms referable to the neoplasm, an incidence which seems somewhat more than coincidental. The average age of patients was 56 years and the youngest was

Fm. 1. Epithelioma arising in anterior tip of urethra in a white man aged 74 years

Fm. 2. Micro1
only 28 years of age. The grade of malignancy was determined in 20 cases and in 19 was either 2 or 3. TREATMENT

In the present series of cases treatment varied depending on the location and extent of the lesion. In the 10 cases in which the growth was located in the penile urethra, amputation, radium and fulguration were employed with equal frequency. Amputation, which may be partial rather than complete, is preferable for the more extensive lesions. It is well to remember, however, that a partial amputation which leaves virtually no urethra which may be grasped

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during micturition to direct the stream may be more of a handicap to the patient than a perineal urethral meatus which can always be used satisfactorily in the sitting position. For a relatively small growth in the region of the fossa navicularis, radium may be applied directly. Fulguration can be used to destroy a relatively small lesion. If there is any question about the complete destruction of the growth in situ by either of these methods, amputation would seem the treatment of choice. Treatment of an epithelioma situated in the membranous or prostatic urethra is somewhat more difficult. In the present series of cases, prostatectomy, cauterization, application of radium, transurethral removal and fulguration and roentgen therapy were employed. Obviously there must be individualization in the choice of treatment, depending on the exact location and extent of the lesion . . Experience has been too limited to permit general conclusions but obviously the same principles apply in the treatment of a malignant lesion in the posterior urethra as in other parts of the body; namely, complete removal or destruction of the growth if at all possible. RESULTS

The number of cases in this group is entirely too small to permit significant opinions regarding results and the efficacy of various types of treatment. From a study of these results, however, certain impressions are gained which are in accord with reports in the literature. Thus, the prognosis in our cases seems more favorable for lesions in the anterior than in the posterior urethra. Since at least half the patients with anterior urethral lesions are living 2 years after operation, while half those with posterior urethral lesions are dead 1 year after operation, probably the difficulty of complete removal of a growth :,,ituated posteriorly may be a factor in this regard. Of the 10 patients who had an epithelioma in the anterior urethra, 3 are known to be dead and 7 are living. Three of these 7 have had a recurrence and none of them is known to have survived for as long as 5 years. The shortest postoperative follow-up in this group of 7 patients was 5 months and the longest 5 years, the average being 21 months. Of the 14 patients who had lesions in the posterior urethra 12 are known to be dead; however, 1 of these lived 4 years and another 9 years and at the time of death had no evidence of recurrence. One other of the 14 patients was alive and apparently well at least 5 years after treatment and 1 patient has not been traced. The patient who had a lesion which involved both the anterior and posterior portions of the urethra died 4 months after treatment, which consisted solely of roentgen therapy. Obviously, the results of both groups of cases leave much to be desired. However, the fact that a few patients have survived as long as 5 years affords some encouragement. For the most part treatment in these cases consisted in complete surgical removal or local destruction of the lesion. COMMENT

The role that urethral stricture plays as an etiologic factor in carcinoma of the urethra is questionable. The incidence of this condition prior to development of the malignant lesion, as reported in the literature, seems as though it might be

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significant, although the majority of patients who have epithelioma of the urethra probably have no antecedent history of stricture. The prognosis for malignant lesions of the urethra is impossible to determine from the literature, as too few cases have been reported 5 or more years following treatment. In general a growth situated in the anterior urethra appears to have a somewhat better prognosis than one situated posteriorly. In our experience this cannot be explained by any difference in time at which these patients presented themselves for treatment, as the duration of symptoms prior to therapy was the same for both groups of patients. It is stated in the literature that lesions in the posterior urethra are recognized later than those in the anterior urethra. The most common symptoms for both groups were hematuria, penile discharge and dysuria. From the meager data available the grade of the lesion has not affected the prognosis significantly. Not included in the present series of cases are a few in which small epitheliomas developed in the urethra subsequent to total cystectomy for carcinoma of the bladder. While an occurrence of this type is not especially frequent, it is en.countered sufficiently often that it should be kept in mind. Particularly if the growth in the bladder involved the region of the vesical neck, follow-up examination should include endoscopic inspection of the remaining portion of the urethra. Recurrences of this type may then be recognized while they are quite small and may be adequately controlled by fulguration. In 2 cases repeated fulguration of this type has been required over a period of several years. As mentioned, however, these cases have not been included in the present study because they are not thought to represent true primary lesions in the urethra. REFERENCES BAILLIE, M. H.: Primary carcinoma of the urethra. Brit. J. Urol., 11: 251, 1939. BARBOSA DE BARROS, J.: Carcinoma primitivo da uretra mascu!ina. Rev. Assoc. paulista de med., 17: 13, 1940. BARROS, W.R.: Squamous cell epithelioma of urethra. Case report. Urol. & Cuta.n. Rev., 44: 637, 1940. DoDSON, A. I.: Transplants from the scrotum for the repair of urethral defects. Tr. Am. A. Genito-Urin. Surgeons, 33: 211, 1940. GRAYES, IL C. AND Gc:rss, L. W.: Tumors of the urethra. J. Urol., 4S: 923, 1941. GR'MALDI, F. E. AND lVL'I.CKINTOSCH, M.: Epitelioma primitivo de la uretra perinea!. Rev. argent. de urol., 9: 2G7, 1940. HARRrSOI\', F. G.: Malignancies of the penis and urethra; report of cases including primary malignant melanoma of penis, and simulating conditiomL Clinics, 3: 20, 1944. HERG!cR, C. C. AND SA1.:ER, H. R.: Primary carcinoma of the male urethra. (Report of 1 case). Urol. & Cutan. Rev., 46: 346, HJ42. Hickey, R. F. AN'D Cou:;,rAN, R. C., ,JR.: Primary carcinoma of the anterior male urethra: case report. J. Urol., 51: 643, 1944. IKEDA, KANO, FOLEY, F. E. B. A.'sD RosENow, JOHN: Malignant priapism; report of primiuy carcinoma of the urethra with priapism. J. Urol., 49: 732, 1943. KREFTZMANN, H. A. R. AN'D CoLLOE'F, BEN: Primary carcinoma of the male urethra. Arch. Surg., 39: 513, 1939. LAv1rnANT, A.: Cancer de l'uretre perineal. Rese0tion. Uretrostomie perineale. Gnerison datant de deux ans. ~ull. Soc. franc,. d'urol., 1940, p. 132. MACQUET, P. AND VERilAEGIIE, :w.: Epithelioma primitif de l'uri'tre penien. Presse med., 35: ,512, 1943. MERSHON, H.F.: Carcinoma of the urethra. Mississippi Valley M. J., 63: 40, 1940. MrLLIK, TERENCE· Carcinoma of the urethra, beginning in the fossa navicularis. Proc. Roy. Soc. Med., 26: 1221, 1933. N1cHoL, J.E.: Two cases of carcinoma of the urethra. Canad. M.A. J., 45: 155, 1941. PJ<;RE7. CA::;TRo, E.: Epitelioma de uretra (fosa navicular). Arch. espafi. urul., 2: U,0, HH5.

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RAU, U. M.: Primary carcinoma of the male urethra, with report of a case. Indian J. Surg., 4: 38, 1942. RILEY, AuGUSTus: Epidermoid carcinoma of the perinea! urethra. Ural. & Cutan. Rev., 45: 20, 1941. RINKER, J. R.: Primary carcinoma of the urethra in the male. Ural. & Cutan.. Rev., 42~ 874, 1938. RoTHE, G.: Zwei Fiille van primiiren Karzinomen der miinnlichen Harnrohre. Zentralbl. f. Chir., 66: 1500, 1939. ScHIAPPAPIETRA, T. AND OLIVA, F.: Sabre dos casos de epiteliomas malipighianos de la. uretra perineal. Rev. argent. de urol., 12: 5, 1943. SCHOLL, A. J., JR. AND BRAASCH, W. F.: Primary tumors of the urethra. Ann. Surg., 76: 246, 1922. WISHARD, W. N., JR.: Primary carcinoma of the male urethra. Tr. Am. A. Genito-Urin. Surgeons, 34: 265, 1941. WISHARD, W. N., JR. AND BODNER, HENRY: Primary carcinoma of the male urethra. J. Urol., 42: 35, 1939. YOUNG, H. H.: A new radical operation for carcinoma of the bulbous urethra; a new use for the penis. Surg., Gynec. & Obst., 68: 77, 1939. ZUCKER, M. 0. AND WEINSTEIN, G. J.: Primary carcinoma of the urethra in the male; report of a case, New Eng. J. Med., 225: 682, 1941.