Penile metastasis from urothelial carcinoma of the bladder: An exceptionally rare localization

Abstract

Penile metastasis from urothelial carcinoma is exceedingly rare (<1%) and typically indicates advanced disseminated disease. We report a 60-year-old male who underwent radical cystoprostatectomy for high-grade urothelial carcinoma (pT4aN1). Before adjuvant chemotherapy, he developed indurated violaceous penile nodules, biopsy-confirmed as cutaneous metastasis. Staging CT revealed systemic relapse involving lungs, liver, and bone. As he was ineligible for cisplatin, he received gemcitabine-carboplatin, since enfortumab vedotin was unavailable locally. This case highlights the aggressive potential of high-grade urothelial carcinoma and the importance of prompt histological evaluation of unusual penile lesions in bladder cancer patients.

1. Introduction

Urothelial carcinoma of the bladder is the most common urological malignancy. The usual metastatic sites include lymph nodes, liver, lungs, and bones. Cutaneous metastases are uncommon, accounting for approximately 0.8–3% of cases.¹ Penile metastases are even rarer, estimated at 0.1–0.5% of secondary lesions from genitourinary cancers.² Fewer than 500 cases of penile metastases from all primary tumors have been reported in the literature.^3,4

2. Case report

A 60-year-old male presented with gross hematuria evolving over 5 months. He was a smoker (40 pack-years) and had hypertension, with no other comorbidity. Initial evaluation revealed a locally advanced urothelial carcinoma of the bladder, and the preoperative staging workup showed no distant metastases. The patient underwent a radical cystoprostatectomy with cutaneous ureterostomy in July 2025.

Histopathological findings:

• •High-grade urothelial carcinoma
• •Macroscopic and microscopic invasion of perivesical fat
• •Pathological stage: pT4aN1

Prior to initiation of adjuvant chemotherapy, a penile lesion appeared on the shaft in November 2025, 4 months after surgery.

Dermatologic examination revealed multiple indurated violaceous nodules and plaques involving the penile shaft and glans associated with local infiltration and diffuse oedema (Fig. 1).

Fig. 1.

Penile lesions, showing nodules, local infiltration and oedema.

A biopsy confirmed a cutaneous metastasis of urothelial origin (Fig. 2). Histological examination showed lymphovascular tumor emboli without epidermal dysplasia. In a patient with known high-grade urothelial carcinoma, these findings supported a urothelial origin. Immunohistochemistry could not be performed because the tissue block was exhausted. A subsequent CT scan (thoraco-abdominal-pelvic) revealed systemic metastatic relapse, including pulmonary, hepatic, bone, and locoregional pelvic involvement. Adjuvant chemotherapy was therefore not given. Systemic treatment for metastatic disease started in December 2025. At that time, ECOG performance status was 2 and creatinine clearance was 57 mL/min. The patient was considered ineligible for cisplatin and received gemcitabine–carboplatin. After five cycles, restaging CT showed a dissociated response: partial response in the lung and lymph nodes, with progression in the liver, peritoneum and bone. Docetaxel-based chemotherapy was then proposed.

Fig. 2.

Cutaneous metastasis of urothelial carcinoma showing lymphovascular emboli (hematoxylin and eosin stain, ×100).

Written informed consent for publication of this case and the accompanying images was obtained from the patient.

3. Discussion

Despite the rich vascularization of the penis, penile metastases remain exceedingly rare.^2,3 Several mechanisms have been proposed, including retrograde venous spread via the Santorini plexus, lymphatic dissemination, arterial spread, and direct extension.⁵

Penile metastasis usually reflects advanced systemic disease and is associated with a poor prognosis, with a reported median survival ranging from 6 to 12 months.^2,3

Therapeutic considerations and response of cutaneous and penile metastases:

The management of metastatic urothelial carcinoma is primarily based on systemic therapy.

First-line treatment with Gemcitabine–Cisplatin is associated with overall response rates of approximately 40–50% and a median overall survival of 13–15 months in advanced disease.⁶

The current standard of care in metastatic urothelial carcinoma has been recently transformed by the results of the EV-302/KEYNOTE-A39 trial, which demonstrated a significant survival benefit with the combination of enfortumab vedotin plus pembrolizumab in the first-line setting.⁷

However, due to the unavailability of enfortumab vedotin in Tunisia, this therapeutic option could not be implemented in our practice. Our patient was also ineligible for cisplatin (ECOG performance status 2, creatinine clearance 57 mL/min) and was treated with gemcitabine–carboplatin. In cisplatin-eligible patients who are not candidates for enfortumab vedotin-based therapy, the combination of gemcitabine, cisplatin, and nivolumab represents a recommended alternative, supported by the results of the CheckMate 901 trial.⁸

Although some cases report partial regression under systemic chemotherapy, most cutaneous metastases show poor or short-lived responses, reflecting aggressive tumor biology.^2,3,9

Local treatments (surgery, radiotherapy) are mainly palliative, aiming to control symptoms such as pain, ulceration, or bleeding, rather than achieving curative outcomes.³

4. Conclusion

Penile metastasis from urothelial carcinoma is an exceptional entity (<1%). Any unusual penile lesion in a patient with bladder cancer should raise suspicion for metastatic disease and warrants histological confirmation. This case highlights the aggressive potential of high-grade urothelial carcinoma and the possibility of rapid systemic dissemination despite negative initial staging.

CRediT authorship contribution statement

Yosr Zenzri: Supervision, Methodology, Formal analysis. Wassim Ammar: Writing – original draft. Farah Bouali: Writing – review & editing, Project administration. Soumaya Gara: Investigation. Meriem Ksentini: Data curation. Ahmed Saadi: Resources. Zahra Ghodhbani: Conceptualization. Amina Mokrani: Visualization. Henda Rais: Validation.

Ethical approval and consent to participate

This case report was conducted in accordance with the ethical standards of the institutional review board of Salah Azaiez Institute and with the 1964 Helsinki Declaration and its later amendments.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and the accompanying clinical images.

Availability of data and materials

Not applicable. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current case report.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used an AI-based language tool in order to improve the clarity and readability of the English text, as the authors are non-native English speakers. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Funding

This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Competing interests

The authors declare that they have no competing interests.