Urethral tumour: rare images of unaware entity

Description

A 55-year man with a history of thin stream of urine and dysuria for the last 7 years presented with mild haematuria followed by acute urinary retention for 2 days. Clinical examination showed indurated mass with urethrocutaneous fistula in perineum (figure 1A). Per-urethral catheter could not be negotiated and so urine was drained by suprapubic catheterisation. Retrograde urethrogram and voiding cystourethrogram were suggestive of filling defect in bulbar urethra (figure 1B,C). Urethroscopy (figure 2A) revealed a broad base lesion arising from dorsal and left lateral wall of distal bulbar urethra occluding the lumen of urethra. MRI showed a low signal intensity heterogeneous mass of bulbo-membranous urethra that invaded into spongiosa and penile skin with bilateral inguinal node involvement (figure 2B). Biopsy was suggestive of transitional cell carcinoma (figure 3). The patient was counselled for cystoprostectomy with total penectomy but he refused. He received 60 Gy of radiotherapy in 30 fractions followed by six cycles of methotrexate, vinblastine, doxorubicin and cisplatin. Follow-up at 3 months showed good local response and absence of progression in regional nodes. Urethral carcinoma is very rare and is less common in men than in women.¹ Symptoms are non-specific^{2 3} and unaware to patients and so presentation is usually delayed.² Because of difficulty in achieving local control,¹ proximal urethral cancer carries a worse prognosis than distal.^{4 5} However, cases of a curative response to chemo-radiotherapy alone have been reported^{6 7} but radical cystoprostectomy, pelvic lymphadenectomy and total penectomy is a standard treatment option for proximal urethral cancers.¹

Figure 1.

(A) Urethrocutaneous fistula at peno-bulbar junction. (B) Retrograde urethrogram showing filling defect at peno-bulbar junction. (C) Voiding cystourethrogram showing filling defect in bulbar urethra.

Figure 2.

(A) Urethroscopy showing growth arising from dorsal and left lateral wall of bulbar urethra. (B) MRI shows that the mass (large arrow) occupies the corpus spongiosum and adjacent skin but has not invaded the corpora cavernosa with bilateral inguinal lymph node involvement (small arrow).

Figure 3.

Histopathology report showing proliferated transitional epithelial cells disposed in papilla formation (arrow) and lamina properia infiltration.

Learning points.

Uretheral cancer

• Uretheral cancer is a rare disease and symptoms are usually non-specific.

• Presentation is usually delayed because of unawareness of symptoms.

• Proximal tumours have a worse prognosis then distal tumours.

• Radical surgery is necessary to achieve good local control in proximal cancers.

• Penile preserving surgery is adequate for local control in distal tumours.

• Overall prognosis is poor.