□ Case Report □

Anterior Urethral Recurrence from an Upper Urinary Tract Urothelial Tumor

Seung Il Jung, Ho Suck Chung, Chang Min Im, Sun-Ouck Kim, Korean Journal of Taek Won Kang, Dong Deuk Kwon, Kwangsung Park, Soo Bang Ryu Vol. 50 No. 7: 718-720, July 2009

From the Department of Urology, Chonnam National University Medical School, DOI: 10.4111/kju.2009.50.7.718 Gwangju, Korea Received：March 19, 2009 We report a case of a metachronous transitional cell carcinoma (TCC) of Accepted：May 27, 2009 the penile in an elderly male after nephroureterectomy. The patient had a history of right nephroureterectomy 18 months previously due to Correspondence to: Taek Won Kang TCC of the upper urinary tract. A solitary urethral recurrence from a TCC Department of Urology, Chonnam National University Medical of the upper urinary tract is rare. An anterior urethral recurrence of a School, 8, Hak-dong, Dong-gu, TCC of the upper urinary tract has not been previously reported in the Gwangju 501-757, Korea literature. The prognosis of a metachronous anterior urethral recurrence TEL: 062-220-6703 of an upper-tract TCC is poor. (Korean J Urol 2009;50:718-720) FAX: 062-227-1643 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 E-mail: [email protected] Key Words: Transitional cell carcinoma, Urethra, Ⓒ The Korean Urological Association, 2009

Patients with upper urinary tract transitional cell carcinoma urethral lumen. (TCC) are at risk for development of bladder , with an Abdominal computed tomography (CT) revealed no pelvic estimated incidence within 5 years that varies in multiple . A magnetic resonance imaging scan of the reports between 15% and 75%.1 Metachronous TCC of the penis revealed a focal area of iso-signal intensity on the T1- urethra in a patient with an upper urinary tract tumor is quite and a heterogeneous high signal intensity on the T2-weighted rare. Only 1 case of a posterior urethral recurrence has been images with irregular peripheral enhancement on contrast- reported to date.2 Here we report a case of a metachronous enhanced images in the region of the penile urethra (Fig. 1). anterior urethral recurrence causing urinary retention from The patient declined and underwent an upper-tract TCC. anterior and perineal urethrostomy, with a 2 cm margin proximal to the palpable tumor (Fig. 2). The intraopera- CASE REPORT tive urethral margins were negative and intraoperative cysto- scopy was within normal limits. The patient made an unevent- In April 2006, a 76-year-old man presented with acute ful postoperative recovery. The final pathology report indicated urinary retention. His urologic history was significant in that a high-grade TCC invading beyond the muscularis into the he had undergone a right nephroureterectomy 18 months previ- periurethral tissue. The resection margins were clear from the ously due to TCC of the upper urinary tract. Histopathologic tumor. The TNM stage was T3NxMx. The patient underwent findings showed a high-grade TCC (pT1N0M0). The patient 2 cycles of combination involving gemcitabine had been followed regularly for 15 months without evidence and (GC). of recurrence until he had urinary retention. Follow-up Three months postoperatively, the patient had no evidence of cystourethroscopy was reported as being within normal limits recurrence on chest x-ray, abdominal CT, and . as recently as 3 months before he presented for urinary Approximately 6 months postoperatively, the patient com- retention. The physical examination revealed a 3x1 cm palpable plained of hip pain and was found to have multiple bony hard mass within the penile urethra. There was no significant metastases and lung metastases detected by bone scan and chest palpable inguinal lymphadenopathy. Cystourethroscopy and CT with no evidence of recurrence on cystourethroscopy and revealed a penile urethral TCC that almost filled the abdominal CT scans. The patient received conservative therapy,

718 Seung Il Jung, et al：Urethral Recurrence from an Upper Tract Urothelial Tumor 719

Fig. 1. Magnetic resonance imaging. (A) Sagittal T1-weighted image with gadolinium administration demon- strates the urethral carcinoma (arrow head) replacing the penile urethra without local extension into the corpus cavernosum. (B) Coronal T1-weighted image with gadolinium administration shows an irregular, peripheral, enhanced penile urethral mass (arrow head).

cases.4,5 Urethral metastasis from other primary sites is quite rare. Metastasis from primary tumors situated in the lung, , lymph glands, skin (malignant ), and colon have been described.6,7 Metachronous carcinoma of the urethra from an upper urinary tract tumor, however, is very rare.2 Recurrence of TCC of the upper urinary tract to the bladder is relatively common.8 However, solitary recurrence of TCC of the upper urinary tract to the urethra is extremely rare. Anterior urethral recurrence from a TCC of the upper urinary tract has not been previously reported in the literature. In our case, the recurrence site from the ureteral tumor was the penile urethra. One case of posterior urethral recurrence has been reported previously, and the recurrence site was the prostatic urethra after a nephroureterectomy.2 Fig. 2. Gross finding. (A) Resected 9 cm anterior urethra. (B) In general, anterior urethral carcinoma is more amenable to Intraluminal protruding 3x1 cm mass in the penile urethra. surgical control, and the prognosis is better than that of posterior urethral carcinoma, which is often associated with including radiation therapy and pain control for bony extensive local invasion and distant metastasis.9 For a tumor metastases, but died 7 months postoperatively. infiltrating the corpus spongiosum and localized to the distal half of the penis, a partial with a 2 cm negative DISCUSSION margin proximal to the visible or palpable tumor is generally successful. If the infiltrating tumor is located in the proximal Approximately 80% of all urethral carcinomas are squamous penile urethra or involves the entire urethra, a total penectomy cell , which arise most commonly in the bulbar and is indicated.10 penile urethra.3 TCCs account for 15% of all carcinomas of the Similar to this case, some authors performed penile-sparing male urethra and arise most commonly in the prostatic urethra. surgery consisting of urethrectomy with sparing of the corpora Urethral TCC recurrence has been reported in 2-6% of patients cavernosa and formation of a perineal urethrostomy for a tumor with an ileal neobladder reconstruction after radical confined to the spongiosum. 10 to prevent recurrence, our for invasive , and an anterior urethra recurrence patient received systemic chemotherapy with GC; however, the of superficial bladder cancer has been reported in 2.6% of patient developed multiple bony metastases and lung metastases 720 Korean Journal of Urology vol. 50, 718-720, July 2009 without local recurrence at 6 months and died at 7 months the prostatic urethra in a patient with history of nephro- postoperatively. ureterectomy for upper urinary tract urothelial tumor. Arch Esp Urol 2004;57:1125-7 Urethral recurrence might occur by hematogenous metastasis, 3. Levine RL. . Cancer 1980;45(Suppl 7):1965-72 and minimal urethral injury from cystoscopic evaluation at 4. Freeman JA, Esrig D, Stein JP, Skinner DG. Management of regular intervals might be a contributing factor to cancer the patient with bladder cancer. Urethral recurrence. Urol Clin seeding. Iatrogenic implantation might be a possible etiology North Am 1994;21:645-51 for urethral recurrence, but the patient underwent nephro- 5.Saika T, Tsushima T, Nasu Y, Arata R, Kaku H, Akebi N, ureterectomy 18 months previously and no recurrence or et al. Anterior urethral recurrence of superficial bladder cancer: its clinical significance. Acta Med Okayama 2003;57:293-7 metastatic disease was observed during the same period, so the 6. Chang YH, Chuang CK, Ng KF, Liao SK. Urethral metastasis possibility of iatrogenic implantation is decreased. Urethral from a colon carcinoma. Urology 2007;69:575 recurrence from an upper urinary tract urothelial tumor is rare, 7. Okaneya T, Inoue Y, Ogawa A. Solitary urethral recurrence but is possible and has a poor prognosis. of sigmoid colon carcinoma. Urol Int 1991;47:105-7 8. Miyake H, Hara I, Arakawa S, Kamidono S. A clinicopa- thological study of bladder cancer associated with upper REFERENCES urinary tract cancer. BJU Int 2000;85:37-41 9. Zeidman EJ, Desmond P, Thompson IM. Surgical treatment 1. Flangan RC. Urothelial tumos of the upper urinary tract. In: of carcinoma of the male urethra. Urol Clin North Am 1992; Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, 19:359-72 editors. Campbell-Walsh urology. 9th ed. Philadelphia: Saun- 10. Sharp DS, Angermeier KW. Surgery of penile and urethral ders; 2006;1638-52 carcinoma. In: Wein AJ, Kavoussi LR, Novick AC, Partin 2. Cruz Guerra NA, del Valle Manteca A, Zamora Martinez T, AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Tarroc Blanco A. Metacronous transitional cell carcinoma of Philadelphia: Saunders; 2006;1011-8