[Primary carcinoma of the female urethra: report of five cases]

Between 1988 and 1996, we treated five patients with primary carcinoma of the female urethra between 65 and 79 years of age. Presenting symptoms included a urethral mass in 2 patients, hematuria in 1, dysuria in 1 and urethral bleeding in 1. Histopathology revealed squamous cell carcinoma in 4 cases and transitional cell carcinoma in 1. Clinical stage according to Grabstald's classification comprised Stage A in two cases, Stages B, C and D in one each. The modes of treatment were surgical resection alone in two, radiation therapy alone in two, and surgery with adjuvant chemotherapy in one case. Three patients without disease and two with disease are olive from 5 to 87 months after diagnosis.

Urethral malignant melanoma closely mimicking urothelial carcinoma

Primary malignant melanoma of the urethra is very rare. In the male, the distal urethra is the most common site. The histopathology does not usually differ from that of melanoma at other body sites. This report describes a case of urethral malignant melanoma which closely resembled urethral carcinoma. It showed both papillary and solid growth, and the diagnosis only became apparent from special stains. Pathologists should be aware of this rare occurrence.

Carcinosarcoma in the region of the female urethra

A 61-year-old woman with acute urinary retention was found to have a carcinosarcoma in the region of the urethra. Evaluation of the computed tomogram suggested a urethral tumor, which was resected by a transperineal approach. She received local radiotherapy after surgery, and is alive at 1-year follow-up with a tumor metastasis to the pelvis.

Prostatic polyp in the prostatic urethra

The authors report on a case of prostatic polyp in the urethral bulb of a 35-year-old man. The presence of this lesion in the urethral bulb is quite unusual and may be overlooked on cystocopic evaluation.

Primary adenocarcinoma in the urethrorectal fistula

A 60-year-old Japanese man was hospitalized because of urinary leakage from the anus on October 3, 1994. Retrograde urethrography detected a fistula between the bulbous urethra and the rectum. Urethrocystoscopy revealed a tumor on the urethrorectal fistula. Tumor biopsy showed a well differentiated adenocarcinoma. Cystourethrectomy with fistulectomy, and ileal conduit urinary diversion were performed. Pathological examination revealed primary adenocarcinoma in the fistula with invasion to the prostatic urethra and bladder wall. The patient showed no evidence of a recurrence as of August, 1996.

Urethral recurrence of an urachal carcinoma: a case report

A 68-year-old man presented with microscopic hematuria. Cystoscopy revealed a papillary and pedunculated tumor in the bladder dome which, on punch biopsy, proved to be adenocarcinoma. Partial cystectomy and urachal remnant resection were performed. Histopathologically, the tumor was diagnosed as an urachal tumor. Four months after surgery, multiple posterior urethral tumors were found; punch biopsy revealed adenocarcinoma, which was quite similar to the previous tumor. Based on the histopathological examination of the transurethrally resected tissue, the urethral tumor was diagnosed as a recurrence of the urachal carcinoma. No evidence of either tumor recurrence or metastasis was found within the 15 months following the second surgery.

Benign polyps with prostatic-type epithelium of the urethra and the urinary bladder

The clinico-pathological features of nine urethral and urinary bladder polyps with prostate-type epithelium are described. The average age of the patients was 46 years. Three patients previously had cystoscopy and the lesion was not noticed on the initial examination. The commonest presentation in this series was haematuria, dysuria and frequency of micturition. One patient presented with postmicturition dribble and another with haemospermia. The polyps contained acini and papillae lined by prostate-type epithelium which was confirmed by immunohistochemical tests for prostate specific antigen and prostate acid phosphatase. In this series no age versus location relationship could be established. Symptoms resolved following resection or initial biopsy followed by fulguration. Recurrence is extremely rare.

Epidermoid carcinoma of the male urethra. Case report

A case of voiding difficulties was investigated. Other than usual prostatic obstruction or urethral stricture, a small mass at the anterior region of the bulbous urethra was present. Detailed investigation by urethroscopy, biopsy, CT imaging and ultrasonography revealed epidermoid carcinoma of the urethra.

Urethral carcinoma metastatic to bone: a case report and literature review

Distant urethral carcinoma metastasis is a very rare event. The following discussion presents a unique case of urethral carcinoma (adenocarcinoma) metastatic to bone and reviews the literature regarding this condition.

Urethral caruncle with atypical stromal cells simulating lymphoma or sarcoma--a distinctive pseudoneoplastic lesion of females. A report of six cases

Six urethral caruncles in women aged 32 to 82 (average, 56) years contained atypical stromal cells raising concern for a neoplasm. The atypical cells varied from spindled to round, the latter predominating, and typically had scant cytoplasm. A minority of the cells were binucleated or multinucleated and often had prominent nucleoli. A single mitotic figure was found in the atypical cells in one case. The atypical cells were characteristically present in an edematous background containing numerous inflammatory cells and were focally crowded together in five cases. The differential diagnosis in these cases included a florid reactive proliferation of lymphoid cells, but immunohistochemical stains failed to support a lymphoid nature for the atypical cells and also helped to exclude malignant lymphoma, the neoplasm most often simulated. Because of the invariable additional component of atypical spindle cells resembling those described in the stroma of the lower female genital tract and in polyps in a variety of sites, the round cells likely represent a variant of this atypical mesenchymal cell. Similar round mesenchymal cells have also been documented in the gastrointestinal tract, especially the stomach. Immunohistochemical stains in this series showed them to be positive for vimentin in four of four cases and for alpha smooth-muscle actin in two of four cases. The prominence of atypical round stromal cells in these cases appears to be a distinctive feature of some urethral caruncles. The presence of these cells should not lead to misinterpretation of the lesion as a neoplastic process.

Ultrasound-guided catheter biopsy of the lower urinary tract: technique and results in 12 dogs

Ultrasound-guided catheter biopsy of lesions affecting the lower urinary tract was attempted in 12 dogs with mucosal lesions affecting the bladder (nine) or urethra (three). Histological biopsies were obtained by catheter biopsy in 10 dogs, enabling diagnosis of transitional cell carcinoma in five, papilloma in two, prostatic carcinoma in two and chronic cystitis in one. Cytological samples alone were obtained in two dogs, one of which enabled a diagnosis of transitional cell carcinoma; the other contained evidence of haemorrhage and inflammation, but squamous cell carcinoma was found in a subsequent excisional biopsy. Intravesicular haemorrhage after biopsy was observed ultrasonographically in two dogs. Ultrasound guidance enables accurate determination of biopsy catheter position. The size of biopsies obtained by this method may limit the accuracy of histological diagnosis.

Transitional cell carcinoma involving the prostate with a proposed staging classification for stromal invasion

PURPOSE

We investigated the effect on survival of transitional cell carcinoma of the prostatic urethra, ducts and stroma, and determined the difference between prostatic stromal involvement occurring via direct extension through the bladder wall versus stromal invasion arising intraurethrally.

MATERIALS AND METHODS

Between August 1971 and December 1989, 489 men underwent radical cystoprostatectomy for transitional cell carcinoma, including 143 (29.2%) identified with prostate involvement by transitional cell carcinoma, in the cystectomy specimen. Patients were separated into 2 groups: 1-19 in whom the primary bladder tumor extended full thickness through the bladder wall to invade the prostate (classified as P4a) and 2-124 in whom prostate involvement arose from within the prostatic urethra.

RESULTS

Five-year recurrence-free and overall survival rates were 25 and 21%, respectively, in group 1 versus 64 and 55%, respectively, in group 2. In the 124 patients in group 2 survival rates were similar for those with prostatic urethral tumors or carcinoma in situ and ductal tumors (no stromal invasion). Five-year overall survival rates without and with stromal invasion were 71 and 36%, respectively (p < 0.0001). Transitional cell carcinoma of the prostatic urethra or ducts does not alter survival predicted by primary bladder stage alone. Prostatic stromal invasion arising intraurethrally significantly decreases survival, which varies based on primary bladder stage (64.6% in stage P1, 30.8% in stages P2/P3a and 13.6% in stage P3b, p = 0.0001). P1 bladder tumors with prostatic stromal invasion arising intraurethrally had a significantly higher survival rate than P4a tumors (64.6 versus 21%, p = 0.0001). P3b bladder tumors with stromal invasion had a survival rate similar to that of P4a tumors (p = 0.78).

CONCLUSIONS

Prostatic urethral or ductal transitional cell carcinoma does not alter survival determined by primary bladder stage alone and it should not be classified as P4a. Prostatic stromal involvement arising intraurethrally significantly decreases survival predicted by primary bladder stage alone. P1 bladder tumors with prostatic stromal invasion arising intraurethrally have a significantly higher survival rate than P4a tumors and they should be separately classified as P1str. Muscle invasive (P2/P3a) bladder tumors with stromal invasion have a higher survival rate than P4a tumors (no statistical significance) and they should be designated separately (that is P2str). P3b bladder tumors with prostatic stromal invasion arising intraurethrally are indistinguishable from P4a tumors.

[Mesonephric adenocarcinoma arising in the female urethral diverticulum]

A forty four-year-old house-wife presented with gross hematuria and difficulty on urination of a year and 3 months duration. Transvaginal examination showed a hen egg-sized soft mass on the anterior vaginal wall. Urine cytology revealed many clusters of malignant cells suggestive of adenocarcinoma. Cystourethrography revealed two urethral diverticula, whose orifices were cystoscopically located at the proximal and distal side of urethral sphincter, respectively. By vaginal digital pressing, a soy-bean sized papillary tumor came out of the proximal diverticulum. Histopathological examination of the biopsied tumor suggested poorly differentiated transitional cell carcinoma with inverted growth. Under the diagnosis of carcinoma arising in the urethral diverticulum, anterior pelvic exenteration with formation of Indiana pouch was carried out. The tumor in the proximal diverticulum was histologically composed of a variety of adenocarcinomatous pattern, such as tubular, papillary and cystic structure with a distinctive pattern of tubules lined by a superficial layer of hobnail cells, leading to the diagnosis of mesonephric adenocarcinoma of urethral diverticulum. Postoperative radiation therapy was given because the diverticulum was adherent to the pubic bone, though lymph node metastasis was negative. She has been well with no evidence of the disease for 1 year and 4 months after the operation. Although the histogenesis of female urethral mesonephric adenocarcinoma was still controversial, this case seems to be the forty fourth case in the world literature.

[Urethral recurrence after cysto-prostatectomy for bladder tumor]

OBJECTIVE

To evaluate the frequency, predictive parameters and prognosis of urethral recurrence after cystoprostatectomy for urothelial bladder cancer.

MATERIAL AND METHODS

From 1989 to 1994, 8 of a series of 185 patients (4.3%) treated by cystoprostatectomy for bladder carcinoma between 1988 and 1993 developed urethral recurrence revealed by urethral bleeding, with a follow-up of 6 to 36 months (m = 16).

RESULTS

The initial bladder tumour was localized in 3 cases and multifocal in 5 cases. The posterior urethra was not involved in 5 cases, but presented lesions of CIS in 1 case and neoplastic infiltration also involving the prostate in 2 cases. These recurrences were treated by urethrectomy, as first-line treatment in 7 cases and after failure of endoscopic treatment in 1 case. A balanic recurrence required distal penectomy following insufficient urethral resection. The course was very rapidly unfavourable for 3 patients with generalized cancer and an intercurrent disease was fatal in 1 other case. With a follow-up of 12 to 44 months (m = 26), 4 patients are alive with no obvious signs of disease progression.

CONCLUSION

The indications for prophylactic urethrectomy can be reserved to patients with positive urethral resection margins, provided all other cases are submitted to strict surveillance. In the context of a replacement bladder, it is essential to exclude neoplastic involvement of the posterior urethra or prostate, especially in patients previously treated by intravesical instillations.

[Inverted papilloma of the posterior urethra: a case report]

A case of inverted papilloma of the posterior urethra is reported. A 59-year-old male was admitted with the chief complaint of difficulty in urination. Cystourethroscopy revealed a polypoid tumor with a smooth surface on the stalk arising from the prostatic urethra, concomitant with prostatic hypertrophy. Transurethral resection of the tumor and the prostate was performed. No evidence of recurrence has been noted in the 9 months after surgery. This is the 26 th case of inverted papilloma of the posterior urethra reported in Japan.

Ultrastructural study of the urothelial lysosomal system in patients with transitional cell carcinoma after transurethral resection and interferon therapy

The epithelial cells of human bladder urothelium contain a prominent lysosomal system on the surface layer which involves autophagic, phagocytotic and excretory processes. The noninvolved urothelium of tumor-bearing patients, however, does not contain this well-developed lysosomal system. Interferon restores the differentiation of the urothelium. Its action on the lysosomal system, however, has not been investigated. We studied ultrastructurally the noninvolved urothelium of eight patients with transitional cell carcinoma who after transurethral resection and intravesicular interferon instillations for 2 years did not develop recurrence. We noted that the number and size of lysosomes increased, being most numerous within the cells of the surface layer. Characteristic large lysosomes with the morphology of multivesicular bodies were also evident. These multivesicular bodies were almost entirely filled with small vesicles containing a dense core. Our findings show that after 2 years of interferon administration a re-appearance of a highly developed lysosomal system of the noninvolved urothelium was evident. This restoration to the normal morphology with reappearance of the lysosomal system, which could be partly attributed to interferon therapy, may be of clinical significance for prevention of tumor recurrence.

Local staging of prostate cancer by endorectal MRI using fast spin-echo sequences: prospective correlation with pathological findings after radical prostatectomy

OBJECTIVE

To evaluate the accuracy of endorectal magnetic resonance imaging (MRI) with fast spin-echo sequences in the local staging of clinically localized prostate cancer.

PATIENTS AND METHODS

Seventy-one patients with a clinical T1 (18 patients) or T2 tumour (53 patients) underwent endorectal MRI 2-12 weeks before radical prostatectomy. Extraprostatic tumour was diagnosed if MRI showed signs of capsular penetration and/or invasion of the seminal vesicle and/or distal urethra or bladder neck. If the pathological examination showed a single positive margin with no periprostatic tissue, the tumour was classified as indeterminate and not as a T3 tumour.

RESULTS

Of the 25 cases of capsular penetration. MRI correctly identified 10 (sensitivity 42%, specificity 100%). Of the 14 cases with seminal vesicle invasion, MRI correctly identified six (sensitivity 43%, specificity 100%), but showed other signs of extraprostatic tumour spread in seven of the eight unidentified cases. Overall, MRI identified 16 of the 30 patients (53%) with occult extraprostatic spread of tumour; there was only one false-positive result. The sensitivity, specificity and accuracy of MRI were 53, 96 and 74%, respectively.

CONCLUSION

Endorectal MRI can reduce the rate of preoperative understaging from 42% to 22% and it can be used for a given individual because it can detect extraprostatic invasion with 96% specificity, ensuring that very few, if any, patients will be deprived of curative surgery.

Clear cell adenocarcinoma of the urethra: a clinicopathologic analysis of 19 cases

Nineteen clear cell adenocarcinomas of the urethra, 18 from women and one from a man, are described. The patients ranged from 35 to 80 years of age (average, 58 yrs). The clinical presentation and gross findings were similar to those of urethral carcinomas, except that 12 tumors, all from women, arose within a urethral diverticulum. On microscopic examination, the neoplasms exhibited the classic triad of tubulocystic, papillary, and diffuse patterns that characterize this tumor. The tumors had the typical cytologic features of clear cell adenocarcinoma, including hobnail cells, flattened cells, and cells with abundant clear cytoplasm. Nuclear pleomorphism was typically at least moderate and was marked in almost half the specimens. Mitotic figures were easily found in almost all the specimens. These cytologic features should aid in distinction of this carcinoma from the benign nephrogenic adenoma, although one of our patients was initially misdiagnosed as having the latter. Immunostaining for prostate-specific antigen and prostatic acid phosphatase was performed on 13 tumors, and all were negative. Follow-up is available for 13 patients. Six of them had no evidence of recurrence up to 10 years postoperatively. Four patients died of disease from 5 months to 42 months postoperatively. Three additional patients have had recurrence but were alive up to 6.5 years after presentation. We conclude that urethral clear cell adenocarcinoma occurs in adults, and in women in the great majority of cases; has a particular association with a urethral diverticulum, which has been present in 56% of the patients; is indistinguishable from clear cell adenocarcinoma of the female genital tract but is not associated with endometriosis; probably does not arise by malignant transformation of nephrogenic adenoma; is usually readily distinguished from the latter because of greater cytologic atypicality and mitotic activity; and does not stain for prostate-specific antigen or prostatic acid phosphatase.

[Mucin histochemical analysis of mucin-forming carcinomas, metaplasias of the urothelium and in persistent urachus]

Twelve cases of mucus secreting metaplasias, nine mucus secreting urothelial carcinomas and three cases of urachus remnants were studied using D-PAS-, m-PAS,- AB pH 2,5/PAS-, HID/AB pH 2,5- and PB/KOH/PAS-technique. Neutral mucins, sialomucins, sulfomucins, O-acylated and unsubstituted or C4- and C7-substituted mucins were detected in different quantities, often intracellular mucus mixtures could be seen. Many differences in the mucus quality of the metaplasias, in comparison to that of the tumors, were not noticeable. Metaplasia associated with carcinoma and mucus secreting carcinomas showed a loss of O-acylated sialomucins and besides diffus positive reaction in m-PAS-technique. Further investigations should confirm if this is really a prognostic factor. O-acylated sialomucins were not only found in metaplastic lesions and urothelial carcinomas but also in metaplasias of the urachus. Therefore it is not possible to distinguish between adenocarcinomas of the urinary bladder and adenocarcinomas derived from the Urachus using PB/KOH/PAS method.

[Urothelial carcinoma of the navicular fossa]

We report a case of transitional cell carcinoma arising in the fossa navicularis. The patient was a 74-year-old man. He had no history of sexually transmitted disease or urethral stricture. Clinically, the tumor was suspected to be a condyloma acuminatum; however, the pathological diagnosis yielded an unexpected result: transitional cell carcinoma. Radiological examinations and cystoscopy showed no other tumor besides the primary cancer in the fossa navicularis. Partial resection of the urethra was performed and the patient has been without evidence of disease for 3 years.

Incidence of urethral tumor involvement in 910 men with bladder cancer

Urethral tumor involvement was examined in 910 patients treated for bladder cancer at a single institution over a period of 25 years. The overall incidence in 2,052 primary and recurrent bladder-tumor events was 6.1%. Risk factors for urethral tumor occurrence are tumors at the bladder neck and recurrent multifocal tumors. Carcinoma in situ (CIS) of the bladder not involving the bladder neck and muscle-invasive tumors with or without lymph-node involvement are not significantly correlated with urethral cancer. Patients at risk for urethral tumors as outlined should be worked up very carefully (multiple urethral biopsies and/or urethral brushings, frozen section of the membranous urethra) before they are considered for an orthotopic neobladder. Altogether, 17 of 89 patients had 1-6 urethral tumor recurrences. The majority of urethral tumors were treated with a single conservative treatment session and did not recur thereafter. A conservative approach toward superficial urethral tumor recurrences in patients with an orthotopic neobladder to the urethra may therefore be feasible.

The ileal neobladder--updated experience with 306 patients

From April 1986 through May 1995, 306 men with primary urothelial carcinoma underwent radical cystoprostatectomy and orthotopic bladder substitution via the ileal neobladder. Altogether, 7.5% of the patients suffered general early complications, including thrombosis, embolism, wound infection, and pneumonia. Specific early complications directly related to formation of the neobladder and requiring surgery included ileus (4%), abscess drainage (2%), and leakage of the ileal anastomosis (0.5%). The early reoperation rate was 6.5%. Early complications that required temporary percutaneous drainage were lymphocele formation (3%) or ureteral obstruction (6%). In all, 9% of our patients required prolonged catheter drainage for leakage of the ileouretheral anastomosis. Late complications requiring reoperation were ileus (2%), abscess drainage (1%), neobladder fistula to the colon (1.5%), ureteral reimplantation because of obstruction (3.6%), and nephrectomy for hydronephrosis (1%). A transurethral incision of the ileouretheral anastomosis was necessary in 7% of cases. Continence was separately addressed by sending each patient and his home physician a detailed questionnaire: Using our criteria (no diapers, no awakenings) the night and day continence rate increased from 67% at 6 months, to 72% at 1 year to 85% at 2 years, finally reacting 90% after 4 years. In part II of this presentation we address the question as to whether the option of orthotopic bladder replacement has any impact on the patient's and physician's decision toward earlier cystectomy. We compared our ileal neobladder cohort with a group of 137 patients that had been operated on during the same time span by the same group of surgeons. There was no negative selection with regard of the tumor stage of our patients. However, as compared with the conduit group, the neobladder cohort had a significantly improved survival rate. This phenomenon is explainable by the significantly lower number of previous transurethral resections of the bladder (TUR-Bs) performed in the neobladder group. The time span between primary diagnosis and cystectomy was 10 months in the neobladder group as compared with 18 months in the conduit patients. These data reinforce our belief that orthotopic bladder replacement using the ileal neobladder yields an extraordinary functional result that can be accomplished with a high degree of patient satisfaction and minimal complication. The availability of orthotopic bladder replacement does indeed stimulate the physicians and patients decision toward earlier cystectomy.