[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.

[Peroperative biopsy of the sub-apical urethra during prostatectomy for cancer]

INTRODUCTION AND OBJECTIVES

Between 35 to 45% of radical prostatectomies (RP) will show positive margins and approximately 50% of patients with positive margins will progress following RP. Peroperative diagnosis of positive margin possibly can improve the currability of RP. We report here the incidence and management of positive urethral margins diagnosed by frozen sections during radical prostatectomy.

METHODS

Frozen sections were performed systematically to analyse the surgical margins during 130 RP performed for localized prostate cancer from january 1989 to december 1993. Peroperative analysis of distal (urethral) and proximal (bladder neck) margins, as well as posterior (Denonvilliers fascia) margins, and every surrounding tissue that was macroscopically abnormal were performed.

RESULTS

Analysis of the distal margins showed no prostatic gland in 68 cases (52%), normal prostatic glands in 56 cases (43%) and neoplastic prostate glands in 6 cases (5%). Further urethral sections with frozen section analysis were performed in 62 cases until the distal margin was free of prostatic glands. Three out of six patients with positive urethral margins had another positive margin that was excised as well. Five out of six patients with positive urethral margins were pT3, NO, MO and one pT2, NO, MO. In the group of patients, with positive urethral margins, the average preoperative PSA serum level was 37 ng/ml and the average tumor weight was 14 g. Postoperative pelvic radiation therapy (45 grays) was performed in 5 of these patients. The mean follow-up is 36 months (12-68). PSA serum level is undetectable in 4 cases, and 0.4 ng/ml in 1 case. Urinary PSA level is undetectable in 5 out of 6 cases.

CONCLUSION

Peroperative analysis of surgical margins, and particularly urethral margins, during RP allows to a better staging and to perform any tumor excision complement if possible. Surgical margins analysis when performed during surgery should help for the choice of the most adapted surgical procedure. In our experience, nerve-sparing RP are performed only when surgical margins are negative on frozen sections.

Paraganglioma of the prostatic urethra. A report of three cases and a review of the literature

OBJECTIVE

To determine the incidence and clinical presentation of prostatic urethral paragangliomas and to compare these findings with paragangliomas occurring in the other sites of the lower urinary tract.

PATIENTS AND METHODS

The clinical records of three patients with prostatic urethral paragangliomas were reviewed, as was the histology of each specimen. The tumours were stained immunocytochemically with neuron-specific enolase, chromogranin, S100 protein, protein gene product 9.5, prostate-specific acid phosphatase and prostate-specific antigen.

RESULTS

The three tumours occurred in elderly men, two of whom presented with haematuria, one of whom also had a vesical transitional cell carcinoma, and the third patient had obstructive symptoms due to co-existent prostatic hyperplasia. The histological appearances and immunocytochemical findings were consistent with paraganglioma. Treatment consisted of local excision and there were no recurrences or metastases at 5 and 6 years in two patients for whom follow-up was available.

CONCLUSION

Urethral paragangliomas are rare tumours arising in elderly men and are hormonally inactive. Although haematuria may be the presenting symptom, it is important to exclude additional more common and possibly more sinister lesions such as transitional cell carcinoma. Local excision appears to be curative.

Cytologic features of clear cell carcinoma of the urethra and urinary bladder

Clear cell carcinoma (CCL) arising in the lower urinary tract is unusual and we report the cytohistologic findings of three cases retrieved from our files. All patients presented with bleeding, and the tumors were localized in either the urethra or bladder base. Filter and cytocentrifuge preparations of the urine were studied and all cases displayed numerous scattered aggregates or single tumor cells in an inflammatory background. The enlarged cells had abundant clear, wispy cytoplasm with discrete vacuolation. Hobnail and signet ring cells were apparent. The nuclei had granular to vesicular chromatin with prominent often multiple nucleoli. The tumors were histologically distinctive and typically had a tubulocystic configuration with varying proportions of papillary and diffuse patterns. One patient has died of metastatic cancer and two are presently free of tumor. The cytohistologic features of this cancer are characteristic and from our review we conclude that this lesion can be diagnosed by cytologic means.

The histogenesis of clear cell adenocarcinoma of the lower urinary tract. Case series and review of the literature

Clear cell adenocarcinoma of the lower urinary tract is a rare neoplasm whose histogenesis has not been thoroughly investigated. We have examined six specimens of clear cell adenocarcinomas collected from three institutions using histological, histochemical, and immunohistochemical techniques. Results indicate that almost all clear cell adenocarcinomas of this region express morphological and antigenic features, suggesting müllerian differentiation, and that müllerian differentiation is not a feature of either nonclear cell adenocarcinomas or normal female paraurethral glands. Including the authors' six specimens, 46 specimens have been reported in the available English literature. The accumulated experience confirms the initial impression that these tumors develop predominantly in the urethras of women and occur over a wide age range. Despite high stage at diagnosis, most patients have been alive with no evidence of disease when reported, a prognosis that seems to apply regardless of length of follow-up.

A unique case of long-term survival in a male patient with malignant melanoma of the distal urethra

Primary malignant melanoma of the urethra in male patients is a rare entity, noted to have a dismal prognosis in recent reviews. No case of long-term disease-free survival in patients with primary malignant melanoma has been previously reported. We report the first such case, and review briefly the factors that could have contributed to our patient's long-term survival. We also illustrate the precursor lesion present six years prior to diagnosis.

Urethral caruncle: an unusual presentation of ovarian tumour

Secondary female urethral cancer presenting as urethral caruncle is extremely rare. We report a primary ovarian adenocarcinoma in a 78-year-old female patient presented initially as a urethral caruncle. This case represents the first reported case in the world literature. The clinical features, investigations and pertinent literature are reviewed.

Mucinous adenocarcinoma of the male urethra

We report a case of primary mucinous adenocarcinoma arising in the bulbomembranous urethra. The patient underwent radical cystectomy and total penectomy, followed by systemic chemotherapy. Metastases in lungs, skin, and lymph nodes (inguinal, iliac, para-aortic, and tracheobronchial) were found within 2 months after operation. We reviewed 37 cases of primary adenocarcinomas of the male urethra.

Squamous cell carcinoma of the distal urethra in a patient with congenital hypospadias

A previously well 43-yr-old man with congenital hypospadias presented with a fungating lesion of 2 mths duration and surrounding the ventral urethral opening. After biopsy showed this to be a squamous cell carcinoma, a definitive procedure of partial penile amputation and urethroplasty was performed. This is believed to be the first reported case of squamous cell carcinoma of the distal urethra in conjunction with hypospadias.

Urethral metastasis from a rectal carcinoma

A 67-year-old man presented with a tumour of the penis. Endoscopy revealed a bleeding tumour. Histological examination showed an adenocarcinoma; urethral metastasis of rectal carcinoma. As far as we know only 6 previous cases have been described.

[Apropos of a case of nephrogenic adenoma in a urethral diverticulum in a woman]

A nephrogenic adenoma in a urethral diverticulum has been observed in a 32 years old black woman. The association of both of these abnormalities is relatively uncommon, however symptomatic and source of complications.

Pelvic exenteration for malignant melanomas of the vagina or urethra with over 3 mm of invasion

Pelvic exenteration has usually been employed as salvage treatment for gynecologic malignancies which have failed primary radiotherapy. The therapeutic mainstay for vulvar melanomas has become wide local excision with or without concurrent regional node dissection. Patients with primary melanoma of the vagina who undergo exenteration as primary therapy may experience 50% 5-year survival if the pelvic nodes are free of metastases. However, the overall 5-year survival for vaginal melanoma is 15%. In our patient population, there have been four patients with vaginal or urethral melanomas treated primarily with pelvic exenteration. The purpose of this study was to report that patients with vaginal or urethral melanomas over 3 mm in thickness may benefit from primary pelvic exenteration. Four patients underwent pelvic exenteration at Indiana University Medical Center for malignant melanoma of the vagina or urethra between 1986 and 1992. The pathologic specimens of all patients were analyzed for thickness, growth pattern, and nodal metastases. Patient age ranged from 50 to 71. Thickness of the melanomas ranged from > 3 to 12 mm. All four patients underwent exenterations, three total and one anterior. All patients had negative pelvic and inguinal nodes at the time of surgery. None of the patients has experienced a recurrence. Three of four patients are alive without evidence of disease at 31 to 97 months following their exenteration. One patient died postoperatively of cardiopulmonary complications. Patients with melanomas of the vagina and female urethra, greater than 3 mm in thickness, may benefit from primary pelvic exenteration.

Female urethral adenocarcinoma: evidence for more than one tissue of origin?

Adenocarcinoma of the female urethra accounts for 10% of all urethral cancers. Controversy continues to exist over the origin of primary urethral adenocarcinomas. The periurethral (Skene's) glands appear to be the homologues of the male prostate as defined by authors evaluating cadaver-derived periurethral glands pathologically and immunohistochemically (prostate-specific antigen (PSA)). It is traditionally assumed that the origin of female urethral adenocarcinoma is the Skene's gland. However, no one has evaluated a series of primary urethral adenocarcinomas in an effort to scrutinize this assumption. We, therefore, evaluated 13 primary adenocarcinomas of the female urethra comparing histologic and immunohistochemical characteristics. Tumors were classified into two major histologic groups: columnar/mucinous (11) and clear cell (2). Excluding one case, the columnar/mucinous tumors resembled either endometrial or colonic adenocarcinoma. The exception was a case bearing a striking resemblance to prostatic adenocarcinoma. Immunohistochemical results revealed positive PSA staining for this tumor alone. The patient's preoperative serum PSA was elevated, but rapidly declined postoperatively. Based on immunohistochemical findings and the presence of distinct histologic subtypes (columnar/mucinous, clear cell), it appears that female urethral adenocarcinoma has more than one tissue of origin with a minority arising from the Skene's glands.

[Inverted papilloma of the female urethra]

OBJECTIVE

Transitional cell inverted papilloma is an uncommon, generally benign tumor that rarely presents in the lower urinary tract. It is characterized by a typical inverted growth pattern and a layer of normal transitional epithelium. One such case is described herein.

METHODS

We report on a 53-year-old female with transitional cell inverted papilloma of the urethra presenting as postmenopausal metrorrhagia. The lesion was removed surgically.

RESULTS

It was a round-shaped, 1.5 cm diameter, polypoid lesion that was resected. Standard pathological analyses disclosed a trabecular type inverted papilloma.

CONCLUSIONS

Transitional cell inverted papilloma of the female urethra is rare. To date it has only been reported in male patients. An additional case of this tumor type is described in a female patient.

MR and CT appearance of urethral clear cell adenocarcinoma in a woman

We present a case of clear cell adenocarcinoma of the female urethra that has been evaluated with CT and MRI. The lesion was a well-demarcated mass surrounded with peripheral enhancement on CT. On MRI a sharply marginated mass was located in the midurethra, giving rise to a smooth elevation of the bladder base. On T2-weighted imaging, the lesion was hyperintense, being surrounded by a ring of lower signal intensity at the periphery. A central urethral dot of lower signal intensity traversed the anterior one-third of the mass but was preserved in its entire length.

Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens

PURPOSE

In an attempt to identify women who may be appropriate candidates for orthotopic lower urinary tract reconstruction, archival cystectomy specimens from female patients undergoing cystectomy for primary bladder cancer were reviewed. These pathological findings should provide a better understanding of tumor involvement at the bladder neck (vesicourethral junction) and urethra in women with transitional cell carcinoma of the bladder.

MATERIALS AND METHODS

Cystectomy specimens of 67 consecutive women undergoing surgery for biopsy proved transitional cell carcinoma of the bladder between July 1982 and July 1990 were pathologically reviewed.

RESULTS

Histological evidence of tumor (carcinoma in situ or gross carcinoma) involving the urethra was present in 9 patients (13%). Tumor was confined to the proximal and mid urethra, and the distal urethra was not involved. All patients with carcinoma involving the urethra had concomitant evidence of carcinoma involving the bladder neck. A total of 17 patients (25%) had tumor involvement of the bladder neck and those with an uninvolved bladder neck also had an uninvolved urethra. The association between the presence of tumor in the bladder neck and urethra was highly significant (p < or = 0.00012). Tumor involving the bladder neck and urethra tended to be more commonly associated with high grade and stage tumors, and node-positive disease.

CONCLUSIONS

Although the fate of the retained urethra following cystectomy for bladder cancer in women is unknown, these results show that women with transitional cell carcinoma of the bladder without evidence of tumor involving the bladder neck are at low risk for urethral malignancy. These patients may be offered lower urinary tract reconstruction that includes preservation of and diversion through the urethra (orthotopic diversion). Urethral surveillance will be necessary, as it is in men after orthotopic urinary diversion.

Fibroepithelial polyps of the renal pelvis: report of two cases and review of the literature

Benign tumors of the urinary tract are rarer than transitional cell carcinomas. Among the benign tumors we have those of epithelial origin (papillomas or low grade transitional cell carcinomas) and those of mesodermal origin (fibrous and angiomatous polyps, hemangiomas and lymphangiomas and neurofibromas), together with a group of miscellaneous lesions including endometriosis, amyloidosis and granulomas. The fibroepithelial polyps of the urinary tract represent between 2-6% of all the benign tumors. This rare tumor is located more frequently in the ureter and only in 11 cases reported since 1929 the location was the renal pelvis. Between 1976 and 1994 we have seen three cases of fibroepithelial polyps of the urinary tract, two of them affecting the renal pelvis and one of them affecting the ureter. We report the cases located in the pelvis and make a review of the cases reported in this location in the last years and discuss the clinical, radiological and cytological criteria that can lead to a preoperative diagnosis of this entity avoiding an unnecessary nephroureterectomy.

Nephrogenic adenoma of the urinary tract: a review of the microscopic appearance of 80 cases with emphasis on unusual features

A detailed review of the microscopic features of 80 nephrogenic adenomas of the urinary tract was undertaken. The lesions occurred in patients who ranged in age from 15 to 94 (average, 52) years. There was a 2:1 male/female ratio. Fifty-five percent of the lesions occurred in the urinary bladder, 41% in the urethra, and 4% in the ureter. The most common microscopic pattern, present in 96% of the cases, was tubular. The tubules were usually small, hollow, and round, but some were solid and occasionally elongated. Their arrangement varied from orderly, sometimes laminar, to pseudoinfiltrative. A basement membrane was appreciable around the tubules in 25% of the cases but was rarely prominent. In two prostatic urethral cases tubules involved the fibromuscular prostatic stroma. A cystic pattern was seen in 72% of the cases. The tubules and cysts most commonly contained eosinophilic secretion but in 25% of the cases the secretion was basophilic. In 12% of the cases some of the tubules were tiny and when they contained basophilic secretion occasionally mimicked signet-ring cells. The third most frequent pattern, seen in 65% of the cases, was papillary to polypoid. Edematous polyps were commonest but thin, delicate filiform papillae were present in 10% of the cases. A complex branching pattern with prominent budding of small papillae was seen in three cases. The papillary-polypoid pattern was usually associated with a tubular component but in three cases it was pure. The final pattern, present in 14% of the cases, was diffuse, but it was prominent in only one case.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic considerations in coexisting bladder and urethral leiomyomata. A case report

BACKGROUND

Leiomyomata of the lower urinary tract in women are rare. Coexisting urethral and bladder leiomyomata have never been reported before.

CASE

A 45-year-old woman, gravida 6, para 5, abortus 1, presented with a one-year history of increasing frequency, nocturia and hesitancy of up to 10-15 minutes at times. An intravenous pyelogram showed an extrinsic mass at the bladder neck. Urethrocystoscopy revealed a regular bulge at the level of the bladder neck on the right side without involvement of the bladder mucosa. Ultrasound showed a 5 x 4.7 x 4-cm mass of heterogeneous echogenicity, posterior to the bladder and anterior to the lower uterine area, with a normal-appearing uterus. The patient underwent surgery for vaginal excision of the tumor. Two separate masses were found at surgery. One small, firm, solid, 2-cm mass was found on the posterior proximal aspect of the urethra, and a larger, soft, 3 x 3-cm mass was found on the posterior lower aspect of the bladder. The masses clearly arose from the urethra and bladder, respectively. Rapid frozen section revealed smooth muscle cells consistent with leiomyomata. Both leiomyomata were entirely resected.

CONCLUSION

Lower urinary tract leiomyomata should always be considered in the differential diagnosis of an anterior vaginal mass in premenopausal women.

Pathology of canine bladder and urethral cancer and correlation with tumour progression and survival

Biopsy and necropsy specimens, comprising 107 primary carcinomas and three mesenchymal tumours, were reviewed from 110 dogs with cancer of the bladder, urethra, or both. Histological classifications developed for the assessment of human bladder cancer were found to be readily applicable to the dog. These classifications are based on histological features, including the pattern of growth, the cell type, the grade of transitional tumour and the depth of invasion of the bladder wall. Features associated with localized disease in canine transitional cell carcinoma included papillary architecture, "in-situ" tumour, low tumour grade and a strong peritumoral lymphoid cell reaction. Features of tumours with metastasis included infiltrating and non-papillary architecture, increasing tumour grade, depth of invasion, vascular invasion and presence of peritumoral fibrosing reaction. Wide variability was found within single tissue samples, indicating that multiple sample sites are necessary for the adequate characterization of a given lesion. Statistically significant correlations were found between: tumour grade and depth of invasion (P < 0.0001); tumour grade and presence of metastases (P < 0.029); and peritumoral desmoplasia and metastases (P < 0.029). It was concluded that canine bladder cancer could be classified for the purpose of clinical management with a modified World Health Organization system as developed for human tumours.

[Urethral leiomyoma during pregnancy. Report of a case and review of the literature]

We present a case of leiomyoma of the urethra diagnosed during pregnancy. The patient a 40 year old woman, gravida II, who presents a mass that depend of the proximal urethra, it was observed in the vaginal introitus, it's growth was progressive after 8th weeks of pregnancy. We realized local excision at 23rd weeks pregnancy. Histopathological examination reported leiomyoma of the urethra. The pregnancy was resolved through cesarean section by fetal indication. Actually the patient is free of symptoms.