Partial Urethrectomy Research Articles

Case Report: Urothelial urethral carcinoma in HIV patient underwent total urethrectomy and perineal urethrostomy

Introduction HIV affects over 38 million people worldwide, affecting the immune system and leading to symptoms like fever, lymphadenopathy, and sore throat. High viral loads can lead to opportunistic infections and tumors. The life expectancy of HIV patients has increased due to high-efficiency combination anti-retroviral therapy. Urothelial carcinoma, a malignant development, damages the urinary canal lining. The connection between HIV and urinary cancers is unclear, the aims of this study to report a case of urethral urothelial Carcinoma in HIV patient who underwent total urethrectomy and perineal urethrostomy. Case presentation A 34-year-old male patient with a papilliferous lump on the glans penis for over six months was admitted to the hospital. Preoperative screening revealed HIV and a urethral mass was found. A partial urethrectomy was performed, revealing high grade papillary urothelial Carcinoma. Five months after surgery, the patient developed a recurrent lump, requiring a total urethrectomy, TUR (transurethral resection) of the mass in the prostatic urethra, and perineal urethrostomy. Conclusion Primary carcinoma of the urethra in HIV patient is an extremely rare case. To date, there is no consensus on the primary urethral carcinoma therapy. The treatment of primary urethral carcinoma is tailored specifically to the patient based on the location, histology, and stage of the carcinoma.

Concomitant Immunotherapy and Metastasis-Directed Radiotherapy in Upper Tract Urothelial Carcinoma: A Biomarker-Driven, Original, Case-Based Proof-of-Concept Study.

Metastatic upper tract urothelial carcinoma (mUTUC) has a poor prognosis. Immune checkpoint inhibitors (ICIs) have demonstrated efficacy in patients with metastatic urothelial carcinoma. However, data supporting the use of ICIs in patients with mUTUC are limited. A promising synergy between ICI and concomitant radiotherapy (RT) has been reported in patients with mUTUC. Our research involved a case-based investigation and emphasized the successful integration of different specialists' skills. Observed after partial urethrectomy procedures for muscle-invasive upper tract urothelial carcinoma (UTUC), the radiological detection of lung metastases prompted us to implement cisplatin-based first-line chemotherapy and molecular characterization in the treatment process. We uncovered alterations in the ERBB2 and FGFR3 genes and mismatch repair deficiency at a molecular level. First-line chemotherapy treatment led to a stable disease, and the patient was started on maintenance immunotherapy with Avelumab. Subsequently, an increase in the size of the lung nodules was described, and the patient received radiotherapy for three lung lesions in combination with immunotherapy. After 3 months, a restaging CT scan reported a complete response, which is still ongoing. We discuss the mechanisms driving RT/ICI synergy and the molecular profile of mUTUC as factors that should be considered in therapeutic strategy planning. Molecular insight enhances the originality of our study, providing a nuanced understanding of the genetic landscape of mUTUC and paving the way for targeted therapeutic strategies. The therapeutic armamentarium expansion encourages the design of a multimodal and personalized approach for each mUTUC patient, taking into account tumor heterogeneity and molecular profiling.

Case Report: A rare case of mucinous adenocarcinoma of the female urethra

Background: Urethral adenocarcinoma is a very uncommon problem in women, with a prevalence of 0.02%. Due to the disease's rarity, there is very little information available about it. Treatment for cancer can have a significant negative influence on a patient's condition. Mucinous adenocarcinomas are a very uncommon type of cancer that is poorly studied. These cancers almost invariably have a worse outcome compared to conventional adenocarcinomas. Case Presentation: A 67 year old woman presented with hematuria and stranguria. A computerised tomography (CT) scan of this patient revealed an urethral tumor. In her histopathologic report we found the tumor cells were arranged in small clusters and single cells were scattered among extracellular mucin and signet ring cell picture, which is consistent with mucionous adenocarcinoma. We then performed partial urethrectomy with negative surgical resection, but the tumor reappeared 18 months later with no symptoms. The patient then decided to undergo radiotherapy for 33 sessions. From a recent MRI follow up the patient remains recurrence free. Conclusions: Early surgical treatment with or without adjuvant radiotherapy appears to be the best option in cases of small, organ-confined disease of urethral mucinous adenocarcinoma. Partial urethrectomy can be performed in this type of cases, which can prevent the use of permanent urinary catheters and further improve the patient's quality of life.

Primary urethral carcinoma: Results from a single center experience

Introduction and aim of the studyPrimary urethral carcinoma (PUC) is a rare neoplastic disease arising in the urethra, without any evidence of a previous or synchronous carcinoma of the entire urinary tract. Since rare diseases are often incorrectly diagnosed and managed, the aim of this study was to analyze the experience of a single urology center in the treatment of PUC, focusing on neoplasms arising from the male anterior urethra. Materials and methodsMedical records of patients with neoplasms at the level of the penile and bulbar urethra who presented at our tertiary referral center between January 1988 and December 2018 were retrospectively reviewed. Patients with carcinoma of the prostatic urethra were excluded. The diagnosis was obtained with the aid of urethroscopy and lesion biopsy. Local staging was performed by means of contrast-enhanced MRI in selected patients. Staging was achieved by clinical examination, ultrasonography, and CT scan. Radical surgery (radical cystectomy + total penectomy + bilateral inguinal lymphadenectomy) was proposed to patients with ≥T2 tumors or cN+ with a good performance status, proximal tumor and without severe comorbidities. In case of nodal involvement, neoadjuvant chemotherapy was additionally offered. Patients with localized disease (<T2) and/or more distal tumors underwent urethrectomy or partial penectomy. Kaplan–Meier curves were evaluated for analysis of overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). ResultsA total of 13 male patients with anterior PUC were studied retrospectively. Total penectomy was performed in 7 cases, while partial urethrectomy was performed in 5 cases, and partial penectomy in 1 case. Of the 7 patients who underwent total penectomy, 5 underwent radical cystectomy with bilateral inguinal lymphadenectomy. Three patients were treated with neoadjuvant systemic chemotherapy, of which 2 were cT3N+ and 1 was cT3N0. The predominant histologic subtype was squamous cell carcinoma (SCC), found in 7 patients (53.8%), while urothelial carcinoma (UC) was present in 5 patients (38.5%) and a malignant fibro-histiocytoma in 1 case. Most patients were diagnosed at advanced stages of the disease, with T2 tumors in 15.4% and T3 tumors in 46.2% of the cases. Median follow-up was 24 months (range 1–294). After surgical treatment, 8 patients (61.5%) presented disease recurrence after a median of 6.3 months, with a 5-year RFS of 58% ± 14%. The 5-year OS rate was 50% ± 14% while the 5-year CSS rate was 66% ± 13%. ConclusionGiven its rarity, urethral carcinoma should be treated in a referral center. Treatment options include a radical approach or penile-preserving surgery (urethrectomy or partial penectomy) in cases of localized disease. Due to the high recurrence rate, strict follow-up is mandatory.

Carcinoma uretral primario: resultados de la experiencia de un único centro

Introduction and aim of the studyPrimary urethral carcinoma (PUC) is a rare neoplastic disease arising in the urethra, without any evidence of a previous or synchronous carcinoma of the entire urinary tract. Since rare diseases are often incorrectly diagnosed and managed, the aim of this study was to analyze the experience of a single urology center in the treatment of PUC, focusing on neoplasms arising from the male anterior urethra. Materials and methodsMedical records of patients with neoplasms at the level of the penile and bulbar urethra who presented at our tertiary referral center between January 1988 and December 2018 were retrospectively reviewed. Patients with carcinoma of the prostatic urethra were excluded. The diagnosis was obtained with the aid of urethroscopy and lesion biopsy. Local staging was performed by means of contrast-enhanced MRI in selected patients. Staging was achieved by clinical examination, ultrasonography, and CT scan. Radical surgery (radical cystectomy + total penectomy + bilateral inguinal lymphadenectomy) was proposed to patients with ≥T2 tumors or cN + with a good performance status, proximal tumor and without severe comorbidities. In case of nodal involvement, neoadjuvant chemotherapy was additionally offered. Patients with localized disease (<T2) and/or more distal tumors underwent urethrectomy or partial penectomy. Kaplan-Meier curves were evaluated for analysis of overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). ResultsA total of 13 male patients with anterior PUC were studied retrospectively. Total penectomy was performed in 7 cases, while partial urethrectomy was performed in 5 cases, and partial penectomy in 1 case. Of the 7 patients who underwent total penectomy, 5 underwent radical cystectomy with bilateral inguinal lymphadenectomy. Three patients were treated with neoadjuvant systemic chemotherapy, of which 2 were cT3N + and 1 was cT3N0. The predominant histologic subtype was squamous cell carcinoma (SCC), found in 7 patients (53.8%), while urothelial carcinoma (UC) was present in 5 patients (38.5%) and a malignant fibro-histiocytoma in 1 case. Most patients were diagnosed at advanced stages of the disease, with T2 tumors in 15.4% and T3 tumors in 46.2% of the cases. Median follow-up was 24 months (range 1–294). After surgical treatment, 8 patients (61.5%) presented disease recurrence after a median of 6.3 months, with a 5-year RFS of 58%±14%. The 5-year OS rate was 50%±14% while the 5-year CSS rate was 66%±13%. ConclusiónGiven its rarity, urethral carcinoma should be treated in a referral center. Treatment options include a radical approach or penile-preserving surgery (urethrectomy or partial penectomy) in cases of localized disease. Due to the high recurrence rate, strict follow-up is mandatory.

Outcomes of perisurgery and short-time follow-up of pelvic exenteration for 17 cases with locally recurrent cervical cancer

Objective: To investigate the perioperative situation and recent effect of pelvic exenteration for patients with locally recurrent cervical cancer. Methods: A total of 17 patients with locally recurrent cervical cancer who underwent pelvic exenteration in Peking University People's Hospital from October 2015 to May 2018 were retrospectively analyzed for their clinical and pathological characteristics, surgical conditions, hospitalization costs, postoperative complications, and survival situation. Results: (1) The median age of 17 patients with locally recurrent cervical cancer was 51 years (range 27-64 years). Pathological type: 13 cases of squamous cell carcinoma, 2 cases of adenocarcinoma, and 2 cases of adenosquamous carcinoma. Thirteen patients received radiotherapy during the initial treatment and 4 patients did not receive radiotherapy. (2) Pelvic exenteration was performed in 17 patients with locally recurrent cervical cancer, of which 9 cases were performed with total pelvic exenteration (operation range including radical cystectomy, partial urethrectomy rectectomy and partial vaginalectomy), and 8 cases with anterior pelvic exenteration operation (operation range including: radical cystectomy, part of urethrectomy and part of vaginalectomy). Of the 17 patients successfully completed the operation. The median operation time was 450 minutes (range 240-760 minutes), the median intraoperative blood loss was 2 200 ml (range 200- 8 400 ml), the median postoperative hospital stay was 17 days (range 9-55 days), the median hospital cost was 83 857 yuan (range 41 588-296 354 yuan). (3) Of the 17 patients underwent pelvic exenteration, 16 of them had early complications, the most common one was fever (14 cases). Fourteen of them had late complications, and the most common one was a urinary system infection (12 cases). (4) The median overall survival time was 26.0 months (range 3-44 months), the median progression-free survival (PFS) time was 9.0 months (range 2-44 months). Among them, 13 patients received radiation therapy during the initial treatment, the median PFS time was 9.0 months (range 2-30 months); 4 patients did not receive radiation therapy in the initial treatment, the median PFS time was 10.5 months (range 2-44 months).Eleven patients received adjuvant therapy after pelvic exenteration, the median PFS time was 12.0 months (range 2-44 months); 6 patients did not receive adjuvant therapy, the median PFS time was 5.0 months (range 2-9 months). Conclusions: Pelvic exenteration has a wide range of operations, many postoperative complications, and high hospitalization costs. Adjuvant treatment after pelvic exenteration could improve the PFS time for some patients. Its clinical value and health economic value need to be further explored.

Primary malignant melanoma of the female urethra: Twenty years of surgical and medical management at a tertiary referral center.

430 Background: Malignant melanoma of the female urethra accounts for less than 1% of all melanoma and less than 4% of urethral cancer. Due to limited data regarding management and outcomes of this condition, we evaluated the management and outcomes of urethral melanoma in females over the last 20 years at our institution. Methods: Patients were identified via retrospective review of the medical record. Those with metastatic disease at initial diagnosis were excluded. We evaluated primary and adjuvant treatments, disease recurrence and overall survival. Results: Fifteen women (median age 71, range 55, 82) were identified. Majority of masses involved the distal urethra (86.6%). All patients underwent primary surgical resection (60.0% partial urethrectomy, 40.0% radical urethrectomy). Disease recurrence and metastatic spread occurred in 73.3% (median 7 months, IQR 4, 12) and 60% (median 6 months, IQR 3, 9) of patients, respectively. 90.9% of patients with recurrence received adjuvant therapy: 5 chemotherapy and radiation, 4 chemotherapy only, 1 anterior exenteration. Of the 9 patients undergoing chemotherapy, treatment regimens were varied and included checkpoint inhibitors (2/9), platinum-based chemotherapy (3/9), tyrosine kinase inhibitors (2/9), taxels (2/9), and alkylating agents (1/9). Median overall survival was 27 months (IQR 7.5, 57.5). Conclusions: Malignant melanoma of the urethra is locally aggressive with a high likelihood of recurrence and metastases resulting in poor long-term survival. Despite high recurrence rates, our data highlight the lack of consensus adjuvant treatment regimens. Future research is required to identify neoadjuvant, combination, and adjuvant treatment approaches to improve disease outcomes.

Partial Urethrectomy for Female Urethral Transitional Epithelial Cell Carcinoma

Partial Urethrectomy for Female Urethral Transitional Epithelial Cell Carcinoma

MP13-03 IMPACT OF SYNCHRONOUS BLADDER CANCER ON RECURRENCE-FREE SURVIVAL AFTER SURGICAL TREATMENT FOR PRIMARY URETHRAL CANCER: RESULTS FROM THE INTERNATIONAL COLLABORATION ON PRIMARY URETHRAL CARCINOMA (ICPUC)

MP13-03 IMPACT OF SYNCHRONOUS BLADDER CANCER ON RECURRENCE-FREE SURVIVAL AFTER SURGICAL TREATMENT FOR PRIMARY URETHRAL CANCER: RESULTS FROM THE INTERNATIONAL COLLABORATION ON PRIMARY URETHRAL CARCINOMA (ICPUC)

Management of primary adenocarcinoma of the female urethra: Report of two cases and review of the literature

Primary adenocarcinoma of the female urethra is rare and only a few retrospective cases have been published. The origin of urethral adenocarcinomas remains unclear. Certain authors have suggested that urethral adenocarcinomas in females originate at the periurethral Skene's glands. We report one case of urethral adenocarcinoma of the proximal urethra in a 44-year-old female who presented with painless urethral bleeding. Abdominal and pelvic CT scan with contrast and chest radiology were unremarkable. Biopsy of the mass revealed adenocarcinoma of the urethra. The patient was treated with partial urethrectomy and was free of disease for more than 5 years. We also present another rare case of mucinous adenocarcinoma in a 52-year-old female who complained of an enlarged urethral mass. Pelvic MRI revealed a tumor surrounding the whole urethra and bilateral inguinal lymph nodes. A puncture biopsy later revealed that the tumor was mucinous adenocarcinoma. Anterior pelvic exenteration with pelvic and bilateral lymph node dissection was performed and chemotherapy was administered. The patient was followed up for 12 months and did not experience local recurrence or distant metastasis. In conclusion, for the diagnosis of urethral cancer, a biopsy is necessary for any suspicious urethral lesions. MRI is recommended for tumor staging. Small, superficial, distal urethral tumors may be treated with excision of the distal urethra. For advanced female urethral cancer, a combination of chemotherapy, radiation therapy and surgery is recommended for optimal local and distant disease control. Regular follow-up is required in these patients.

Secondary Transobturator Tape Procedure after Combined Pelvic Organ Prolapse Repair

A 66-year-old female who underwent a partial urethrectomy complained of severe incontinence due to intrinsic sphincter deficiency. Bone anchor surgical technique was performed, but in 3 years, serious pelvic organ prolapse had occurred. Consequently, anterior and posterior tension-free vaginal mesh operation was planned. Preoperative urodynamic examination predicted postoperative stress incontinence, and concurrent transobturator tape (TOT) surgery was performed. After 3 months, stress incontinence reoccurred, and secondary TOT was performed. Relapse was probably caused by dislocation of the first TOT towards the bladder neck. Thus, the secondary TOT was placed distal to the initial tape towards the external urethral meatus, and proper tension was applied. After the operation, stress incontinence was cured. Thus, a second TOT procedure, with proper positioning and tensioning, can effectively cure stress incontinence that occurs after an initial TOT procedure.

Multimodal Treatment Approach to Advanced Female Urethral Squamous Cell Carcinoma

Introduction and Objectives: Primary squamous cell carcinoma of the female urethra is rare. Given the small number of cases seen, no uniform regimen for optimal treatment has been identified. We set out to review the outcomes of women with advanced urethral squamous cell carcinoma treated with a multimodality approach in order to gain insight into the optimal treatment of this rare malignancy. Methods: We identified five women with advanced urethral squamous cell carcinoma treated by a single surgeon (RJK). After obtaining IRB approval, a retrospective chart review was performed and treatment strategies and outcomes were analyzed. Results: We report on 5 cases of squamous cell carcinoma of the female urethra treated utilizing a multimodal approach. Surgical therapy included anterior exenteration in two patients, partial urethrectomy in two patients and transurethral resection in one. Patients were treated with radiation in a neoadjuvant (2 cases), adjuvant (2 cases), or definitive (1 case) fashion. Four of five patients received chemotherapy. With a mean follow-up of 39 months (range 3 to 50), 4 patients remain without evidence of disease while one patient developed lung metastases 33 months after treatment. None had a locoregional tumor recurrence. Conclusion: Multi-modality approach combining surgery, radiotherapy, and chemotherapy can be effective therapeutic intervention for locally advanced, squamous cell carcinoma of the female urethra. For patients who have a significant surgical risk or desire to pursue an organ-preservation strategy, a trimodality approach of limited surgical excision combined with radiotherapy plus chemotherapy may be a reasonable alternative to anterior pelvic exenteration.

Primary melanoma of the female urethra

We evaluate tumor characteristics, recurrence and survival following surgical treatment for female urethral melanoma.A review of the records of all female patients with primary localized urethral melanoma (11, mean age 68 years) who underwent partial urethrectomy (7) or radical extirpation (4) from 1950 to 1999 was performed to determine disease specific survival and/or tumor characteristics correlating with survival. Clinical and pathological stage, tumor location, nodal status, adjuvant therapy and tumor pathological components including depth, width, necrosis and vascular/lymphatic invasion, were evaluated. Overall disease recurrence, crude and disease specific survival rates were calculated using the Kaplan-Meier method.Malignant melanoma occurred in the distal urethra in all 11 cases with local extension into the vagina (T3) in 7. Mean depth of invasion was 6.1 mm and mean tumor width was 2.0 cm. No vascular/lymphatic invasion or tumor necrosis was seen pathologically. No patient had received adjuvant therapy at the time of initial surgery. There were 7 recurrences (6 of 7 within 1 year postoperatively). Of the 7 cases of partial urethrectomy, urethral recurrence (1 with concurrent lung metastasis) developed in 5 and none had bladder recurrence. Those who underwent radical surgery had recurrence in the pelvis and lungs (1) and inguinal lymph nodes (1). Crude and disease specific survival ± standard error at 3 years was 27 ± 15% and 38 ± 19%, respectively.Primary female urethral melanoma is associated with a rapid and high local recurrence rate (60% at 1 year). Overall and cancer specific survival at 3 years is 27% and 38%, respectively. Local failure may in part be due to inadequate resection.

Partial urethral resection in the surgical treatment of vulvar cancer does not have a significant impact on urinary continence. A confirmation of an authority-based opinion

Partial resection of the urethra is sometimes necessary in the surgical treatment of locally advanced vulvar cancer. In this study, the frequency of urinary incontinence after partial urethral resection was compared with that of patients who were treated without partial resection of the urethra. Eighteen patients with vulvar cancer encroaching or infiltrating the urethra, treated by a radical vulvectomy and partial urethrectomy, were compared with 17 patients treated by vulvectomy without partial removal of the urethra. Data on urinary incontinence pre- and postoperatively from both groups were retrospectively collected from the patient files. A questionnaire on urinary incontinence was sent to a subset of patients from both groups in order to get information on the current micturation pattern. In four out of 18 patients (22%) with a partial urethrectomy, incontinence was reported, versus two out of 17 patients (12%) in the control group (P= 0.860). Eight patients in the study group and 12 in the control group are currently alive, and all responded to the questionnaire. Two (25%) in the study group and three (25%) in the control group reported to have current symptoms of urinary incontinence. This retrospective study shows that partial resection of 1-1.5 cm of the distal urethra in addition to a radical local excision for vulvar cancer does not result in a significant increase in the frequency of urinary incontinence, compared with vulvar cancer patients without partial urethrectomy.

Gangrena de Fournier secundaria a cateterismo uretral

We report one case of Fournier's gangrene secondary to urethral catheterization. We describe the clinical case, in which the initial cause was identified, and perform a short bibliographic review. Although Fournier's gangrene was initially considered as idiopathic in etiology, currently it is possible to identify the entrance site of the infection. In the present case the insertion of a urethral catheter was the starting mechanism, associated with factors such as diabetes and alcoholism which favour its development. The patient was treated by surgical debridement and partial urethrectomy but finally died. We want to point out that urethral instrumentation should be done by expert hands due to the severity of possible complications. We should insist in the need of precocious treatment with wide spectrum antibiotics, radical debridement and complete urologic evaluation.

Surgical treatment for local control of female urethral carcinoma

We reviewed 53 patients (mean age 63 years) who underwent partial urethrectomy ( n = 26) or radical extirpation ( n = 27) for primary female urethral cancer from 1948 through 1999. Clinical stage, histology, high pathologic stage (3 or 4) and grade, tumor location, nodal status, surgery type, adjuvant therapy, and treatment decade were candidate outcome predictors. The predominant carcinomas were squamous cell ( n = 21), transitional cell (TCC) ( n = 15), and adenocarcinoma ( n = 14). For adjuvant therapy, 20 patients had radiation (8 preoperatively), 2 had radiation + chemotherapy, and 1 had chemotherapy alone. During mean follow-up of 12.8 years, 27 patients had recurrence; 15 local only, 2 distant only and 10 local + distant. Of patients undergoing partial urethrectomy for pT1-3 tumors, 6/27 (22%) had urethral recurrence. Overall, there were no bladder recurrences. Recurrence-free survival ± standard error (SE) at 10 years was 45 + 8%. Those who recurred had a cancer mortality rate of 71% at 5 years postrecurrence. The estimated 10-year cancer-specific survival (CSS) and crude survival (CS) rates were 60 ± 8% and 42 ± 7%, respectively. Pathologic stage was predictive for local recurrence ( P = 0.02) and CSS ( P = 0.01). Positive nodes on pathology were related to local and distant recurrence and CSS ( P = 0.01). Upon review, partial urethrectomy resulted in a high urethral recurrence rate (22%) with no bladder recurrences. These patients may be better served with radical urethrectomy and creation of continent catheterizable stoma.

Outcome of Surgical Treatment for Primary Malignant Melanoma of the Female Urethra

We evaluate tumor characteristics, recurrence and survival following surgical treatment for female urethral melanoma. A review of the records of all female patients with primary localized urethral melanoma (11, mean age 68 years) who underwent partial urethrectomy or radical extirpation from 1950 to 1999 was performed to determine disease specific survival and/or tumor characteristics correlating with survival. Clinical and pathological stage, tumor location, nodal status, adjuvant therapy and tumor pathological components including depth, width, necrosis and vascular/lymphatic invasion, were evaluated. Overall disease recurrence, crude and disease specific survival rates were calculated using the Kaplan-Meier method. Malignant melanoma occurred in the distal urethra in all 11 cases with local extension into the vagina (T3) in 7. Mean depth of invasion was 6.1 mm and mean tumor width was 2.0 cm. No vascular/lymphatic invasion or tumor necrosis was seen pathologically. No patient had received adjuvant therapy at the time of initial surgery. There were 7 recurrences (6 of 7 within 1 year postoperatively). Of the 7 cases of partial urethrectomy, urethral recurrence (1 with concurrent lung metastasis) developed in 5 and none had bladder recurrence. Those who underwent radical surgery had recurrence in the pelvis and lungs and inguinal lymph nodes. Crude and disease specific survival +/- standard error at 3 years was 27 +/- 15% and 38 +/- 19%, respectively. Primary female urethral melanoma is associated with a rapid and high local recurrence rate (60% at 1 year). Overall and cancer specific survival at 3 years is 27% and 38%, respectively. Local failure may in part be due to inadequate resection.

Diagnosis and Reconstruction of the Dorsal or Circumferential Urethral Diverticulum

Uncommonly a saddlebag urethral diverticulum (UD) may extend circumferentially around the urethra dorsally or anteriorly with compromise of the adjacent tissues. Excision of the entire mucosalized surface of this type of UD may leave an extensive gap in the urethra. Unfortunately the full extent of a saddlebag UD is often not appreciated on preoperative imaging and it is only discovered intraoperatively when potential reconstructive flaps have already been compromised. The advent of endoluminal magnetic resonance imaging (eMRI) has provided outstanding preoperative staging that has greatly aided in the successful reconstruction of the cases. We present our experience with the diagnosis and reconstruction of these complex UDs. A review of 41 patients with UD at a single institution revealed 9 with circumferential involvement of the urethra confirmed on eMRI. All patients had voiding cystourethrography as the initial diagnostic modality. Four of the 9 patients had had at least 1 prior attempt at surgical repair elsewhere. Presenting symptoms included severe pain in 7 of the 9 patients, recurrent cystitis in 7, a vaginal mass in 2 and mixed urinary incontinence in 6. Eight of the 9 patients had undergone attempted surgical repair. Surgical reconstruction consisted of complete division of the urethra to access the dorsal wall of the UD with partial urethrectomy. Urethral continuity was restored by end-to-end urethroplasty in 5 patients and by tubularizing the dorsal (anterior) wall of the UD to construct a neourethral segment in 3. A Martius flap and pubovaginal sling were used selectively. Postoperatively voiding cystourethrography was performed in all patients to document absence of the UD. Self-administered patient questionnaires were completed preoperatively and postoperatively. All patients report subjective relief of pain. Six of 8 patients did not use pads for incontinence. One patient used 2 to 3 pads daily for stress urinary incontinence symptoms and 1 had persistent urgency with rare incontinence, for which she used 1 pad daily. Complications included a distal urethrovaginal fistula in 1 patient and urethral stricture in 1. Circumferential UD is an unusual problem. However, with the use of eMRI as a diagnostic and staging modality the incidence may be higher than previously realized. Preoperative knowledge of the extent of the UD is helpful in ensuring complete excision of the UD and optimizing urethral reconstruction. We conclude that excision and reconstruction of the circumferential UD is possible with excellent symptomatic and anatomical results.

Magnetic resonance imaging of a “saddle bag” urethral diverticulum

A woman presented with pelvic pain and recurrent urinary tract infections 2 years after transvaginal repair of a urethral diverticulum, Martius flap, and pubovaginal fascial sling. Physical examination revealed a tender 2-cm anterior vaginal wall mass. Voiding cystourethrography (VCUG) demonstrated a urethral diverticulum with possible circumferential involvement of the urethra (“saddlebag”diverticulum)(Fig.1).Cystourethroscopy demonstrated a wide diverticular neck at the 4 o’clock position in the urethral lumen, approximately 1.5 cm from the bladder neck. Magnetic resonance imaging (MRI) with an endovaginal coil was performed to evaluate the postsurgical anatomy as well as the anterior extent of the diverticulum relative to the urethral lumen. There was no evidence of the previously placed fascial sling or Martius fat pad on the MRI scan. The fluid-filled diverticulum (Fig. 2, open arrows) was seen completely encircling the urethra, with the inner mucosal lining of the diverticulum adherent to the outer wall of the urethra. Figure 2 demonstrates the usual anatomic location of urethral diverticula, which often dissect between the two leaves of fascia comprising the urethropelvic ligament1 (Fig. 2, large solid arrows). The junction of the urethral lumen and the diverticular cavity (neck of the diverticulum [Fig. 2, small arrow]) is seen as a disruption in the circumferential continuity of the spongy tissue of the urethra in approximately the same location as seen on cystourethroscopy. In the sagittal plane (Fig. 3), the diverticulum appears to extend anterior and posterior to the urethra (large arrow) from near the bladder neck to beyond the midurethra in close proximity to both sphincteric areas. The potential compromise or damage to both proximal and distal continence mechanisms was an important consideration during the planned excision and reconstruction of this complex urethral diverticulum. The patient underwent transvaginal excision of the diverticulum with a partial urethrectomy, urethral reconstruction, Martius flap, and pubovaginal fascial sling. At exploration, the diverticulum was noted to completely encircle the urethra and was tightly adherent to the urethral wall, as noted on the MRI scan. Fortunately, the MRI scan predicted this occurrence, and a portion of the dorsal diverticular wall was preserved to facilitate construction of a segment of neourethra. Although the true incidence is unknown, urethral diverticula may occur in up to 1% to 6% of the population.1 Presentation is nonspecific but may include pain, dyspareunia, anterior vaginal wall mass, and recurrent urinary tract infection.2 The sensitivity and specificity of VCUG and MRI in the diagnosis of urethral diverticula have not been clearly delineated; however, MRI may be more sensitive in the diagnosis of complex urethral abnormalities.3 In cases where the diverticular neck is narrowed, inflamed, or edematous, or when the diverticulum is loculated, VCUG may underestimate the size and/or extent of the diverticulum because the contrast medium may not flow freely From the Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Reprint requests: Daniel S. Blander, M.D., Department of Urology, University of Texas-Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75235-9110 Submitted: February 2, 1998, accepted: September 18, 1998 FIGURE 1. Right posterior oblique voiding image demonstrating a urethral diverticulum with possible circumferential involvement of the urethra. IMAGES IN CLINICAL UROLOGY

Primary malignant melanoma of male urethra

A case of primary malignant melanoma of the male urethra is reported. Treatment included partial urethrectomy, bilateral inguinal and iliac lymphadenectomy, and post-surgical systemic chemotherapy. After thirty-six months, the patient is alive with cutaneous, pelvic lymph node, and gastric metastases.