A Contemporary Analysis of Urethral Recurrence following Radical Cystectomy.

PURPOSE: Oncologic outcomes following urethral recurrence (UR) remain incompletely described, with reports limited by small cohort sizes. We evaluated risk factors for UR as well as cancer-specific survival (CSS) and overall survival (OS) among patients with UR. MATERIALS AND METHODS: We reviewed our institutional radical cystectomy (RC) registry to identify patients with UR. Cox proportional hazards regression was used to assess risk factors for UR. Kaplan-Meier and Cox models were used to assess the relationship between UR and CSS/OS as well as to compare outcomes following symptomatic vs asymptomatic presentation of UR. RESULTS: Overall, 2,930 patients underwent RC from 1980 to 2018, with a median postoperative followup of 7.1 years (IQR 2.8-13.1), of whom 144 (4.9%) were subsequently diagnosed with UR. Carcinoma in situ (HR 1.98, 95% CI 1.30-3.04), multifocal disease (HR 1.59, 95% CI 1.07-2.36) and prostatic urethral involvement at RC (HR 3.01, 95% CI 1.98-4.57) were associated with increased risk of UR. UR was associated with decreased CSS (HR 7.30, 95% CI 5.46-9.76) and OS (HR 1.86, 95% CI 1.54-2.24). A total of 63/144 patients were diagnosed with UR based on symptoms, while 104/144 patients with UR underwent urethrectomy. Patients with symptomatic UR had higher tumor stage at urethrectomy (≥pT2 in 13.1% vs 3.1%, p=0.007), while patients with asymptomatic UR experienced longer median CSS (12.1 vs 6.1 years) and OS (8.30 vs 4.82 years; p=0.05 for both). CONCLUSIONS: We identified pathological risk factors for UR after RC and report adverse subsequent survival outcomes for these patients. Presentation with symptomatic UR was associated with higher tumor stage and poorer prognosis, supporting a value to continued urethral surveillance after RC.

Immunotherapy combined with high- and low-dose radiation to all sites leads to complete clearance of disease in a patient with metastatic vaginal melanoma.

A 73-year-old woman with metastatic vaginal mucosal melanoma that had progressed on ipilimumab and nivolumab experienced clinical and radiographic complete response to dual checkpoint inhibitor immunotherapy given in combination with high-dose plus low-dose radiation. General characteristics and treatment options in this disease are highlighted.

Urethral involvement is associated with higher mortality and local recurrence in vulvar melanoma: a single institutional experience.

Vulvar malignant melanoma (VMM), although uncommon, comprises 5-10% of all vulvar malignancies. Local control is notoriously poor in VMM with recurrence rates of 30-50% compared with approximately 3% in cutaneous melanomas. We studied clinicopathologic features of 37 women with VMM, after reviewing three decades of clinical follow-up data in our institutional databases. Most patients were Caucasian (n = 35) with an average age at diagnosis of 60.6 years (range 23-83). The most common subtype was mucosal lentiginous melanoma (n = 25). We compared Kaplan-Meier survival curves of 31 patients defined by clinical and microscopic attributes using exact log-rank tests. Younger patients at diagnosis (23-64 years), those with thin melanomas (≤1 mm), and those with Clark's level II or III tumors had better 5-year survival rates than older patients (65-83 years) and those with thick melanomas (>1 mm) and those with Clark's level IV or V (P ≤ 0.05), respectively, by exact log-rank test. Local recurrence of melanoma occurred in 15 patients. Nine patients (24%) had eventual urethral involvement by malignant melanoma, and this feature was associated with significantly shorter survival (P = 0.036). Patients with urethral involvement had shorter median time to death and worse 5-year survival rates. Given that spread to the urethra is common in VMM and urethral recurrence is also associated with mortality, pathology excision specimens should be carefully reviewed with attention to urethral involvement as a potentially important prognostic factor.

Risk factors and oncological outcomes of urethral recurrence in male patients with muscle invasive bladder cancer after radical cystectomy combined with urinary diversion: a propensity score-matched case control study.

BACKGROUND: Radical cystectomy (RC) is the primary treatment strategy for muscle invasive bladder cancer (MIBC). However, it carries a high risk of urethral recurrence (UR) in male patients. The risk factors and oncological outcomes of UR remain unclear. We aimed to identify the risk factors and oncological outcomes of UR in male patients with MIBC after RC combined with urinary diversion. METHODS: After propensity score matching, we evaluated 137 male patients with MIBC who underwent RC combined with urinary diversion at our center between January 1, 2007 and December 31, 2015. Patient demographics, comorbidity, and perioperative data were recorded. Univariate and multivariate Cox proportional hazards regression were used to estimate the hazard ratio and 95% confidence intervals. Cancer-specific survival (CSS) and overall survival (OS) were measured using the Kaplan-Meier curve with log-rank test. P < 0.05 was considered statistically significant. RESULTS: Of the 310 patients, 30 (9.7%) patients underwent UR. In the matched group, the independent risk factors of UR were history of TURB (HR = 3.069, P = 0.018), tumor stage (T3 vs. T2, HR = 3.997, P = 0.014; T4 vs. T2, HR = 2.962, P = 0.015), and tumor multifocality (HR = 2.854, P = 0.011). The CSS and OS of patients with UR were equivalent to the patients without UR (P = 0.295, P = 0.616). CONCLUSION: This propensity score-matched case-control study showed that UR is not rare in male patients with MIBC after RC combined with urinary diversion. We identified three independent risk factors of UR: history of TURB, tumor stage, and tumor mutifocality. The oncological outcomes were equivalent between patients with and without UR. These findings could help improve treatment strategies and follow-up schedules.

The Metastasis of Renal Cell Carcinoma to the Urethra and Local Tumor Recurrence.

We present the case of metastasis of renal cell carcinoma to the urethra in a 77-year-old woman who underwent -nephrectomy 6 years ago due to renal cell carcinoma. After 3 years, she returned to the ward due to a small, palpable nodule in the area of the urethra that turned out to be a cancer of the clear cell carcinoma. Despite the resection of the -lesion with negative margins in the pathology examination, a local regrowth in the same area was diagnosed in the MRI 8 months after the first episode of metastasis and was successfully removed. The patient keeps urine properly.

Ureteral involvement by metastatic malignant disease.

Ureteral metastases from other primary cancers are very rare. Treatment of these metastases is difficult and outcomes are poor. A thorough literature review was done with the aim of finding characteristics that may influence survival rates of patients with ureteral metastases. Systematic literature searches of PubMed and Web of Science were performed in Jan 2019. A total of 79 papers that included 265 patients with cancer metastases to their ureters were finally considered for evidence synthesis. Prostate, bladder, breast, gut cancer and lymphoma were the predominant primary tumors. The median interval time from primary tumor diagnosis to ureter metastasis was 28.5 months. The median survival time after diagnosis of ureter metastasis was 18 months. Risk factors of survival were analyzed. Age, sex, hydronephrosis, ureter side, and segment were not associated with survival. Interval time and treatment were associated with overall survival. Further analysis indicated that patients who underwent surgery had better outcomes.

A Case of Metastatic Prostate Cancer to the Urethra That Resolved After Androgen Deprivation Therapy.

An 83 year-old male with Gleason score 4+3 prostatic adenocarcinoma status post brachytherapy developed obstructive voiding symptoms 9 years after brachytherapy. Prostate-specific antigen was 0.67. Cystoscopy noted multiple papillary urethral tumors concerning for primary urethral carcinoma. Immunophenotype of biopsies supported diagnosis of Gleason score 4+4 prostatic adenocarcinoma. Androgen deprivation therapy was started. Cystoscopy performed 4 years later, for microhematuria workup, noted complete resolution of the urethral tumors. We present a patient with little serum Prostate-specific antigen change with urethral prostatic adenocarcinoma metastasis that resolved after androgen deprivation therapy.

Isolated Urethral Metastasis From a Primary Ovarian Malignancy.

BACKGROUND: Epithelial ovarian cancer (EOC) is the deadliest of gynaecological cancers, often manifesting itself at a later stage (stage 3 and 4). Metastases and recurrences tend to be limited to the abdominopelvic cavity, and cutaneous metastases are rare. CASE SUMMARY: We report an interesting case of a 51-year-old who presented 2 years after her initial treatment with surgery and adjuvant chemotherapy for a stage IIB with an isolated recurrence in the external urethral meatus. CONCLUSION: This case highlights the need for clinicians and patients to remain vigilant during follow-up visits to rule out recurrences despite nonspecific symptoms reported by patients.

Treatment and outcomes of urethral recurrence after orthotopic neobladder replacement in patients with bladder cancer - practice in a single centre.

Objectives To report on the treatment of urethral recurrence after orthotopic urinary diversion at our institution. Methods We retrospectively reviewed clinical information of urethral recurrence in patients who underwent radical cystectomy and orthotopic urinary diversion between January 1998 and January 2013. Results Of 341 patients, 282 presented for follow-up (median follow-up: 56 months; range: 1-174 months). Eight patients developed local recurrence of urothelial cancer after radical cystectomy. The rate of urethral recurrence (1.4%) in female patients who underwent orthotopic urinary diversion was lower than in male patients (3.3%). The median (range) time to recurrence was 33 (6-120) months after radical cystectomy and orthotopic urinary diversion. Recurrences were treated by transurethral resection of tumour, urethrectomy, neobladder resection, revision of urinary diversion, adjuvant chemotherapy, or radiation therapy, based on individual circumstances. Survival analysis showed that 5-year cancer-specific survival was significantly higher in patients with urethral recurrence alone (83.3%), compared with patients with other recurrences, including pelvic/abdomen recurrence and distant metastasis (26.8%). Conclusions En bloc urethrectomy and revision of urinary diversion remain the principle surgical choices. Selection of transurethral tumour resection was based on tumour stage and was used in carefully chosen patients. Cancer-specific survival might depend on multidisciplinary therapy.

[Two Cases of Urethral Clear Cell Adenocarcinoma with Suspected Recurrence of Uterine Cancer].

Herein, we report two cases of urethral clear cell carcinoma in two patients who had previously undergone radical hysterectomyfor utetine cancer. Case 1 presented with bloodyvaginal discharge and case 2 presented with acute urinaryretention. Magnetic resonance imaging revealed a periurethral tumor in both cases. Both cases were suspected to be recurrence at first. However, pathological findings of the transurethral resection-biopsyshowed clear cell adenocarcinoma in both cases. Subsequentlyradical cystourethrectomy and pelvic lymphadenectomy were performed in both cases. Surgical findings showed tumor invasion of the vaginal muscularis in case 1 and invasion of the anterior wall of the vagina and bladder neck in case 2. Although adjuvant postoperative therapywas not performed, there has been no evidence of recurrence to date.

Rare metastatic sites of renal cell carcinoma: urethra and spermatic cord.

INTRODUCTION: About 20% of patients with a diagnosis of primary renal cell carcinoma (RCC) present directly with metastatic disease. The aim of the present manuscript is to describe, for the first time a RCC metastasis located to the distal female urethra and to present an update on metastatic locations to the male spermatic cord. MATERIALS AND METHODS: We report two cases of rare RCC metastases. The first concerns a 92-year-old female patient who came to our attention for recurrent urethral bleeding, which was initially believed to be secondary to urethral mucosal ectropion. Pathology demonstrated a RCC metastasis. The second concerns a 67-year-old male patient with a previous history of RCC who came to our attention for the finding of palpable, mobile and indolent right inguinal lump. Given the past history of malignancy, it was excised and revealed to be a RCC metastasis. DISCUSSION: In the first case, the pathologic specimen allowed the detection of an unknown renal tumor, whereas in the second, the previous neoplastic history of the patient has led clinicians to focus on a possible neoplastic recurrence, perform a correct excision of the node, and begin an early systemic therapy. CONCLUSIONS: These cases are emblematic of possible unexpected RCC metastasis. These findings should be taken into account in order to clarify the differential diagnosis and to address these patients to a correct therapeutic course.

Urethral recurrence after cystectomy: current preventative measures, diagnosis and management.

To summarise the current literature on the diagnosis and management of urethral recurrence (UR) after radical cystectomy (RC), as UR after RC is rare but associated with high mortality. With the recently increased use of orthotopic bladder substitution and the questionable benefit of prophylactic urethrectomy, identification of patients at high risk of UR, management of the remnant urethra, and treatment of UR become critical questions. A review of the PubMed database from 1980 to 2014 was performed to identify studies evaluating recurrent urothelial cancer of the urethra after RC. The search terms used included 'urethral recurrence', 'cystectomy' or 'cystoprostatectomy'. Selected studies provided information on the type of urinary diversion performed, the incidence of UR, and the time to UR. Incidence of UR after RC ranges from 1% to 8% with most recurrences occurring within the first 2 years after surgery. Increased risk of UR is associated with involvement of the prostate, tumour multifocality, bladder neck involvement, and cutaneous diversion. The median overall survival after UR ranges from 6 to 54 months and the 5-year disease-specific survival after UR is reported to be between zero and 83%. UR remains a relatively rare event. Current literature suggests that urethral wash cytology may be useful in patients with intermediate- to high-risk of recurrence to enable early detection of non-invasive disease, which may be amenable to conservative therapy before urethrectomy.

Urethral Metastasis from Rectal Adenocarcinoma: A Case Report and Review of the Literature.

CASE: A 73-year-old man with Dukes' C adenocarcinoma of the rectum, pT3N2bM0, stage IIIB, presented with voiding difficulties including poor stream and terminal dribbling for one month. The patient was under careful surveillance and had no postoperative recurrence. Physical examination revealed a palpable irregular nodular lesion (0.5 × 0.5 cm(2)) at the penile-scrotal junction. He underwent urethroscopy, which showed a cauliflower lesion in the pendulous urethra. Transurethral resection was performed and histopathologic and immunochemical staining demonstrated a metastatic moderately differentiated urethral adenocarcinoma from the colorectal primary. OUTCOME: His voiding disorder improved significantly post-operation and he commenced second-line chemotherapy combined with regional radiotherapy. Follow-up urethrocystoscopy and abdominal computed tomography demonstrated no recurrence or metastatic disease. His tumor marker remained within the normal range for 12 months. CONCLUSION: Urethral metastasis from primary colon cancer is extremely rare. This disease, with its various atypical presentations, presents a diagnostic challenge to the clinician. In patients with recurrent or persistent lower urinary tract symptoms, further urologic workup including thorough history taking, physical examination, and imaging surveys is warranted.

A rare case of metachronous penile and urethral metastases from a rectal mucinous adenocarcinoma.

Metastatic lesions in the penis are uncommon in patients with prostate or bladder cancer but penile metastatic lesions from rectal tumours are rare with only 65 cases reported in the literature. We describe the case of a 70-year-old man who developed metastatic lesions within his corpus cavernosum 2 years after being diagnosed and treated for a mucinous adenocarcinoma of the rectum and a year after a wedge resection of an isolated lung metastasis. He proceeded with total penectomy and intraoperatively two skip lesions were also found within the wall of his urethra; histological analysis proved that these were also metastatic lesions. A perineal urethrostomy was formed with the remaining macroscopically healthy urethra. He made a good recovery from his operation and continued his treatment under the oncology team.

Recurrence of sigmoid colon carcinoma in the retained urethra after cystectomy: A case report and review of the literature.

Urethral recurrence arising from a primary colorectal adenocarcinoma is rare. Here, we report a case of urethral recurrence of sigmoid colon cancer, which developed after cysto-prostato-sigmoidectomy for sigmoid colon cancer invading the bladder. The patient underwent urethrectomy successfully and is currently tumor-free. Surgeons who follow patients with colorectal cancer invading the bladder should be aware of this case. The early detection of recurrence improves the chances for disease-free survival.

Extra-prostatic transgene-associated neoplastic lesions in transgenic adenocarcinoma of the mouse prostate (TRAMP) mice.

Male transgenic adenocarcinoma of the mouse prostate (TRAMP) mice are frequently used in prostate cancer research because their prostates consistently develop a series of preneoplastic and neoplastic lesions. Disease progression in TRAMP mouse prostates culminates in metastatic, poorly differentiated carcinomas with neuroendocrine features. The androgen dependence of the rat probasin promoter largely limits transgene expression to the prostatic epithelium. However, extra-prostatic transgene-positive lesions have been described in TRAMP mice, including renal tubuloacinar carcinomas, neuroendocrine carcinomas of the urethra, and phyllodes-like tumors of the seminal vesicle. Here, we describe the histologic and immunohistochemical features of 2 novel extra-prostatic lesions in TRAMP mice: primary anaplastic tumors of uncertain cell origin in the midbrain and poorly differentiated adenocarcinomas of the submandibular salivary gland. These newly characterized tumors apparently result from transgene expression in extra-prostatic locations rather than representing metastatic prostate neoplasms because lesions were identified in both male and female mice and in male TRAMP mice without histologically apparent prostate tumors. In this article, we also calculate the incidences of the urethral carcinomas and renal tubuloacinar carcinomas, further elucidate the biological behavior of the urethral carcinomas, and demonstrate the critical importance of complete necropsies even when evaluating presumably well characterized phenotypes in genetically engineered mice.

Urethral metastasis from a sigmoid colon carcinoma: a quite rare case report and review of the literature.

BACKGROUND: Urethral metastatic adenocarcinoma is extremely rare. Moreover, only 9 previous cases with metastases from colorectal cancer have been reported to date, and not much information on urethral metastases from colorectum is available so far. CASE PRESENTATION: We report our experience in the diagnosis and the management of the case with urethral metastasis from a sigmoid colon cancer. A 68-year-old man, who underwent laparoscopic sigmoidectomy for sigmoid colon carcinoma four years ago, presented gross hematuria with pain. Urethroscopy identified a papillo-nodular tumor 7 mm in diameter in the bulbar urethra. CT-scan imaging revealed the small mass of bulbous portion of urethra and solitary lung metastasis. Histological examination of the tumor obtained by transurethral resection showed moderately differentiated adenocarcinoma, which was diagnosed as a metastasis of a sigmoid colon carcinoma pathologically by morphological examination. Immunohistochemical analysis of the urethral tumor revealed the positive for cytokertin 20 and CDX2, whereas negative for cytokertin 7. These features were consistent with metastatic adenocarcinoma of the sigmoid colon cancer. As the management of this case with urethral and lung metastasis, 6-cycle of chemotherapy with fluorouracil with leucovorin plus oxaliplatin was administered to the patient, and these metastases were disappeared with no recurrence of disease for 34 months. CONCLUSION: Urethral metastasis from colorectal cancer is a very rare occurrence. However, in the presence of urinary symptoms, the possibility of the urethral metastasis should be considered.

[Malignant priapism: conservative management of a case]. / Priapismo maligno: un caso manejado de forma conservadora.

Priapism is an urological emergency which requires investigation, especially to differentiate between ischemic and non-ischemic priapism. Initial management is carried out through aspiration and gasometry of blood from the corpus cavernosum. We report the case of a 69-year-old patient with urothelium carcinoma of the bladder T2 G3 and metastasis in urethra/corpus cavernosum who requested an emergency consultation because of edema and a penile erection lasting several days. Due to the poor prognosis and the imaging test, a conservative management was carried out.

Follow-up after radical cystectomy based on patterns of tumour recurrence and its risk factors.

CONTEXT: Following cystectomy, approximately 50% of patients will present tumour recurrence. A recurrence may be local, systemic or occur in the urethra or upper urinary tract. OBJECTIVE: To analyse the characteristics, risk factors and outcomes of patients with tumour recurrence following cystectomy so as to subsequently propose a cancer follow-up protocol. ACQUISITION OF EVIDENCE: Analysis of original articles and reviews related to tumour recurrence and follow-up after radical cystectomy for urothelial tumour. Articles were obtained from Pubmed searches. SUMMARY OF THE EVIDENCE: Systemic and local recurrences following cystectomy appear in 20%-35% and 5%-15% of cases, respectively. Some 80%-90% are diagnosed in the first 3 years, with the majority concentrated in the first 24 months. Common factors related to an increased risk of local and systemic recurrence are a pathologic stage ≥pT3, the presence of positive margins and the extension of the lymphadenectomy. The incidence of recurrence in the upper urinary tract and urethra is 2%-6% and 4%-6%, respectively. Both types of recurrence may appear late and share risk factors such as signs of multifocal disease, a history of non-muscle-invasive bladder cancer, multiplicity, presence of ISC, urinary tract tumours and prostatic urethral tumours. Tumours in the distal ureteral cystectomy specimen and tumours in the prostatic urethra are also risk factors related to the appearance of tumours in the urinary tract and urethra, respectively. CONCLUSION: Understanding the natural history of urothelial bladder carcinoma and the risk factors related to the appearance of tumour recurrence following cystectomy are essential for designing an appropriate follow-up protocol. The follow-up of patients with risk factors for local or systemic recurrence will achieve maximum efficiency during the first 3 years. The follow-up should be extended for patients with risk factors for presenting upper urinary tract or urethral tumours.