Urology

Benign tumors and lesions

 Non cutaneous
• Congenital and acquired inclusion cysts
• Retention cysts
• Syringomas (sweat gland tumors)
• Neurilemoma
• Angioma, lipoma
• Iatrogenic pseudotumor following injections
• Pyogenic granuloma following injections

 Cutaneous

• Pearly penile papules (normal in 15% of postpubertal males)
• Zoon balanitis (shiny, erythematous plaque on glans or prepuce)
• Lichen planus (fl at-topped violaceous papule)

Viral-related lesions

 Condyloma acuminatum
• This is also known as genital warts
• Related to human papillomavirus (HPV) infection.
• There are soft, usually multiple benign lesions on the glans, prepuce and shaft; they may occur elsewhere on genitalia or perineum.


• A biopsy is worthwhile prior to topical treatment with podophyllin 5%have urethral involvement, which may require diathermy.

 Bowenoid papulosis

 Resembles carcinoma in situ, but with a benign course.
 Multiple papules appear on the penile skin, or a fl at glanular lesion.
 These should be biopsied.
 HPV is the suspected cause.

 Kaposi sarcoma

 This reticuloendothelial tumor.
 Second-most common malignant penile tumor.
 In immunocompromised men, particularly in gay men with HIV/AIDS.
 Treatment is palliative, with intralesional chemotherapy, laser, cryoablation, or radiotherapy.

Premalignant cutaneous lesions

 Histologically benign lesions are recognized to have malignant potential.
 Occur in close association with SCC of the penis.
 A chronic red or pale lesion on the glans or prepuce is a cause for concern.
 Early follow-up after use of steroid, antibacterial, or antifungal creams is recommended.
 If persistent, biopsy is advised.


 Balanitis xerotica obliterans (BXO)
 Also known as lichen sclerosus et atrophicus.
 This is a common sclerosing condition of glans and prepuce.
 It occurs at all ages.
 Most commonly presents as non-retractile foreskin (phimosis).
 Obstructed and spraying voiding.
 Occurs in association with penile SCC.

 Leukoplakia:

 Solitary or multiple whitish glanular plaques.
 Usually involve the meatus.
 Treatment is excision and histology.
 associated with in situ SCC;
 Follow-up is required.

 Erythroplasia of Queyrat:

 Known as carcinoma in situ of the glans, prepuce, or penile shaft.
 A red, velvety, circumscribed painless lesion occurs, though it may ulcerate, resulting in discharge and pain.
 Treatment is excision biopsy if possible; radiotherapy, laser ablation, or
topical 5-fl uorouracil may be required. Histology reveals hyperplastic mucosal cells with malignant features.


 Bowen disease: this is carcinoma in situ of the remainder of the keratinizing genital or perineal skin.
 Treatment is wide local excision, laser, or cryoablation.

 Buschke–Löwenstein tumor:

 known as verrucous carcinoma or giant condyloma acuminatum,
 An aggressive locally invasive tumor of the glans.
 Metastasis is rare, but wide excision is necessary to distinguish it from
SCC.
 Urethral erosion and fi stulation may occur.

Squamous cell carcinoma (SCC)

 is the most common penile cancer,accounting for 95% of penile malignancies.
 Others include Kaposi sarcoma and, rarely, basal cell carcinoma, melanoma, sarcoma, and Paget disease.
 Metastases to the penis are occasionally seen from the bladder, prostate,
rectum, and other primary sites.

Incidence and etiology of SCC

 1% of male cancers.
 Age: penile cancer incidence rises during the sixth decade and peaks in the eighth decade. It is unusual <40 years of age, but has been rarely reported in children.
 Premalignant lesions42% of patients with penile SCC are reported to have had a pre-existing penile lesion.
 A prepuce (foreskin):penile cancer is rare in men circumcised at a young age. Smegma that forms from desquamated epithelial cells is thought to be a primary instigating factor in penile cancer; good hygiene and circumcision limit smegma accumulation.
 Geography:Highest incidence worldwide is in Brazil. It is virtually non- existent in Israel.
 Human papilloma virus (HPV) genital wart infection, especially with types
16, 18, and 21.
 Multiple sex partners.
 Smoking and tobacco.


Pathology and staging of penile SCC
 Believed to be preceded by carcinoma in situ.
 SCC starts as a slow-growing papillary, flat or ulcerative lesion on the glans
(48%), prepuce (21%), glans and prepuce (9%), coronal sulcus (6%), or shaft (2%).
 The remainder is indeterminate.
 It grows locally beneath the foreskin before invading the corpora cavernosa, urethra, and, eventually, the perineum, pelvis, and prostate.
 Metastasis is initially to the superficial then deep inguinal and, subsequently,
iliac and obturator lymph nodes.
 Skin necrosis, ulceration, and infection of the inguinal lymph nodes may lead to sepsis or hemorrhage from the femoral vessels.
 Blood-borne metastasis to lungs and liver is rare (1–10% of cases).

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 SCCs are graded using the Broder classification system:

• Grade I: well differentiated, keratinization, prominent intercellular bridges, keratin pearls
• Grade II to III: greater nuclear atypia, increased mitotic activity, decreased keratin pearls
• Grade IV: cells deeply invasive, marked nuclear pleomorphism, nuclear mitoses, necrosis, lymphatic and perineural invasion, no keratin pearls

Presentation

 About 15–50% of patients delay presentation for >1 year because of embarrassment, personal neglect, fear, or ignorance.
 A hard, painless lump on the glans penis is the most common presentation.
 A bloody discharge may be confused with hematuria.
 Rarely, a groin mass or urinary retention are presenting symptoms.


Investigations
 A biopsy is indicated.
 Chest radiology, pelvic CT scan,
 serum calcium, and
 Liver function tests are usually obtained.

Treatment

 The management of penile cancer should take place in regional or supraregional centers that can provide multidisciplinary surgical and oncological expertise.
 The first-line treatment of penile cancer, regardless of the inguinal node status, is surgery
 Circumcision is appropriate for preputial lesions, but local recurrence is observed in 22–50%.

1/ Primary tumor:

 for smaller G1–2 Ta–1 tumors
 Penis-preserving wide excision of glanular lesions with skin graft glanular reconstruction.
 Alternatives to surgery include laser or cryoablation, radiotherapy or
brachytherapy, photodynamic therapy, or topical 5-fl uorouracil.
 For G3T1 and more advanced tumors, partial or total penile amputation is required, depending on the extent of the tumor.
• Radiotherapy remains an alternative
 Patients with M1 disease are offered palliative surgery.

2/ Lymphadenopathy:

 Six weeks of broad-spectrum antimicrobials (e.g., Augmentin or cephalosporin) are given after the primary tumor has been removed.
 If nodes become clinically nonpalpable (50% of patients), who may then be followed up.
 For those with persistent inguinal lymphadenopathy, in the absence of demonstrable pelvic or metastatic disease, bilateral inguinal lymphadenectomy should be considered


 Radiotherapy and chemotherapy:
 Are alternative or adjuvant treatments for metastatic nodal disease in unfi t, elderly, or inoperable patients.
 Prophylactic lymphadenectomy:
 This is currently practiced in the United States for tumors exhibiting vascular invasion, are high grade, or stages T2–4.

 Distant metastatic disease:

 This is treated using single-agent systemic chemotherapy: cisplatin, bleomycin,or methotrexate.

Urethral cancer

 Primary urethral cancer is rare, occurring in elderly patients.
 It is 4 times more common in women than in men.

 Risk factors:

 Urethral stricture and sexually transmitted disease are implicated.
 Direct spread from tumor in the bladder or prostate is more common.

 Pathology and staging:

 75% are SCC, occurring in the anterior urethra;
 15% are UC, occurring in the posterior/prostatic urethra;
 8% are adenocarcinoma;
 And the remainder includes sarcoma and melanoma.
 Urethral cancer metastasizes to the pelvic lymph nodes from the posterior urethra
 To the inguinal nodes from the anterior urethra in 50% of patients.


Staging is by the TNM system

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TO No evi de nce of primary tumor

Urethra (n1ale and fennale)

Ta Noni rwasive papi llary carcinoma

Tis Carcinoma i n situ

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T2 Turn or i rwa es corpus spongiosum. prostate. or periu rethral m us.de

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T4 Turn or i nva es. ad jacent organs. indu ding bladder


Transit i orna l cell carcirnoma of the prostatic urethra

Ti s Carcinoma i n situ. pros.tat jc u reth rn (pu) or prostati c ducts (pd)

T1 Turn or i rrvades subepithe hal connecti'ife tissue

T2 Turn or i nva es prostatic stroma c.o rpus spongios.um. or peri u rethral mus.de

T3 Tumor i rwades th rough prostati c capsule. corpus cavemos.un1. or bladder nee k

T4 Tumor i rrva es ad jacent organs including bladder

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M1 Distant metastasis present

Presentation

 This is often late; many patients have metastatic disease at presentation
• Painless hematuria; initial, terminal, or a bloody urethral discharge
• Voiding-type LUTS (less common)
• Perineal pain (less common)
• Periurethral abscess or urethrocutaneous fi stula (rare)
• Past history of sexually transmitted or stricture disease
• Examination may reveal a hard, palpable mass at the female urethral meatus or along the course of the male anterior urethra. Inguinal lymphadenopathy, chest signs, and hepatomegaly may suggest metastatic disease.

Differential diagnosis

 In men
 • Urethral stricture
 • Perineal abscess
 • Metastatic disease involving the corpora cavernosa
 • Urethrocutaneous fi stula (secondary to benign stricture disease)

 In women

 • Urethral caruncle
 • Urethral cyst
 • Urethral diverticulum
 • Urethral wart (condylomata acuminata)
 • Urethral prolapse
 • Urethral vein thrombosis
 • Periurethral abscess


 Investigations
 Cystourethroscopy,
 Biopsy.
 Bimanual examination under anesthesia.
 Chest radiography
 abdominopelvic CT scan.

Treatment

1/ for localized anterior urethral cancer, radical surgery or radiotherapy are the options.
 Male patients would require perineal urethrostomy.
 Postoperative incontinence is minimum.
 For posterior/prostatic urethral cancer,
 cystoprostatourethrectomy should be considered for men in good overall health,
 While anterior pelvic exenteration (excision of the pelvic lymph nodes, bladder, urethra, uterus, ovaries, and part of the vagina) should be considered for women.

2/ for locally advanced disease, a combination of preoperative radiotherapy and surgery is recommended.
3/ For metastatic disease, chemotherapy is the only option with regimens of systemic cisplatin, bleomycin, and methotrexate or 5-fl uorouracil.