Laparoscopic Radical Cystourethrectomy in a Patient with Adenocarcinoma of the Female Urethral Diverticulum

Abstract

Adenocarcinomas arising in the female urethra have been rarely reported. Here we report a case of laparoscopic radical cystourethrectomy with incontinent urinary diversion in a patient with adenocarcinoma in the urethra and bladder. A 60-year-old female presenting with a history of recurrent cystitis and painless hematuria was referred to our facility with voiding difficulty and a urethral mass. Radiologic evaluation showed an enhanced mass in the urethra and bladder neck. Cystoscopic biopsy of the mass in the bladder neck revealed an adenocarcinoma. Laparoscopic radical cystourethrectomy with anterior vaginal wall excision followed by extracorporeal incontinent urinary diversion was performed. Primary carcinomas arising in a urethral diverticulum have rarely been reported and account for only 5% of all urethral malignancies [1]. Most of these tumors arise from squamous or transitional cells, and only 20% are adenocarcinomas of unknown origin.Because of the rarity of such tumors, a treatment strategy has not been established, but radical cystourethrectomy with pelvic lymph node dissection and urinary diversion appears to be the most beneficial modality for nonmetastatic disease. Many authors have reported on an open approach; however, we performed laparoscopic radical cystourethrectomy with bilateral pelvic lymph node dissection and anterior vaginal wall excision followed by ileal urinary diversion with a minimal abdominal incision. CASE REPORTA 60-year-old female with a history of recurrent cystitis and painless gross hematuria for 3 years was referred to our institution complaining of intermittent urinary retention. The patient had undergone a radical hysterectomy with bilateral salpingo-oophorectomy due to squamous cell type cervical cancer 20 years ago. Physical examination revealed a firm mass on the anterior vaginal wall. Urine cytology was nonspecific. Serum CEA and CA 19-9 were within normal limits. During cystourethroscopy, a papillary growing tumor was found at the bladder neck (Fig. 1). We found no definite mass lesion during urethrography; however, a urethral narrowing was revealed. Magnetic resonance imaging (MRI) showed a urethral mass invading the base of the bladder and the anterior vaginal wall with no pelvic lymph node enlargement. The mass showed homogeneous, low signal intensity on T1-weighted images and inhomogeneous contrast enhancement after gadolinium administration. On T2-weighted images, the mass showed high signal intensity surrounded by a low signal intense rim (Fig. 2).A fan-shaped four-port laparoscopic transperitoneal approach was performed (one 10 mm port placed at 10 mm above the umbilicus [camera], one 12 mm right pararectal trocar, one 12 mm trocar placed laterally in the right lower quadrant [assistant port], and one 5 mm trocar placed between the left anterior iliac spine and the umbilicus).Mild adhesion was observed around the ureter. After ureteral dissection, we clamped the ureter close to the ureterovesical junction by using a Hem-o-Lok clip and performed a frozen biopsy....

Urethral diverticulum carcinoma in females—a case series and review of the English and Japanese literature

“…The differential diagnosis of increasing debris or thickening within the diverticulum includes infection and inflammatory change within the UD and biopsies may yield no evidence of malignancy as in 2/3 of our UDC cases. Cystoscopy was unhelpful in our cases but may play an important role in the pathological diagnosis and in localization of the tumor origin ( 1 ) with neoplasm in the diverticulum or urethra noted on cystoscopy in 23/29 (79%) cases in those series reporting its use ( 7 , 9 , 10 , 12 , 21 , 23 , 31 , 42 , 53 , 54 , 57 , 72 , 73 , 77 , 96 , 98 , 100 ).…”

Primary Female Urethral Carcinoma A Case Report. A Review of the Diagnosis and Treatment

“…The most frequent histological subtype is columnar/mucinous adenocarcinoma and there are around 15% of clear cell of them. 1,3 Tumors origins in distal paraurethral duct come from female Skene's glands (homogeneity of male prostate gland) are matched by positive immunostains of PSA and prostatic acid phosphatase. PSA elevation is objective and declines after surgery.…”

“…9,10 The local excisions or urethrectomies resulted in postoperative complications, local recurrence or distal metastasis and aggressive treatment as anterior exanteration (specially the posterior urethral lesion), radical cystectomy with urinary diversion and pelvic/groin lymphadenectomy showed promising results with 87% of recurrence disease-free at 6months to 2years. 3,6,11 In anterior urethral lesions preferred wide extirpation (total or parcialurethrectomy) and if a superficial lesion is, can be treated with local extirpation. 5,12 For tumors less than 2cm curative radiation or surgery with or without adjuvant radiotherapy have been proposed as treatment options, whereas; bulky injury is being treated with brachy (BR) / external beam radiotherapy (RE)(45-50Gy) as a conservative organ therapeutic and if there are nodal disease the doses are 60-65Gy.…”

Primary Clear Cell Adenocarcinoma in a Female Urethral Diverticulum: A Case Report and Review

“…Approximately 50% of urethral cases occur in a urethral diverticulum [5]. Urethral diverticula malignancies were first described in 1951 by Hamilton and Leach [6], with the 100 cases [7,8] that have been subsequently described the majority have been adenocarcinomas [9,10]. Pathologically there are three major patterns of CCA: diffuse, papillary and tubulocystic.…”