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Urology Journal

UNRC/IUA

Vol. 1, 1-4 Winter 2004

Printed in IRAN

INTRODUCTION

Primary urethral carcinoma in males is respon-

sible for less than 1% of their malignant dis-

eases.(1) Approximately 50% to 75% of these

lesions are originated from posterior urethra

(prostatic, membranous, and bulbar urethra),

anterior urethra, and mostly from meatus and

fossa vanicularis.(2) In males, if the tumor

remainders originate from anterior urethra, the

most common symptom will be difficult urina-

tion and nodule sensation. In more advanced

stages signs would be urinary obstruction or

incontinence secondary to bladder overflow.

Hematuria, purulent discharges, decrease in cal-

iber and urinary pressure, straining during uri-

nation, dysuria, abscess around urethra, and fis-

tula formation are also seen.(2) In large lesions of

anterior urethra, a mass on the ventral surface

of penis may be palpable.(2) Painful ejaculation,

priapism, penile ulcer, and sexual dysfunction

could be the causes of referral. Size of penis

could be increased due to tumor, indurations,

and edema. Loss of appetite, weight loss, and

malaise are later complaints of the disease sec-

ondary to chronic infection. 

The duration between the beginning of symp-

toms and diagnosis may even be 3 years that is

most often due to patient embarrassment and

sometimes because of misdiagnosis. Sever hem-

orrhage is an important symptom of urethral

cancer in patients who undergo urethral stricture

treatment with gentle dilation. Medical examina-

tion and earlier cystoscopy could decrease mis-

takes in diagnosis.(3) Penile examination should

be systematically performed, beginning from the

end of penis towards urogenital diaphragm.

Palpation of corpus spongiosum and corpus cav-

ernosum to detect any mass, hardness, or both

could be of help in estimating the severity of dis-

ease.(3)

CASE REPORT

A 66-year old married farmer form Rafsanjan,

southeast of Iran, with chief complaint of

decrease of urinary force, hematuria, clot in the

urine, sensation of mass, and hardness at the

end of penis and both groins.

Herniorrhaphy had been conducted for the

patient 2.5 years before, after which he had

developed acute urinary retention followed by

open prostatectomy. He had suffered from uri-

nary retention after the removal of catheter. He

had been catheterized again, hospitalized for a

while, and finally after a period his catheter had

been removed.

No urinary complication was reported till a few

months before our visit. He had no history of

smoking or any other disease. He used pest poi-

son for his trees 2-3 times annually without con-

sidering protective measures. He had 10 healthy

children.

In clinical examination, a 4×4 cm2 hard oval

mass at the end of penis with no extension to

skin and meatus was palpated. In the right

inguinal region a 4×4 cm2 and in the left

inguinal region a 3×3 cm2 mobile hard mass with

no pain and redness were observed (fig.1).

Mild leukocytosis, hematuria, and pyuria were

reported in his laboratory tests. His urine cul-

ture was negative. Other hematological, biochem-

A Case of Primary Urethral Carcinoma and Inguinal

Lymphatic Metastasis with Partial Penectomy and Limited

Inguinal Lymphadenectomy

NAJAFI SEMNANI M

Department of Urology, Birjand University of Medical sciences, Birjand, Iran

KEY WORDS: urethral carcinoma, inguinal lymphatic metastasis, partial penectomy

Accepted for publication 



A CASE OF PRIMARY URETHRAL CARCINOMA AND INGUINAL LYMPHATIC METASTASIS

WITH PARTIAL PENECTOMY AND LIMITED INGUINAL LYMPHADENECTOMY

ical, and liver and kidney function tests were nor-

mal. He had normal DRE and IVU too.

Cystoscopy was done under anesthesia. The

whole 4 cm glandular urethra was invaded by the

tumor. Proximal urethra was normal. The blad-

der was totally examined and there was no

lesion. Biopsies were taken from the bladder

wall, bladder neck, and finally form the tumor.

Pathology results were normal for bladder sam-

ples and showed undifferentiated SCC in the

mass.

Consequently, the patient underwent partial

penectomy with bilateral superficial inguinal lym-

phadenectomy. A circumferential incision was

made 2 cm proximal to the tumor.

The penis was cut 6.5 cm distally and a biopsy

was taken form the proximal margin of urethra

(samples A and B). Then left and right superfi-

cial and limited inguinal lymphadenectomy was

conducted. Palpable lymph nodes were removed

and sent to pathology as seven groups (samples

C-I).

Results of pathology of penis sample indicated

infiltrative tumor with a dimension of 3×3×4 cm3

and an invasion to corpus cavernous, which is 4

mm beneath the skin and 8 mm from meatus.

Microscopic analysis showed vessel invasion in

a section of tumor. Proximal margin of surgery

was reported normal.

Diagnosis of tumor (SCC) was again confirmed.

Biopsy of the rest urethral margin was normal

(B). All lymph nodes were tumorless except for

that of superior right inguinal region (D).

Macroscopic examination of sample D indicated

a 2×3×5 cm3 creamy tissue, which included 4 cm

(0.5-2.7) lymph nodes, two of which were

tumoral, of whom one demonstrated perinodal

with extracapsular invasion.

The patient was refered to an oncologic surgi-

cal center for classic right inguinal lymphadenec-

tomy. However, he refrained from referral.

To date, 60 months after surgery, no local

recurrence was observed in examination and

inguinal regions were normal (fig. 2). According

to the patient, the length of the penis was ade-

quate to void straightly and intercourse. In the

MRI taken 44 months post-operatively, pelvic and

inguinal regions were tumorless.

DISCUSSION

Most often primary urethral tumor occurs at

the age of 60 to 80 years and the mean age at

diagnosis is 60 years.(4) No precise etiologic fac-

tor has been reported but long-term urethral

infection, urethral stricture, chronic inflamma-

tion, sexually transmitted diseases, urethritis,

and trauma are proposed as risk factors.

This patient had no history of urethral infec-

tion or stricture and only a long-term catheteri-

zation following herniorrhaphy and prostatecto-

my was reported.

A considerable number of patients have a his-

tory of exposure to carcinogens or cigarette

smoking. Nonetheless, there is still no epidemio-

logic study concerning these factors as a

causative mechanism for urethral cancer.(4) The

patient had no smoking history. However, he was

in contact with pesticides.

In males if the tumor develops at anterior ure-

thra, the most common complaint would be diffi-

cult urination and nodal sensation. Sever hemor-

2

FIG. 1. A hard mass at the end of penis and the

right and left inguinal regions is observed.

FIG. 2. The rest of the

penis and the scar of

bilateral superficial

inguinal lymphadenec-

tomy 60 months after

surgical treatment



A CASE OF PRIMARY URETHRAL CARCINOMA AND INGUINAL LYMPHATIC METASTASIS

WITH PARTIAL PENECTOMY AND LIMITED INGUINAL LYMPHADENECTOMY

rhage is one of the primary symptoms of ure-

thral cancer in patients who undergo gentle

dilatation for urethral stricture.

Early cystoscopic examination could reduce

mistakes in diagnosis.(2) This patient was

referred with low urinary flow, hematuria, hard-

ness, and mass sensation at the end of penis and

inguinal regions.

The examination of penis should begin from its

end towards urogenital diaphragm. Bimanual

examination should be done for detecting

prostate lesions, invasion to trigone, and adhe-

sion to the pelvic wall. Systematic examination

of inguinal region should be done to detect their

involvements.

Urethroscopy and cystoscopy should be per-

formed. Pelvic CTscan should be conducted in

the cases of all tumors except for superficial and

most distal ones. IVU is essential for urethral

TCC. Taking ample biopsies from the lesions is

very important which is mostly conducted

through urethra.

Treatment has two parts:

A. Treatment of tumor: According to the

tumor location and size, there are four general

treatment options: 1. conservative treatment and

local excision; 2. partial penectomy; 3.radical

penectomy; 4. total removal of penis, urethra,

scrotom, and anterior pubis associated with

cystoprostatectomy.

Since patient had a limited tumor at the end of

penis and at least 2 cm of normal urethra could

be removed in a way that patient could void

straightly, partial penectomy was done. A biopsy

was taken separately which was tumorless and

the study of sample indicated that surgical mar-

gin was also without tumor. Sixty months later,

no local recurrence was noted and the patient

had satisfactory intercourse.

B. Lymph nodes treatment: Urethral can-

cer tends to local lymphatic invasion, which is

occurred before distant metastasis. Lymph nodes

of anterior urethra are directly drained into deep

and superficial inguinal lymphatic glands.

Several principals should be considered in the

treatment of lymph nodes: 1. it is confirmed by

several researchers that if lymph nodes are pal-

pable, there will be a high risk of nodal involve-

ment. This is contrary to SCC of penis in which

palpable inguinal masses may have no tumoral

involvement and patient is recommended for lym-

phadenectomy after antibiotic therapy.(3, 6) 2.

inguinal lymphadenectomy could be a definite

treatment in male urethral cancer; therefore, any

case of palpable lymphatic gland should be treat-

ed by classic and complete lymphadenectomy.

Limited lymphadenectomy is recommended for

patients who refrain from classic lymphadenecto-

my after the confirmation of nodal involvement.

This may indicate that limited and superficial

lymphadenectomy could be a successful treat-

ment, which leads to long-term survival with

minimal involvement of inguinal lymphatic

glands. Superficial inguinal lymphadenectomy in

this patient led to definitive treatment 60

months later.

Of course, most researchers believe that if

there is no palpable inguinal node, prophylactic

lymphadenectomy will be of no value.(3, 6) Some

applied radiotherapy successfully to treat pri-

mary tumor of urethra and lymph nodes metas-

tasis(4), while, some others believe that radiother-

apy is met with unacceptable results.(3)

REFERENCE

1. Dalbagnai G, Zhang ZF, et al. Male urethral

carcinoma: analysis of treatment outcome.

Urology 1999; 53: 1126-32.

2. Mostofi FK, Davis CJ, et al. Carcinoma of the

male and female urethra. Urol Clin North

Am 1992; 19: 347-48.

3. Zeidman EJ, Desmond P, et al. Surgical treat-

ment of carcinoma of the male urethra. Urol

Clin North Am 1992; 19: 359-67.

4. Foeman JD, Lichter AS. The role of radiation

therapy in the management of the male and

female urethra. Urol Clin North Am 1992;

19: 383-9.

5. Vapnek JM, Hricak H. Recent advances in

imaging studies for staging of penile and ure-

thral carcinoma. Urol Clin North Am 1992;

19: 257-66.

6. Levine RL. Urethral cancer. Cancer 1980; 45:

1956-72.

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