Holmium laser fulguration of superficial urothelial carcinoma of the pendulous urethra.

Urothelial carcinoma may occur anywhere in the urinary tract including the pendulous urethra. To prevent urethral stricture after resection and monopolor fulguration we describe the use of the holmium laser to fulgurate recurrent pTa UC from the urethra. The surgical approach was staged and provided excellent long term results for management of superficial UC.

INTRODUCTION

Most newly diagnosed urothelial cancers (UC) of the bladder are nonmuscle invasive.[1] They have a tendency to recur after initial treatment, including at sites outside the bladder such as the urethra.[2] The urethra may be the site of recurrence after previous cystectomy but occur less frequently prior to cystectomy.[3] Patients with noninvasive disease in the bladder may prefer to keep their bladders and urethras to preserve normal voiding function. Due to the rarity of distal urethral UC, limited studies have been performed. There have been a variety of treatments including urethral chemotherapy, resection, open surgery, as well as fulguration with the Nd: Yag or Ho: Yag Laser to treat recurrence of UC. We describe a case wherein a distal urethral noninvasive UC was ablated using holmium laser technique (Ho: YAG).

CASE REPORT

The patient is a 83-year-old man with an history of noninvasive urothelial carcinoma 6 years prior to presentation previously treated with TURBT and an induction course of intravesical of BCG therapy. He presented to the spinal cord injury unit after a cauda equina syndrome developed following lumbar spine surgery. Due to his previous UC history, the standard surveillance of urothelial carcinoma was used to investigate for recurrence. A cytology was obtained and showed atypical cells in groups. The initial office flexible cystoscopy demonstrated a noninvasive appearing UC covering approximately 50% of his pendulous urethra with frondular lesions. The prostatic and membranous urethra were spared. The patient was taken to the operating room for cystourethroscopy under anesthesia, biopsies and upper urinary tract evaluation. The upper urinary tracts were negative for lesions on retrograde pyelogram and bladder and urethral biopsies were obtained with similar pathology as seen on office cystoscopy. On pathology, the biopsies showed low-grade superficial urothelial carcinoma (pTa) with a small focus of high-grade carcinoma [Figure 1]. Surgical options were then discussed and the patient wanted a bladder sparing minimally invasive surgery. Therefore, the patient was taken back to the operating room for a second look TURBT and a staged fulguration of urothelial carcinoma with the holmium laser [Figures 2 and 3]. Using holmium:YAG laser vaporization through a 21-Fr cystoscope, the lesions in the pendulous urethra were ablated using a 600 μm fiber with settings of 8 Hz and 1.0 Joules (8 Watts). Only one half of the urethra was treated for fear of urethral stricture. A total time of 20 minutes was taken for the procedure with minimal discomfort postoperatively. Mitomycin C was instilled (40 mg in 20 cc of sterile water) for 1 hour immediately after the procedure. This was done due to his history of UC in the bladder as well as cells from the ablation may have been introduced into the bladder with the irrigation fluid. A 22-F Silastic Foley catheter was placed and continued for 4 days after surgery. We subsequently performed the second stage of the procedure which included treatment of the other half of the lesions after one month once an office cystoscopy revealed there was no urethral stricture formation. After the second therapy he elected for BCG therapy and he has now been under surveillance for 18 months without cystoscopic evidence of a urethral recurrence and no formation of urethral stricture [Figure 4].

Figure 1

Urethral biopsy with superficial UC

Figure 2

Preoperative photograph of pendulous urethra

Figure 3

Laser ablation

Figure 4

Postoperative photograph of pendulous urethra

DISCUSSION

Urothelial carcinoma of the pendulous urethra is exceedingly rare with minimal literature to provide accurate incidence. Although a different scenario, urethral recurrence after cystectomy is approximately 9% which may give some insight into prevalence.[3] While the primary treatment of recurrent UC is resection and or fulguration with or without the use of intravesical therapy, the efficacy in the urethra is unknown.[1] We were concerned that resection would cause significant bleeding and the use of monopolar energy with the Bugbee electrode would cause urethral stricture. Therefore, we considered treatment with the holmium laser as it provides tissue destruction with a depth of penetration of about 0.5 mm but is very controlled.[4] Ho: YAG laser therapy has been accepted as a means of fulguration in superficial bladder cancer.[156] The holmium laser has also provided therapeutic use in urethral stricture disease.[7] Despite the use of holmium laser to treat lesions of the ureter, there have been no reports of diffuse fulguration of the urethra to determine if this may cause urethral stricture. Previous reports suggest that using the Ho: YAG for ureteral fulguration of UC is effective and the stricture rate is less than 9%.[4] The case was performed in a staged fashion and provided effective treatment without urethral recurrence.