Transurethral resection of bladder tumor in a case of metastatic carcinoma prostate with penile prosthesis implant.

Synchronous presentation of genitourinary tract malignancies is common, and more so for carcinoma prostate and carcinoma urinary bladder. Each of the carcinomas is treated as per their stage at presentation. Here, we report a case of metastatic carcinoma prostate with penile implant presenting with bladder lesion managed by transurethral resection of bladder tumor (TURBT) through perineal urethrostomy. Copyright:

INTRODUCTION

Bladder tumor is the second most common genitourinary malignancy, and it can occur commonly with other genitourinary malignancies, usually prostate. The incidence of concomitant presentation of carcinoma prostate and carcinoma bladder is 18–19 times more common than normal population.[1]

The initial assessment and management of patients with bladder lesion involve cystourethroscopy followed by transurethral resection of bladder tumor (TURBT). The presence of a penile implant may make TURBT difficult. Perineal urethrostomy is indicated for long segment stricture which failed conservative management and urethroplasty,[2] total penectomy for carcinoma penis,[3] inaccessibility to bladder due to obesity for transurethral resection.[4] We describe the use of a perineal urethrostomy to perform TURBT in this patient.

CASE REPORT

An 80-year-old patient with a Shah® malleable penile implant since 11 years came with complaints of back pain for 6 months and voiding difficulty. His prostate-specific antigen was 77.67 ng/ml, and ultrasonography showed a lesion of 4 cm on the right lateral wall of bladder with prostatomegaly. Core biopsy of the prostate showed adenocarcinoma of prostate with Gleason score 8 (4 + 4) with perineural invasion. Prostate-specific membrane antigen (PSMA) - positron emission tomography (PET) showed PSMA positive tumor involving the prostate gland with intense PSMA uptake along left superior poster lateral peripheral wall region. PSMA expressing metastatic lesion involving enlarged left supraclavicular, retroperitoneal, and bilateral iliac nodes and disseminated sclerotic lesions involving base of the skull, multiple cervical, dorsolumbar vertebrae seen, sternum, clavicle, scapulae sacrum, pelvis, and bilateral femori. PSMA – PET showed a non-PSMA avid soft-tissue mass lesion of 4 cm in the right lateral wall of bladder; and hence, contrast enhanced computed tomography of abdomen was done which showed a contrast-enhancing lesion on the right lateral wall of bladder [Figure 1]. The patient was planned for TURBT. The patient was counseled for a perineal urethrostomy and that it is advisable to have permanent perineal urethrostomy for follow-up and reresection; however, he refused the creation of permanent urethrostomy. A rigid resectoscope could be passed through the meatus only till the prostatic urethra and the tumor was visualized using flexible cystoscopy. A perineal urethrostomy was created through a midline perineal approach [Figure 2a], and 2 cm opening was made in bulbar urethra through which resectoscope was passed [Figure 2b] and tumor was resected completely. The urethrostomy was closed [Figure 2c] and a urethral catheter was placed for continuous bladder irrigation. The histopathology showed high grade papillary urothelial carcinoma without muscle invasion. He was started on luteinizing hormone-releasing hormone agonists for his prostate cancer.

Figure 1

Computed tomography image of bladder tumor

Figure 2

(a) Approach to perineal urethrostomy (b) Resection of tumor with resectoscope (c) Closed perineal urethrostomy

DISCUSSION

Synchronous malignancies of the genitourinary tract are not rare, and these malignancies are treated as per their stage at the time of presentation. There is a paucity of literature mentioning TURBT in a patient with penile implant where rigid resectoscope could not be negotiated. One case report has mentioned TURBT in case of penile implants, but they were able to resect tumor through per urethral route.[5] Our case of perineal urethrostomy for TURBT in a case of penile implant is novel and can be used for other conditions where per urethral access becomes difficult like complete urethral strictures.

Declaration of patient consentd

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.