Case Report


Korean J Androl. 2011 Apr;29(1):88-90. English.
Published online Apr 30, 2011.  https://doi.org/10.5534/kja.2011.29.1.88
Copyright © 2011 The Korean Andrological Society
Penile Squamous Cell Carcinoma Diagnosed following Treatment of Urethrocutaneous Fistula after CO2 Laser Therapy for Misdiagnosed Penile Lesion: Report of a Case
Young Joo Kim,1 Sung Dae Kim,1 Hyeon Ju Kim,2 Young Hee Maeng,3 and Jung Sik Huh1
1Department of Urology, Jeju National University School of Medicine, Jeju, Korea.
2Department of Family Medicine, Jeju National University School of Medicine, Jeju, Korea.
3Department of Pathology, Jeju National University School of Medicine, Jeju, Korea.

Correspondence to: Jung Sik Huh. Department of Urology, Jeju National University School of Medicine, 1-dong, Jeju 690-756, Korea. Tel: 064-717-1410, Fax: 064-717-1131, Email: urohjs@jejunu.ac.kr
Received March 03, 2011; Accepted April 11, 2011.

Abstract

The complications of the treatment of penile lesion are wide ranging, urethrocutaneous fistula being one of the less common. This complication affects the ventral aspect of the penis. We present a rare case of urethrocutaneous fistula after vaporization of penile lesion by CO2 Laser. One fistula was at ventral aspect of the penis. A 43-year-old male presented with passage of urine from one opening. He had undergone a vaporization by CO2 laser, 2 times. Urethrocutaneous fistula repairs was performed with biopsy of the edge of fistula site. Squamous cell carcinoma was confirmed. He subsequently underwent a partial penectomy. It is very important that biopsy was performed before vaporization of even small size skin lesion. This case is reported along with a brief review of the literature.

Keywords:
Cutaneous fistula; Penile disease; CO2 laser

Carcinoma of the penis is rare disease (0.58/100,000) in the United state,1 In developing countries, the incidence is relatively common, due in part to cultural and hygienic differences.2, 3

With the improvement of living standards and hygienic habits in recent years, the incidence of carcinoma of the penis is declining.1 Several etiologic risk factors have been recognized in the development of this malignancy. Exposure to the human papillomavirus, lack of neonatal circumcision (especially when associated with phimosis), and exposure to tobacco, among other causes, have been implicated.3, 4

Neodymium:yttrium-aluminum-garnet (Nd:Yag) and CO2 lasers have been used primarily in penile skin lesions, because Laser treatment of penile lesion has several advantages. We described a rare case of urethrocutanoeus fistula after treatment of CO2 laser for penile lesion along with a brief review of the literature.

Case Report

A 43-year-old male presented with passage of urine from one opening at the distal portion ventral site of penile shaft near corona with irregular margin. A No. 16 Fr Foley catheter was inserted into bladder via external urethral orifice. He had been undergone a vaporization by CO2 laser, 2 times at private clinic. The patient initially was mistook for a small size wart and was treated without diagnostic biopsy. After 1 month, penile lesion was recurrent at same site of first lesion of penile shaft and retreated by CO2 laser without biopsy. After 1 week, during urination urine was passed ventral site of penis. He had neither other past medical history nor symptoms of the other lesion and denied any hematuria and urinary symptoms except urinary dribbling. On physical examination, there was one urethrocutaneous fistua which had clear margin without penile mass and no inguinal palpable lesions. Blood chemistry and urinalysis was normal range. Under spinal anesthesia, urethrocutaneous fistula repair and biopsy of the edge of fistula site were performed after a NO. 16 Fr Foley catheter was inserted. The result of biopsy was squamous cell carcinoma of the penis (Fig. 1). CT scan and bone scan revealed no abnormal finding. Partial penectomy without ilioinguinal lymph node dissection was performed (Fig. 2). Postoperative pathology investigations confirmed that it was a well-differentiated squamous cell carcinoma of the penis involving the skin nearby, whereas the surgical margin was negative (Fig. 3). Follow-up has consisted of 12 month CT scan and neither recurrence nor distant metastasis has been observed during a 12 month follow-up visit after complete therapy.


Fig. 1
The microphotograph of biopsied tissue shows infiltrating strands and islands of neoplastic squamous cells around the fistulous tract (H&E, ×40).
Click for larger image


Fig. 2
This photography shows the cutting surface of partial penectomy. A arrow indicates the site of urethrocutaneous fistula repair.
Click for larger image


Fig. 3
Tissue sections from the penectomy specimen reveals well-differentiated squamous cell carcinoma (A: H&E, ×100, B: H&E, ×200).
Click for larger image

Discussion

Penile carcinoma is uncommon developed countries. The precise etiology of penile cancer remains obscure, but an association between the disease and the absence of circumcision or poor hygiene is well established. Exposure to the human papillomavirus, and exposure to tobacco, among other causes, have been implicated.2, 3

Patient characteristics concerning age at onset, presenting clinical symptoms, the anatomic location of initial lesion, a delayed diagnosis and the stage of disease are agreement with most large series. The most common presenting symptoms were a mass and an ulcer, infrequently pain. The obvious psychological problem associated with genital disfigurement has prompted the development of organ sparing techniques. The treatments of penile carcinoma were phodynamic therapy, 5-Fluorouracil cream, cryosurgery with liquid nitrogen and Nd-YAG laser therapy.5-8 Laser treatment of T1 and T2 stage carcinoma penis has several advantages. During or post laser, there is no blood loss, pain relief is achieved with oral analgesics, there is no wound infection, and antibiotic administration is not required. Local treatment failure can be treated with repeat laser application, partial or total penectomy.8 Leijite et al9 reported retrospective multi-institutional series laser therapy, local incision, and radiotherapy were compared to partial or total penectomy. Local recurrence rates were higher with penile preservation compared to partial or total penectomy (27.7% versus 5.3). Five year disease specific survival in those who locally recurred was 92%, however, prompting the authors to conclude that there is little impact on survival from utilizing phallic preservation procedures. Stein and kendall10 reported that seven patients with penile lesion were treated with laser therapy and, all had excellent results without complication. Our case had a complication of urethrocutaneous fistula after CO2 laser therapy for penile lesion. Although there are many modality of treatment for penile skin lesion, it is important to evaluate penile lesion, such as penile papilloma, nodule, genital ulcerative lesion, condyloma and carcinoma. An early diagnosis is a major matter in order to avoid tumoral spread and multilating surgery. As the therapeutic approach was conservative, many of the pathological diagnoses were based exclusively on the tumor biopsy specimen.

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