# Treatment of Low-Grade Bulbar Transitional Cell Carcinoma with Urethral Instillation of Mitomycin C

Authors: Emmanuel J. Melonakos; Richard A. Santucci
Journal: Advances in Urology
 (2008)

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## Abstract

A 63-year old man was referred to us after three rapid recurrences of low-grade urethral papillary transitional cell carcinoma of the bulbar urethra, after repeated primary excision. Cystoscopy confirmed 3-4 low-grade urethral transitional cell carcinomas, which were subsequently fulgurated. After urethral healing, a solution of Mitomycin C (40 mg/80 cc) was instilled into the urethra for fifteen minutes and held in place with a  penile clamp. Urethral instillations were repeated weekly for six weeks. The patient is currently disease-free more than one year and three months posttreatment. This case highlights the successful treatment of urethral carcinoma with topical chemotherapy, which is usually reserved for the bladder, using a slight modification of standard technique.


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## Body

## 1. Introduction

Cancer in the male
urethra is rare, representing less than 0.5% of all malignancies in males [1, 2]. It is seen
primarily in the sixth decade of life, with approximately 55–65% of tumors
located in the bulbar part of the urethra  and 30–35% occur in the
anterior urethra [3]. Prognoses are not good for patients with advanced stages
of bulbar urethral cancer, with only a 26% survival rate [4]. Bulbomembranous
urethral tumors are typically diagnosed later than more anterior cancers, but
prognosis is good if treated at early stages [4]. The chief problem in treating
urethral carcinoma is how to expose the urethra to topical chemotherapy agents
such as BCG or Mitomycin C. We present a case illustrating how to place
chemotherapy effectively in the urethra, to curative effect in a patient with
multiple previous failures of simple fulgaration.


## 2. Case Presentation

A 63-year old male
was referred to our practice with recurrent, low-grade, bulbar urethra
transition cell carcinoma which had recurred after two previous excisions.The patient was taken to the
operating room for a third excision, where several urethral tumors were
removed. Pathology showed T1, Grade 1 urothelial carcinoma. A large caliber
urethral stricture in the area was also treated with urethrotomy at the same
time. After surgical excision, he
underwent 6 weekly installations of 40 mg Mitomycin C reconstituted in 80 cc of
saline. While the usual method of
intravesical chemotherapy involves installation through a bladder catheter, in this
case we used a catheter-tip “Toomey” syringe (Bard; Covington, Ga, USA) to
gently instill the medication into the urethral meatus, then used a penile
clamp (Storz; Culver City, Calif, USA) to keep the column of medication in the
urethra for 15 minutes.The patient suffered usual side effects of Mitomycin, including self-limited
fatigue, dysuria, daytime urinary frequency up to every hour, and nocturia 2-3 X nightly [5]. All symptoms but nocturia
resolved by the 6th treatment. He had cystoscopy and voided cytology
examinations at 2, 6, and 12 and 18 months without recurrence of stricture or
development of urethral cancer recurrences. (Previous recurrences X3 had been
evident within 3 months of resection). The urethra appeared largely pink and
healthy, with only small areas of white scar tissue marking the areas of
previous urethral tumor resection.


## 3. Discussion

Intraurethral Mitomycin C is Possible
We report the successful application of Mitomycin C to urethral carcinoma, by a
method of intraurethral installation and penile clamping to keep the agent in
urethral contact. Local side effects included irritative voiding symptoms, but
seemingly no more severe than after intravesical administration. Other authors
have described significant complications including urethral stricture after
Mitomycin was mixed into lidocaine jelly and placed into the urethra in one
case. Penile and urethral complications
of Mitomycin have also been reported after intravesical administration: (1) glans
necrosis after high dose (60 mg) [6], (2)
urethral sloughing, and (3) necrosis of the corpus spongiosum [7]. Despite these rare complications, practitioners
wishing to treat urethral superficial transitional cell carcinoma with topical
agents might consider this simple approach in their patients.


## 4. Conclusion

To our knowledge, this is the first case of bulbar, low-grade papillary
transitional cell carcinoma treated successfully by application of liquid
Mitomycin C. This technique provides a method for application of Mitomycin
directly to the urethral mucosa.



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*Source: 173694-2008-10-28.xml*