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Squamous cell carcinoma of the bulbar urethra.

Case Report A 49-year-old man with a history of balanitis xerotica obliterans and meatal stricture treated with circumcision and meatoplasty 4 years before presented with a recurrent urinary tract infection. Urethroscopy revealed a lesion in the bulbar urethra, which was confirmed to be a squamous cell carcinoma (SCC) with histology. Magnetic resonance imaging (MRI) confirmed a bulky tumor that emanated from the bulb of the penis, abutted the anorectal junction, and extended to involve the corpora cavernosa, the urogenital diaphragm, the apex of the prostate, and the levator ani. [F]fluorodeoxyglucose positron emission tomography (PET) showed an avid primary lesion with biliateral inguinal lymph node avidity. The multidisciplinary consensus was treatment with radical chemoradiotherapy to obtain local control and treat potential micrometastatic disease followed by radical surgery with curative intent and to gain local control if restaging imaging showed no metastatic disease. The patient received six cycles of cisplatin and 60 Gy of radiotherapy in 30 fractions over 38 days. Restaging MRI 6 weeks after completion of chemoradiotherapy showed a decrease in size of the tumor with central necrosis and a new lesion in the distal penis. PET showed a partial metabolic response in the primary tumor (Figs 1A, PET at diagnosis and 1B, 6 weeks after chemoradiotherapy), persisting mild uptake in a single inguinal node, and new mild uptake in an external iliac node, which was thought to be reactive and was subsequently confirmed by using fine-needle aspiration. Because of the good response to chemoradiotherapy, the consensus was to repeat imaging in 6 weeks to assess a possible ongoing response to chemoradiotherapy before radical surgery. Six weeks later, PET showed interval progression (Figs 2A, PET 6 weeks after chemoradiotherapy and 2B, 12 weeks after chemoradiotherapy), with more intense uptake in the primary tumor, that extended down the penile shaft and was confluent with the distal penile lesion previously seen by using MRI with increased avidity in the inguinal node. MRI showed local extension of the primary tumor, which abutted the anterior rectal wall and infiltrated through the levator ani into the perineum. Because of the rapid local progression of disease, increasing pelvic pain, and absence of distal metastases, a radical en bloc resection was performed, which required abdominoperineal resection, right inguinal superficial lymphadenectomy, cystoprostatectomy with ileal conduit, penectomy, scrotal excision, and bilateral orchidectomy (Fig 3). The