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Early penile metastasis as the first sign of urothelial carcinoma spread

We report the case of a 65-year-old man who underwent transurethral resection of the bladder for a urothelial neoplasm of the bladder; pathological analysis reported bladder wall infiltration by a high-grade carcinoma. Radical cystoprostatectomy without urethrectomy and a Bricker urinary diversion was carried out a month later. Pathological analysis rendered pT4aN2M0(TNM 2009) with free surgical borders. No neoadjuvant therapy was carried out. A total of 15 days after surgery, the patient developed penile pain. Physical examination showed painful priapism. Corporeal aspiration for gas analysis was intended, but we were not able to obtain any blood for analysis. Ultrasound exploration showed no abnormalities. With the clinical suspicion of metastasis, abdominal computed tomography including the penis was carried out and showed heterogeneous areas in the corpus cavernosum, which might be related to thrombosis, hematoma or metastasis. Furthermore, a fine-needle aspiration specimen was insufficient for pathological diagnosis. Hence, drainage was intended, but only a few milliliters of blood were extracted, prompting the suspicion of tumoral invasion. Thereafter, biopsy from the right corpus cavernosum and sparse blood from the left corpus cavernosum were taken. The pathological analysis showed urothelial carcinoma in both samples. Despite all initial measures, including a high dose of narcotics, pain was unmanageable. Therefore, the patient underwent radical penectomy. The pathology report yielded urothelial carcinoma with extensive metastatic invasion of the corpus cavernosum, corpus spongiosum and glans penis (Fig. 1). After the penectomy, postoperative pain was managed with acetaminophen. Penile metastasis is a rare event. The most common observed signs and symptoms of metastasis to the penis in order of frequency are: malignant priapism (40%), urinary retention, penile nodules, ulceration, perineal pain, edema, generalized swelling, broad infiltrative enlargement, dysuria and hematuria. Most cases of penile metastasis are metachronous. The time interval between primary tumor and penile metastasis ranges from 3 to 60 months and the time interval between diagnosis of penile metastasis and death ranges from 0.25 to 18 months. The average survival in patients presenting with penile metastasis is very short (3.9 months from diagnosis), as it is highly associated with advanced disease. In our patient, metastasis became evident 25 days after surgery, which is very prompt. In 1956, Paquin and Roland postulated several mechanisms to explain tumor spread: venous retrograde spread, lymphatic spread, direct anatomical extension, arterial spread and iatrogenic spread. In our patient, the dissemination is thought to have occurred by venous retrograde spread, as surgical margins were free. Priapism initial treatment should be managed with intracavernosal irrigation and instillation of phenylephrine, as well as shunts; further treatment includes arterial embolization and dorsal nerve section, and in cases of metastasis with intractable pain total penectomy might be employed. Local excision, partial or total penectomy, external beam radiation and chemotherapy have not been shown to improve survival. In the present case, we found intracavernosal irrigation useless because of the extensive infiltration; and the pain was unmanageable with narcotics, therefore we offered the patient radical penectomy with good results.