687
CASE REPORTS
References Cass,A. S.,Khan,A. U.,Smith,S. e t d (1981) Neonatal perirenal urinary extravasation with posterior urethral valves. Urology, 18,258. Friedland, G. W., Filly, R., Goris, M. ef d (eds) (1983). Uroradiology : an Integrated Approach. Volume 2, pp. 13861391. Edinburgh, New York: Churchill Livingstone. Hinman, F., Oppenheimer, 0. E. and Katz, I. L. (1983). Accelerated obstruction at ureteropelvic junction in adults. J. Urol., 129,812-8 14. Krane, R. J. and Retik, A. B. (1974). Neonatal perirenal extravasation. J . Urol., 111,96. Requests for reprints to: B. M. S. Al Saleh, Department of Urology, Central Hospital, P.O. Box 233, Abu Dhabi, United Arab Emirates.
Primary Malignant Melanoma of the Male Urethra Fig. 2 Chest X-ray showing massive left pleural effusion. Below the right side of the diaphragm (arrow) the intraperitoneal fluid displaces gas-containing bowel towards and lateral to the liver.
correctionof metabolic acidosis and antibacterialtherapy the patient’s general condition improved and renal function returned to normal. The left percutaneous nephrostomy continued to drain an adequate amount of urine but only a few ml were drained from the right side. Two weeks later a modified left Anderson-Hynes pyeloplasty was carried out. Six months later the patient was asymptomatic and his renal function has remained normal.
Comment Hydronephrosiscaused by pelviureteric obstruction does not always progress, but may increase rapidly and without warning in adult life (Hinman et al., 1983). Most patients with giant hydronephrosis present with an abdominal mass which may cause respiratory distress, and occasionally with intraperitoneal urinary extravasation. This occurs most often in infants with primary obstructive megaureter, posterior urethral valves or vesicoureteric reflux (Krane and Retik, 1974; Cass et al., 1981). The most important aspect of management is early diagnosis with accurate pre-operative delineation of the anatomy of the affected kidney. In patients with urinary ascites and urothorax, early drainage allows the renal function to improve before appropriate surgical treatment is undertaken.
Y. OYABU and K. ETO, Department of Urology, Kurume University School of Medicine, Kurume, Japan
Case Report A 63-year-old man presented with a 9-month history of urethral bleeding. Retrograde urethrography demonstrated an irregular filling defect in the bulbous urethra (Fig. 1). Biopsy of the urethral tumour revealed malignant melanoma (Fig. 2). Although total emasculation and bilateral inguinal and pelvic lymph node dissection were performed, and chemotherapy with dacarbazine, nimustine and vincristine was administered, the patient died 4 months after operation.
Comment Primary malignant melanoma of the male urethra is rare; only 32 cases have been reported in the English literature (Paw-Sang et al., 1988) and 7 in the Japanese literature (Yamamoto et al., 1989). Most patients were diagnosed in the sixth or seventh decade. Urinary symptoms were common and included a palpable mass, dysuria, bloody penile discharge and other voiding complaints. The most common sites were the fossa navicularis and the meatus, the occurrence rate in the proximal urethra being only 20%. Radical surgery involving total penectomy with en bloc urethrectomy has been recommended for distal and proximal lesions, as the local recurrence
BRITISH JOURNAL OF UROLOGY
688
are indicated in patients with lymph node involvement and metastasis. Despite aggressive therapy, patients with urethral melanoma have a poor prognosis. Only 9 of 40 patients (23%) were free of disease at the time of the reports, and most tumour-related deaths occurred within 3 years of diagnosis.
References Pow-Sang, J. M., Klimberg, I. W., Hackett, R. L. et d (1988). Primary malignant melanoma of the male urethra. J . Urol., 139,13041 306. Stein, B. S. and Kendall, A. R. (1984). Malignant melanoma of the genitourinary tract. J . Urol., 132,859-868. Yamamoto, N., Maeda, S., Takeuchi, T. et d (1989). Malignant melanoma of the male urethra: a case report. Acra. Urol. Jpn., 35,123-126. Requests for reprints to: Y. Oyabu, Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830 Japan. Fig. 1 Retrograde urethrography demonstrating irregular shadow defect on bulbous urethra.
Chylous Ascites following Retroperitoneal Lymph Node Dissection for Testis Cancer P. M.T. WESTON, J. E. GREENLAND and D. M. A. WALLACE, Department of Urology, Queen Elizabeth Hospital, Birmingham
Chylous ascites is an uncommon complication following retroperitoneal surgery. We report a case of chylous ascites following retroperitoneal lymph node dissection for genitourinary cancer which responded to paracentesis and a medium-chain triglyceride diet. Case Report
Fig. 2 Urethral tumour showing malignant melanoma. (Fontana-Masson’sstain x 400).
rate after partial penectomy is high (Paw-Sang et al., 1988). Cystoprostatectomy and pelvic lymph node dissection have also been used to treat lesions in the proximal urethra and the penoscrotal junction (Stein and Kendall, 1988). Radiology and chemotherapy have shown limited benefit, although they
A 24-year-old male had previously undergone a right orchiectomy for malignant teratoma undifferentiated, staged IIC by CT scan. Cytoreduction had been attempted with several courses of combination chemotherapy (BOP/VIP) over a 3-month period. Repeat scanning had shown persistence and cystic transformation of the retroperitonealmass. Retroperitoneallymph node dissection was, therefore, performed via a transabdominal midline approach. An infrarenal dissection was performed and all macroscopic disease removed using the technique described by Donohue (1988). Histology showed foci of mature differentiatedteratoma. The patient was discharged after an uneventful recovery but was readmitted as an emergency 6 weeks
CASE REPORTS
References Cass,A. S.,Khan,A. U.,Smith,S. e t d (1981) Neonatal perirenal urinary extravasation with posterior urethral valves. Urology, 18,258. Friedland, G. W., Filly, R., Goris, M. ef d (eds) (1983). Uroradiology : an Integrated Approach. Volume 2, pp. 13861391. Edinburgh, New York: Churchill Livingstone. Hinman, F., Oppenheimer, 0. E. and Katz, I. L. (1983). Accelerated obstruction at ureteropelvic junction in adults. J. Urol., 129,812-8 14. Krane, R. J. and Retik, A. B. (1974). Neonatal perirenal extravasation. J . Urol., 111,96. Requests for reprints to: B. M. S. Al Saleh, Department of Urology, Central Hospital, P.O. Box 233, Abu Dhabi, United Arab Emirates.
Primary Malignant Melanoma of the Male Urethra Fig. 2 Chest X-ray showing massive left pleural effusion. Below the right side of the diaphragm (arrow) the intraperitoneal fluid displaces gas-containing bowel towards and lateral to the liver.
correctionof metabolic acidosis and antibacterialtherapy the patient’s general condition improved and renal function returned to normal. The left percutaneous nephrostomy continued to drain an adequate amount of urine but only a few ml were drained from the right side. Two weeks later a modified left Anderson-Hynes pyeloplasty was carried out. Six months later the patient was asymptomatic and his renal function has remained normal.
Comment Hydronephrosiscaused by pelviureteric obstruction does not always progress, but may increase rapidly and without warning in adult life (Hinman et al., 1983). Most patients with giant hydronephrosis present with an abdominal mass which may cause respiratory distress, and occasionally with intraperitoneal urinary extravasation. This occurs most often in infants with primary obstructive megaureter, posterior urethral valves or vesicoureteric reflux (Krane and Retik, 1974; Cass et al., 1981). The most important aspect of management is early diagnosis with accurate pre-operative delineation of the anatomy of the affected kidney. In patients with urinary ascites and urothorax, early drainage allows the renal function to improve before appropriate surgical treatment is undertaken.
Y. OYABU and K. ETO, Department of Urology, Kurume University School of Medicine, Kurume, Japan
Case Report A 63-year-old man presented with a 9-month history of urethral bleeding. Retrograde urethrography demonstrated an irregular filling defect in the bulbous urethra (Fig. 1). Biopsy of the urethral tumour revealed malignant melanoma (Fig. 2). Although total emasculation and bilateral inguinal and pelvic lymph node dissection were performed, and chemotherapy with dacarbazine, nimustine and vincristine was administered, the patient died 4 months after operation.
Comment Primary malignant melanoma of the male urethra is rare; only 32 cases have been reported in the English literature (Paw-Sang et al., 1988) and 7 in the Japanese literature (Yamamoto et al., 1989). Most patients were diagnosed in the sixth or seventh decade. Urinary symptoms were common and included a palpable mass, dysuria, bloody penile discharge and other voiding complaints. The most common sites were the fossa navicularis and the meatus, the occurrence rate in the proximal urethra being only 20%. Radical surgery involving total penectomy with en bloc urethrectomy has been recommended for distal and proximal lesions, as the local recurrence
BRITISH JOURNAL OF UROLOGY
688
are indicated in patients with lymph node involvement and metastasis. Despite aggressive therapy, patients with urethral melanoma have a poor prognosis. Only 9 of 40 patients (23%) were free of disease at the time of the reports, and most tumour-related deaths occurred within 3 years of diagnosis.
References Pow-Sang, J. M., Klimberg, I. W., Hackett, R. L. et d (1988). Primary malignant melanoma of the male urethra. J . Urol., 139,13041 306. Stein, B. S. and Kendall, A. R. (1984). Malignant melanoma of the genitourinary tract. J . Urol., 132,859-868. Yamamoto, N., Maeda, S., Takeuchi, T. et d (1989). Malignant melanoma of the male urethra: a case report. Acra. Urol. Jpn., 35,123-126. Requests for reprints to: Y. Oyabu, Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830 Japan. Fig. 1 Retrograde urethrography demonstrating irregular shadow defect on bulbous urethra.
Chylous Ascites following Retroperitoneal Lymph Node Dissection for Testis Cancer P. M.T. WESTON, J. E. GREENLAND and D. M. A. WALLACE, Department of Urology, Queen Elizabeth Hospital, Birmingham
Chylous ascites is an uncommon complication following retroperitoneal surgery. We report a case of chylous ascites following retroperitoneal lymph node dissection for genitourinary cancer which responded to paracentesis and a medium-chain triglyceride diet. Case Report
Fig. 2 Urethral tumour showing malignant melanoma. (Fontana-Masson’sstain x 400).
rate after partial penectomy is high (Paw-Sang et al., 1988). Cystoprostatectomy and pelvic lymph node dissection have also been used to treat lesions in the proximal urethra and the penoscrotal junction (Stein and Kendall, 1988). Radiology and chemotherapy have shown limited benefit, although they
A 24-year-old male had previously undergone a right orchiectomy for malignant teratoma undifferentiated, staged IIC by CT scan. Cytoreduction had been attempted with several courses of combination chemotherapy (BOP/VIP) over a 3-month period. Repeat scanning had shown persistence and cystic transformation of the retroperitonealmass. Retroperitoneallymph node dissection was, therefore, performed via a transabdominal midline approach. An infrarenal dissection was performed and all macroscopic disease removed using the technique described by Donohue (1988). Histology showed foci of mature differentiatedteratoma. The patient was discharged after an uneventful recovery but was readmitted as an emergency 6 weeks
