Exam 3/Lecture 4 case study

Question 1

• What is epipadias and hypospadias?
• What does it promote?
• Conditions are treated how?

Answer 1

• Epispadias: urethral orifice on dorsal surface of penis
• Hypospadias: urethral orifice on ventral surface of penis
• Promote urinary tract obstruction or urinary incontinence
• Conditions are repaired surgically

Question 2

How are they surgically corrected?

Answer 2

• Surgical incision to create new urethral cavity/groove (a,b); cavity is lined with bladder mucosa, catheter is inserted (c), surgical wound is closed (d), later catheter is removed when new urethral tract has healed (e)
• Typically requires consecutive urethral correction to accommodate growth

Question 3

• What are the pros and cons of using bladder mucosa?
• What are complications of surgery?

Answer 3

• Advantages of using bladder mucosa: can proliferate in urine environment
• Disadvantages using bladder mucosa include: graft rejection, prolapse, risk for metaplastic change, development of benign tumors (chronic irritation)
• Complications (40% cases) include formation of strictures, novel urethral fistulas and glans dehiscence

Question 4

What was patient history and presentation (age 9)?

Answer 4

• Hypospadias repair at age 5
• At 9 years the hypospadias repair failed resulting in formation of distal urethral fistula that went untreated, but allowed for urinary voiding
• Fistula: abnormal connection between two body parts

Question 5

What was patient history and clinical presention at 27 years old?

Answer 5

• At 27 years, pt presents with urethral stricture, multiple urethral fistulas, recurrent lower urinary tract infections
• Within past 2 months, pt has had symptoms of urinary obstruction, difficulty voiding, straining to urinate, weak urine stream
• Progressive penile swelling & pain
• Physical examination reveals multiple, large ulcerated lesions throughout penis with several fungating cutaneous tracts drained as purulent fluid & urine
• Also noted is congenital penoscrotal transposition, but no testicular abnormalities
• Also noted are enlarged, firm bilateral inguinal lymph nodes

Question 6

What was the lab tests?

Answer 6

• Lab tests negative for HIV, HPV & other STDs
• Positive for UTI (bacteria)
• Cystourethroscopy revealed 4 penile urethrocutaneous fistulas which could be probed, indiscernible native urethra, <2cm mass with irregular borders at distal bladder neck

Question 7

What was the biopsy result? what was done?

Answer 7

• All biopsies identified as squamous cell carcinoma
• Some cancers were keratinizing, squamous cell carcinoma in situ
• Some cancers showed areas of invasive, poorly differentiated squamous cell carcinoma
• PET scan was suspicious for regional metastasis to inguinal and iliac lymph nodes

Question 8

What did the patient undergo? Diagnosed with?

Answer 8

• Pt underwent radical penectomy, bilateral inguinal & pelvic lymphadenectomy & perineal urethrostomy (incision/dilation of urethral stricture)
• Diagnosed with stage III, T3N2M0 penile cancer with 2/38 inguinal nodes +ve, pelvic lymph nodes negative

Question 9

Underscores how patients can do what?

Answer 9

can adapt to situations (maintain sexual behavior & urinary voiding) rather than seeking medical attention

Question 10

Unique reporting of failed hypospadias repair linked to what?

Answer 10

metaplastic transformation – penile squamous cell carcinoma
– Especially since penile squamous cell carcinoma is rare
– Generally in males > 40-50 years