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Condyloma Acuminata of the Bladder
THE JOURNAL OF UROLOGY
Vol. 88, No. 1 July 1962 Copyright© 1962 by The Williams & Wilkins Co. Printed in U.S.A.
CONDYLOMA ACUMINATA OF THE BLADDER HAROLD KLEIMAN
AND
Condyloma acuminata is a disease usually con-fined to the moist, cutaneous surfaces about the external genitalia and anal region. It is thought to be caused by a filtrable virus. Approximately 5 per cent of patients afflicted with this condition had involvement of the internal urinary tract, but all were limited to the urethra. 1 • 2 Goldenberg3 first reported condyloma acuminata of the urethra in 1891. Morrow, McDonald and Emmett4 reported 27 cases and Gartman 5 reported 60 cases of intraurethral condyloma acuminata. The site of urethral involvement is most frequent in the external meatus or distal urethra. Rarely is the entire urethra involved and never has the posterior urethra alone been involved. Machacek and Weakley 6 reported one case of giant condyloma acuminata involving the entire urethra with invasion of the corpora cavernosa and corpus spongiosum. Table 1 represents a summation of cases reported since 1952. 4- 6 No cases of condyloma acuminata invading the bladder have been reported in the available English literature.
YORK LANCASTER
had been ruptured in an automobile accident. Several attempts to reanastomose the urethra were unsuccessful. In 1950, he underwent nephrectomy for chronic inflammatory destruction of the right kidney. Physical examination revealed normal vital signs and major systems except for a friable, ulcerated, cauliflower mass, approximately 10 cm. in diameter, at the site of the cystostomy (fig. 1, A). Rectal examination disclosed a large, moderately fixed mass in the area of the bladder, prostate, and seminal vesicles. Excretory urography revealed normal function and structure of the left kidney and ureter, but surgical absence of the right kidney. The urethrogram revealed TABLE
CASE REPORT
J. W., 24994, was first seen by one of us (Y. L.) in September 1959, for a growth in the area of a suprapubic cystostomy. He had worn a catheter inserted through the cystostomy since 1930, at which time the prostato-membranous urethra
1
Location
Number
Per Cent
Meatus ....................... . Distal 4 cm ................... . Penoscrotal. .................. . Entire ........................ . Posterior urethra alone ....... .
56 22 5 5 0
64.0 25.0 5.5 5.5 0.0
Total. ...................... .
88
100.0
complete obstruction in the area of the prostatomembranous urethra. Cystoscopy was performed through the suprapubic sinus and the entire bladder appeared to be involved. Biopsy revealed benign condyloma acuminata. Treatment with podophyllin and oral bismuth failed to produce any appreciable change. On September 23, 1960, an ileal loop diversion of the Bricker type was performed. The postoperative course was complicated by a small bowel obstruction which required surgical relief on October 2. The patient was reluctant to undergo cystectomy and another course of podophyllin was tried to see whether it might produce better control now that the urine had been diverted. Again, there was no appreciable improvement in the lesion. On January 5, 1961, total cystectomy and prostatectomy were accomplished. It was
Accepted for publication December 12, 1961. Read at the annual meeting of the South Central Section, American Urological Association, Inc., Hot Springs, Ark., September 18-22, 1961. 1 Gersh, I.: Condylomata acuminata of the male external genitalia: an effective method of surgical treatment. Urol. Cutan. Rev., 49: 432445, 1945.
2 Culp, 0. S. and Kaplan, I. W.: Condylomata acuminata, two hundred cases treated with podophyllin. Ann. Surg., 120: 251-256, 1944. 3 Goldenberg, H.: Quoted by Morrow, McDonald and Emmett. 4 4 Morrow, R. P., McDonald, J. R. and Emmett, J. L.: Condylomata acuminata of the urethra. J. Urol., 68: 909-917, 1952. 5 Gartman, E.: Intraurethral verruca acuminata in men. J. Urol., 76: 717-718, 1956. 6 Machacek, G. F. and Weakley, D. R.: Giant condyloma acuminata of Buschke and Lowenstein. AMA Arch. Derm., 82: 41-47, 1960.
52
CONDYLOMA ACUMINATA OF THE BLADDER
Fm. l. 11, condyloma at site of supra.pubic cystostomy. B, surgical specimen, bladder opened necessary to remove a very large skin segment. The lesion was densely attached to the pelvic walls and pubic rami as well as to the tip of the appendix by thick, inflammatory scar tissue. Recovery was complicated by sloughing of the central skin flap. A postoperative excretory urogram is shown in figure 2. Since :\farch 15, 1961, the patient has done heavy manual labor and is much more pleased with the ileostomy than with the catheter inserted through the suprapuhic cystostomy. The gross specimen described by Dr. Paul M. Obert (fig. 1, B) measured 9 by 10 by 7 cm. with a portion of elliptical skin measuring 9 by 5 cm. The skin area, suprapubic sinus, and body of the bladder, with the exception of the trigone and bladder neck, were filled with a papillomatous lesion which was grayish-pink to white. The bladder wall was thickened to 2 cm. An attached portion of ureter 3 cm. in length was present, hut not grossly involved. 1licroscopic sections (figs. 3 and 4) taken through the papillomatous area revealed hyperkcrntosis and parakeratosis. The rete pegs were elongated and showed moderate acanthosis. The basal layer was well defined and there was no evidence of invasion. In the deeper layers of the bladder wall, there was dense, chronic, nonspecific inflammatory reaction. The thickening of the bladder wall was due to fibroblastic proliferation and many contained lymphocytes and
Fru. 2. Postoperative excretory urogram
histiocytes. Sections through the uninvolved skin showed marked vacuolization of the ma! cells especially in the upper half of thP thickened epidermis. Sections through tlw tri gone and left ureter revealed orderly transition,11 epithelium with chronic inflammatory in the submucosa and muscularis. Diagnosis:
54
KLEIM,,N AND LANCASTER
Fm. 3. A, microscopic section. X 45. B, microscopic section.XlOO Benign condylorna acurninata of the bladder, suprapubic sinus, and abdominal skin with no evidence of malignancy. Begley and Compere 7 treated a histologically pronm case of conclyloma acuminata of the bladder in a 38-year-olcl woman in 1954. Mapharsen and chloropactin accomplished nothing. Slight 7 Begley, G. F. and Compere, D. E.: Personal communication.
improvement followed external radiation, but progressive obstructive symptoms of the urethra and left ureter developed. In 1956, biopsi0s again showed only conclyloma acuminata. It was necessary to perform a left nephrostomy and in 1957, an ilea! conduit and total cystectomy were perform.eel. By this time, the bladder contained an infiltrating transitional cell carcinoma. This patient required colostomy in September 1957,
CONDYLOMA ACUMINATA OF THE BLADDER
55
FIG. 4. A, microscopic section. X 500. B, microscopic section.XlOOO
because of rectal obstruction. She died in March 1958, some 4 years after treatment was started. Autopsy revealed no malignant extension other than in the bladder wall itself. SUMMARY
A case of invasion of the bladder by condyloma acuminata has been presented. This condition does not respond to conservative measures that
yield results on externally located lesions. We believe that the lesion must be considered "malignant by position" when the bladder is involved. Fortunately for the patient whose case is reported, the area of the trigone and ureter had not become involved prior to surgical therapy. Our experience, coupled with that of Begley and Compere,7 would indicate that early radical surgical excision of condyloma acuminata of the bladder is the treatment of choice.
Vol. 88, No. 1 July 1962 Copyright© 1962 by The Williams & Wilkins Co. Printed in U.S.A.
CONDYLOMA ACUMINATA OF THE BLADDER HAROLD KLEIMAN
AND
Condyloma acuminata is a disease usually con-fined to the moist, cutaneous surfaces about the external genitalia and anal region. It is thought to be caused by a filtrable virus. Approximately 5 per cent of patients afflicted with this condition had involvement of the internal urinary tract, but all were limited to the urethra. 1 • 2 Goldenberg3 first reported condyloma acuminata of the urethra in 1891. Morrow, McDonald and Emmett4 reported 27 cases and Gartman 5 reported 60 cases of intraurethral condyloma acuminata. The site of urethral involvement is most frequent in the external meatus or distal urethra. Rarely is the entire urethra involved and never has the posterior urethra alone been involved. Machacek and Weakley 6 reported one case of giant condyloma acuminata involving the entire urethra with invasion of the corpora cavernosa and corpus spongiosum. Table 1 represents a summation of cases reported since 1952. 4- 6 No cases of condyloma acuminata invading the bladder have been reported in the available English literature.
YORK LANCASTER
had been ruptured in an automobile accident. Several attempts to reanastomose the urethra were unsuccessful. In 1950, he underwent nephrectomy for chronic inflammatory destruction of the right kidney. Physical examination revealed normal vital signs and major systems except for a friable, ulcerated, cauliflower mass, approximately 10 cm. in diameter, at the site of the cystostomy (fig. 1, A). Rectal examination disclosed a large, moderately fixed mass in the area of the bladder, prostate, and seminal vesicles. Excretory urography revealed normal function and structure of the left kidney and ureter, but surgical absence of the right kidney. The urethrogram revealed TABLE
CASE REPORT
J. W., 24994, was first seen by one of us (Y. L.) in September 1959, for a growth in the area of a suprapubic cystostomy. He had worn a catheter inserted through the cystostomy since 1930, at which time the prostato-membranous urethra
1
Location
Number
Per Cent
Meatus ....................... . Distal 4 cm ................... . Penoscrotal. .................. . Entire ........................ . Posterior urethra alone ....... .
56 22 5 5 0
64.0 25.0 5.5 5.5 0.0
Total. ...................... .
88
100.0
complete obstruction in the area of the prostatomembranous urethra. Cystoscopy was performed through the suprapubic sinus and the entire bladder appeared to be involved. Biopsy revealed benign condyloma acuminata. Treatment with podophyllin and oral bismuth failed to produce any appreciable change. On September 23, 1960, an ileal loop diversion of the Bricker type was performed. The postoperative course was complicated by a small bowel obstruction which required surgical relief on October 2. The patient was reluctant to undergo cystectomy and another course of podophyllin was tried to see whether it might produce better control now that the urine had been diverted. Again, there was no appreciable improvement in the lesion. On January 5, 1961, total cystectomy and prostatectomy were accomplished. It was
Accepted for publication December 12, 1961. Read at the annual meeting of the South Central Section, American Urological Association, Inc., Hot Springs, Ark., September 18-22, 1961. 1 Gersh, I.: Condylomata acuminata of the male external genitalia: an effective method of surgical treatment. Urol. Cutan. Rev., 49: 432445, 1945.
2 Culp, 0. S. and Kaplan, I. W.: Condylomata acuminata, two hundred cases treated with podophyllin. Ann. Surg., 120: 251-256, 1944. 3 Goldenberg, H.: Quoted by Morrow, McDonald and Emmett. 4 4 Morrow, R. P., McDonald, J. R. and Emmett, J. L.: Condylomata acuminata of the urethra. J. Urol., 68: 909-917, 1952. 5 Gartman, E.: Intraurethral verruca acuminata in men. J. Urol., 76: 717-718, 1956. 6 Machacek, G. F. and Weakley, D. R.: Giant condyloma acuminata of Buschke and Lowenstein. AMA Arch. Derm., 82: 41-47, 1960.
52
CONDYLOMA ACUMINATA OF THE BLADDER
Fm. l. 11, condyloma at site of supra.pubic cystostomy. B, surgical specimen, bladder opened necessary to remove a very large skin segment. The lesion was densely attached to the pelvic walls and pubic rami as well as to the tip of the appendix by thick, inflammatory scar tissue. Recovery was complicated by sloughing of the central skin flap. A postoperative excretory urogram is shown in figure 2. Since :\farch 15, 1961, the patient has done heavy manual labor and is much more pleased with the ileostomy than with the catheter inserted through the suprapuhic cystostomy. The gross specimen described by Dr. Paul M. Obert (fig. 1, B) measured 9 by 10 by 7 cm. with a portion of elliptical skin measuring 9 by 5 cm. The skin area, suprapubic sinus, and body of the bladder, with the exception of the trigone and bladder neck, were filled with a papillomatous lesion which was grayish-pink to white. The bladder wall was thickened to 2 cm. An attached portion of ureter 3 cm. in length was present, hut not grossly involved. 1licroscopic sections (figs. 3 and 4) taken through the papillomatous area revealed hyperkcrntosis and parakeratosis. The rete pegs were elongated and showed moderate acanthosis. The basal layer was well defined and there was no evidence of invasion. In the deeper layers of the bladder wall, there was dense, chronic, nonspecific inflammatory reaction. The thickening of the bladder wall was due to fibroblastic proliferation and many contained lymphocytes and
Fru. 2. Postoperative excretory urogram
histiocytes. Sections through the uninvolved skin showed marked vacuolization of the ma! cells especially in the upper half of thP thickened epidermis. Sections through tlw tri gone and left ureter revealed orderly transition,11 epithelium with chronic inflammatory in the submucosa and muscularis. Diagnosis:
54
KLEIM,,N AND LANCASTER
Fm. 3. A, microscopic section. X 45. B, microscopic section.XlOO Benign condylorna acurninata of the bladder, suprapubic sinus, and abdominal skin with no evidence of malignancy. Begley and Compere 7 treated a histologically pronm case of conclyloma acuminata of the bladder in a 38-year-olcl woman in 1954. Mapharsen and chloropactin accomplished nothing. Slight 7 Begley, G. F. and Compere, D. E.: Personal communication.
improvement followed external radiation, but progressive obstructive symptoms of the urethra and left ureter developed. In 1956, biopsi0s again showed only conclyloma acuminata. It was necessary to perform a left nephrostomy and in 1957, an ilea! conduit and total cystectomy were perform.eel. By this time, the bladder contained an infiltrating transitional cell carcinoma. This patient required colostomy in September 1957,
CONDYLOMA ACUMINATA OF THE BLADDER
55
FIG. 4. A, microscopic section. X 500. B, microscopic section.XlOOO
because of rectal obstruction. She died in March 1958, some 4 years after treatment was started. Autopsy revealed no malignant extension other than in the bladder wall itself. SUMMARY
A case of invasion of the bladder by condyloma acuminata has been presented. This condition does not respond to conservative measures that
yield results on externally located lesions. We believe that the lesion must be considered "malignant by position" when the bladder is involved. Fortunately for the patient whose case is reported, the area of the trigone and ureter had not become involved prior to surgical therapy. Our experience, coupled with that of Begley and Compere,7 would indicate that early radical surgical excision of condyloma acuminata of the bladder is the treatment of choice.