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Intraurethral Condylomata Acuminata: Clorpactin as an Adjunct to Therapy
THE JOURNAL OF UROLOGY
Vol. 86, No. 4 October 1961 Copyright @ 1961 by The Williams & Wilkins Co.
Printed in U.S.A.
INTRAURETHRAL CONDYLOMATA ACUMINATA: CLORPACTIN AS AN ADJUNCT TO THERAPY RUSSELL SCOTT, JR.
AND
ROBERT STELL
From the Cora and Webb Mading Department of Surgery, Division of Urology, Baylor University College of Medicine, Houston, Texas
Condyloma acuminatum is a wart-like lesion which occurs on the skin of the pubic region, genitalia, urethral mucosa, and on occasion may extend into the bladder. This lesion is believed to be auto-inoculable and contagious. The causative micro-organism has not been definitely identified, but is considered by most authorities to be a filterable virus. 1 Podophyllin is recognized as an effective treatment for the external condylomata acuminata. 2 Transurethral resection or coagulation is the usual treatment for intraurethral condylomata acuminata, but repeated recurrences are often a problem. 3 One reported case required cystectomy due to extension into the bladder. 4 The 2 cases of intraurethral condylomata acuminata in this report were troublesome because of multiple recurrences following fulguration. Clorpactin * instillations were thought to be helpful adjuncts in therapy. Clorpactin is believed to be an effective agent for killing free tumor cells 5 , 6 viruses,7 and bacteria, including tubercle bacilli. 8 Clorpactin conAccepted for publication March 10, 1961. 1 Morrow, R. P., McDonald, J. R. and Emmett, J. L.: Condylomata acuminata of the urethra. J. Urol., 68: 909-917, 1952. 2 Culp, 0. S. and Kaplan, I. W.: Condylomata acuminata: Two hundred cases treated with popophyllin. Ann. Surg., 120: 251-256, 1944. 3 Gartman, E.: Intraurethral verruca acuminata in men. J. Urol., 75: 717-718, 1956. 4 Hooks, C.; Personal communication. * The form of clorpactin with a sufficiently high degree of activity exhibiting cytocidal properties against viable tumor cells is presently known as clorpactin XCB. This is the form described in the original paper (Gliedman, Grant, Vestal, Rogers and Karlson: Chlorpactin, a surgical adjunct. Surg. Forum, 8: 104-108, 1957). 5 McDonald, C. T., Howie, J. S., Weeks, P. M. and Thomas, C. G., Jr.: Limiting factors in the prophylaxis of the spread of cancer at operation by chemotherapeutic methods. Surg. Forum, 8: 164-168, 1957. 6 Thomas, C. G., Weeks, P. M. and Brown, B. C.: Control of free tumor cell growth by topical chemotherapeutic agents. Surg. Forum, 9: 598603, 1958. 7 Sanders, M. and Soret, M. G.: Virucidal activity of WCS-90. Antibiotics, 5: 629, 1955. 470
sists of a group of hypochlorous acid derivatives which form a slightly acid and highly buffered solution when dissolved in water. This solution exhibits excellent penetrating power and almost no tissue toxicity. In one study, tumor cells were injected intraperitoneally into laboratory animals. Clorpactin injected within 48 hours was effective in the control of the tumors. 6 It seemed logical to assume that clorpactin might be of value in inhibiting the recurrence of tumors thought to be of viral origin. CASE REPORTS
Case 1. The first patient was 34 years of age. Urologic evaluation in 1953 revealed multiple tumors of the urethra which were fulgurated at 3 month intervals during the course of a year. Each time the condition was thought to have been completely eradicated. The pathological diagnosis of these tumors removed was considered to be condylomata acuminata. From 1954, until first seen by us in 1958, the patient remained asymptomatic and did not receive urologic attention. Physical examination at this time was normal except for a mild meatal stenosis and a small papillary type tumor which could be seen inside the meatus. In July 1928, panendoscopy revealed about thirty papillary tumors distributed evenly from the fossa navicularis to the external sphincter. There were no tumors in the prostatic urethra or bladder. Six of the tumors were biopsied, and all the other tumors and the bases of the biopsy sites were fulgurated with a resectoscope. At the completion of the fulguration the urethra appeared free of tumors. Review of the microscopic sections revealed tumors of the urethra, compatible with condylomata acuminata. Three months later panendoscopy revealed many recurrent papillary tumors of the urethra which were carefully fulgurated. Two months later panendoscopy res Wolinsky, E., Smith, M. M. and Steenken W., Jr.: Tuberculocidal activity of clorpactin, a new chlorine compound. Antibiotic Med., 1: 382, 1955.
T>JTHA lH(BTHHAL CO:'-;DYLO:VIAT.\ ACUJVIl>JAT:\
n,aled n:rnny rnipillarr tumors scattered along the urethra which were biopsied ancl fulguratecl. The appearantc of the tumors was unchanged. It waR apparent that the tumors were not re.,pmHling to fulgmation alone. Recent reports in the literature indicated that clorpac:tin was effrcotive in killing free tumor ce,lls. For this n,ason, a cm1rse of clorpactin irrigatiorrn of the urethrn w a;, arl vised. Thr patient was supplinl with clorpactin powder which he kept in his rdrige,rator at homr. He \\ a~ instructed to fill a clean 1000 cc bottle with tap w:,ter and add 2 gm. c.lorpaetin. This solution wcmld be kqit in thP refrigerator and cliscarcled at the end of a 1Ycek. other day the; patient mmld instill 20 ce solution into trw urc,thra aml clamp the nwatus for 2 minutes. He IH>uld allow the clorpadin to drain out, wait 2 minutes, then n>id. This was continued for :3 rn
urethral cond?lomata acmninat.a. were tl1u1 rice! out. Daily urethral instillation~ with pactin were n,sumed 2 after Urn 1in,thral fulguration. One rnonth later examination vealed three persistent lesicms whicl1 were resectc:d am! fulgurnted. l:rcthral instillations of tin were continued. Two rnontlrn later the was fonncl to have a single ne11mnu1. tum in the prostatic urethm which wa~ rated. Clorpaetin instillations wen: c:ontimierl for 4 rnonths. The' irrigations were discontinuE:cl ·.vhr:n repeated pancndoscopic cxa.minat1ons "I, 4, ,1,1Hi 7 months showed no rec:nrrcnt rnirrnta. Roth of the cases dc-'monstrat
Intrnurethral conclylomata ac:nminat:i a 1"t: fn·" quently diffiC'ult to eradicate:. l"rethml instillations of c:lorpactin mnv be, ful in preventing reC'UJTe'nc:e., rtfter trnns1tn,thr:,l fulguration of r·oml)·lonrnta. :1.cuminata ,1 licnev,,:· the Irsions are extensive or have rlernonstrut.1,rJ ;.i. tendenl')' to n'c.nr. Two cas1,s are presenter! where intraurdhn1I instillation of clorpactin solution \\"ct~ lrnve eontribukd to the rnrr'
Vol. 86, No. 4 October 1961 Copyright @ 1961 by The Williams & Wilkins Co.
Printed in U.S.A.
INTRAURETHRAL CONDYLOMATA ACUMINATA: CLORPACTIN AS AN ADJUNCT TO THERAPY RUSSELL SCOTT, JR.
AND
ROBERT STELL
From the Cora and Webb Mading Department of Surgery, Division of Urology, Baylor University College of Medicine, Houston, Texas
Condyloma acuminatum is a wart-like lesion which occurs on the skin of the pubic region, genitalia, urethral mucosa, and on occasion may extend into the bladder. This lesion is believed to be auto-inoculable and contagious. The causative micro-organism has not been definitely identified, but is considered by most authorities to be a filterable virus. 1 Podophyllin is recognized as an effective treatment for the external condylomata acuminata. 2 Transurethral resection or coagulation is the usual treatment for intraurethral condylomata acuminata, but repeated recurrences are often a problem. 3 One reported case required cystectomy due to extension into the bladder. 4 The 2 cases of intraurethral condylomata acuminata in this report were troublesome because of multiple recurrences following fulguration. Clorpactin * instillations were thought to be helpful adjuncts in therapy. Clorpactin is believed to be an effective agent for killing free tumor cells 5 , 6 viruses,7 and bacteria, including tubercle bacilli. 8 Clorpactin conAccepted for publication March 10, 1961. 1 Morrow, R. P., McDonald, J. R. and Emmett, J. L.: Condylomata acuminata of the urethra. J. Urol., 68: 909-917, 1952. 2 Culp, 0. S. and Kaplan, I. W.: Condylomata acuminata: Two hundred cases treated with popophyllin. Ann. Surg., 120: 251-256, 1944. 3 Gartman, E.: Intraurethral verruca acuminata in men. J. Urol., 75: 717-718, 1956. 4 Hooks, C.; Personal communication. * The form of clorpactin with a sufficiently high degree of activity exhibiting cytocidal properties against viable tumor cells is presently known as clorpactin XCB. This is the form described in the original paper (Gliedman, Grant, Vestal, Rogers and Karlson: Chlorpactin, a surgical adjunct. Surg. Forum, 8: 104-108, 1957). 5 McDonald, C. T., Howie, J. S., Weeks, P. M. and Thomas, C. G., Jr.: Limiting factors in the prophylaxis of the spread of cancer at operation by chemotherapeutic methods. Surg. Forum, 8: 164-168, 1957. 6 Thomas, C. G., Weeks, P. M. and Brown, B. C.: Control of free tumor cell growth by topical chemotherapeutic agents. Surg. Forum, 9: 598603, 1958. 7 Sanders, M. and Soret, M. G.: Virucidal activity of WCS-90. Antibiotics, 5: 629, 1955. 470
sists of a group of hypochlorous acid derivatives which form a slightly acid and highly buffered solution when dissolved in water. This solution exhibits excellent penetrating power and almost no tissue toxicity. In one study, tumor cells were injected intraperitoneally into laboratory animals. Clorpactin injected within 48 hours was effective in the control of the tumors. 6 It seemed logical to assume that clorpactin might be of value in inhibiting the recurrence of tumors thought to be of viral origin. CASE REPORTS
Case 1. The first patient was 34 years of age. Urologic evaluation in 1953 revealed multiple tumors of the urethra which were fulgurated at 3 month intervals during the course of a year. Each time the condition was thought to have been completely eradicated. The pathological diagnosis of these tumors removed was considered to be condylomata acuminata. From 1954, until first seen by us in 1958, the patient remained asymptomatic and did not receive urologic attention. Physical examination at this time was normal except for a mild meatal stenosis and a small papillary type tumor which could be seen inside the meatus. In July 1928, panendoscopy revealed about thirty papillary tumors distributed evenly from the fossa navicularis to the external sphincter. There were no tumors in the prostatic urethra or bladder. Six of the tumors were biopsied, and all the other tumors and the bases of the biopsy sites were fulgurated with a resectoscope. At the completion of the fulguration the urethra appeared free of tumors. Review of the microscopic sections revealed tumors of the urethra, compatible with condylomata acuminata. Three months later panendoscopy revealed many recurrent papillary tumors of the urethra which were carefully fulgurated. Two months later panendoscopy res Wolinsky, E., Smith, M. M. and Steenken W., Jr.: Tuberculocidal activity of clorpactin, a new chlorine compound. Antibiotic Med., 1: 382, 1955.
T>JTHA lH(BTHHAL CO:'-;DYLO:VIAT.\ ACUJVIl>JAT:\
n,aled n:rnny rnipillarr tumors scattered along the urethra which were biopsied ancl fulguratecl. The appearantc of the tumors was unchanged. It waR apparent that the tumors were not re.,pmHling to fulgmation alone. Recent reports in the literature indicated that clorpac:tin was effrcotive in killing free tumor ce,lls. For this n,ason, a cm1rse of clorpactin irrigatiorrn of the urethrn w a;, arl vised. Thr patient was supplinl with clorpactin powder which he kept in his rdrige,rator at homr. He \\ a~ instructed to fill a clean 1000 cc bottle with tap w:,ter and add 2 gm. c.lorpaetin. This solution wcmld be kqit in thP refrigerator and cliscarcled at the end of a 1Ycek. other day the; patient mmld instill 20 ce solution into trw urc,thra aml clamp the nwatus for 2 minutes. He IH>uld allow the clorpadin to drain out, wait 2 minutes, then n>id. This was continued for :3 rn
urethral cond?lomata acmninat.a. were tl1u1 rice! out. Daily urethral instillation~ with pactin were n,sumed 2 after Urn 1in,thral fulguration. One rnonth later examination vealed three persistent lesicms whicl1 were resectc:d am! fulgurnted. l:rcthral instillations of tin were continued. Two rnontlrn later the was fonncl to have a single ne11mnu1. tum in the prostatic urethm which wa~ rated. Clorpaetin instillations wen: c:ontimierl for 4 rnonths. The' irrigations were discontinuE:cl ·.vhr:n repeated pancndoscopic cxa.minat1ons "I, 4, ,1,1Hi 7 months showed no rec:nrrcnt rnirrnta. Roth of the cases dc-'monstrat
Intrnurethral conclylomata ac:nminat:i a 1"t: fn·" quently diffiC'ult to eradicate:. l"rethml instillations of c:lorpactin mnv be, ful in preventing reC'UJTe'nc:e., rtfter trnns1tn,thr:,l fulguration of r·oml)·lonrnta. :1.cuminata ,1 licnev,,:· the Irsions are extensive or have rlernonstrut.1,rJ ;.i. tendenl')' to n'c.nr. Two cas1,s are presenter! where intraurdhn1I instillation of clorpactin solution \\"ct~ lrnve eontribukd to the rnrr'