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Papillary Pseudotumor of the Prostatic Urethra: Proliferative Papillary Urethritis
THE JOURNAL OF UROLOGY
Vol. 111, January
Copyright © 1974 by The Williams & Wilkins Co.
Printed in U.S.A.
PAPILLARY PSEUDOTUMOR OF THE PROSTATIC URETHRA: PROLIFERATIVE PAPILLARY URETHRITIS ROGER SCHINELLA,* JOEL THURM
AND
HELEN FEINER
From the Departments of Pathology and Urology, Bellevue Hospital and New York University Medical Center, New York, New York
Non-neoplastic growths in the prostatic urethra are usually congenital (ectopic prostate tissue and fibroepithelial polyps). A case is described of a papillary lesion of the verumontanum which is neither congenital nor neoplastic but is inflammatory in origin. The name papillary pseudotumor (proliferative papillary urethritis) is suggested.
August 23. The surgical specimen (5028-72) consisted of multiple whitish fragments of tissue weighing in aggregate 6.5 gm. Microscopic examination revealed adenomatoid and fibromuscular hyperplasia of the prostate (benign prostatic hypertrophy) with moderate to severe edema and mild chronic inflammation of the urethral mucosa. One fragment showed a large edematous urethral mucosa! fold of the same size and appearance as was seen in the biopsied lesion and was interpreted as a remnant of it (fig. 2). Convalescence was uneventful.
CASE REPORT
A 72-year-old man was admitted to Bellevue Hospital because of a burn on his buttock. He was found to have urinary tract infection. Urine cultures yielded Klebsiella organisms. The hematologic and blood chemical determinations were normal. An excretory urogram revealed moderate left hydronephrosis with relative ureteropelvic junction obstruction. The right kidney was normal. A post-void film revealed residual urine, suggesting bladder neck obstruction. At cystoscopy on July 26, 1972 a papillary lesion was noted arising from the right side of the verumontanum and posterior urethra. Biopsy (4429- 72) consisted of 2 reddish-brown fragments of unidentifiable tissue, each measuring about 4 mm. in diameter. On microscopic examination the specimen showed edematous, thick mucosa! fronds covered by an epithelium which varied from cuboidal to low columnar (fig. 1). Prostatic ducts entered in the sulci between the projections. Occasional thin-walled distended vessels were seen in the edematous stroma. On serial sections no prostatic glands were identified. Periodic acid, Schiff stain (PAS) before and after diastase digestion revealed diastase resistant PAS positive material only in the lumina of ducts and on the surfaces of the cells lining prostatic ducts and urethral mucosa. Similar staining reactions were found in randomly obtained autopsy sections of prostatic urethral and prostatic ductal epithelium used as controls, whereas within prostatic acini finely granular diastase resistant PAS positive material was seen within the cells as has been described. 1 Cystoscopic examination revealed trabeculation of the bladder. A 25 gm. occlusive prostate was found. No other papillary lesions were noted. Transurethral prostatectomy was performed on
Several lesions must be differentiated from the papillary pseudotumor described herein. The lesion most closely resembling it is a transitional cell papilloma. On microscopic examination the latter shows thin fibrovascular cores and thick layers of transitional cells over the surface. The pseudopapillary tumor shows thick edematous relatively avascular cores and is covered with stratified low columnar to cuboidal cells. In addition one can often identify prostatic ducts entering in the sulci between the projections of the papillary pseudotumor, whereas this would happen only fortuitously in a transitional cell papilloma in the prostatic urethra. The possibility that the lesion could be a variant form of ectopic prostatic glands 2 was ruled out by serial sections which did not show prostatic acini. PAS stain with and without diastase showed positive material only in the lumina of prostatic ducts or at the luminal surface of cells of the prostatic urethra and ducts. The small irregular deeply basophilic intracytoplasmic PAS positive particles described by Butterick and associates as characteristic of prostatic acinar cells were not found in our case. Another lesion in the category of congenital papillary or polypoid lesions of the prostatic urethra is the fibroepithelial polyp described in children. 3 The latter is coarsely polypoid rather than papillary, occurs in male children and microscopically shows glands entrapped in a myxoid edematous stroma.
Accepted for publication July 20, 1973. * Requests for reprints: Pathology Department, Bellevue Hospital, New York, New York 10016. 1 Brandes, D. and Bourne, G. H.: Histochemistry of the human prostate: normal and neoplastic. J. Path. Bact., 71: 33, 1956.
2 Butterick, J. A., Schnitzer, .B. and Abell, M. R.: Ectopic prostatic tissue in urethra: a clinicopathological entity and a significant cause of hematuria. J. Urol., 105: 97, 1971. 3 Downs, R. A.: Congenital polyps of the prostatic urethra. A review of the literature and report of two cases. Brit. J. Urol., 42: 76, 1970.
DISCUSSION
38
PAPILLARY PSEUDOTUMOR OF PROSTATIC URETHRA
FIG. 1. A, papillary pseudotumor of prostatic urethra. Note edematous stroma and sulci between projections. H & E, reduced from x60. B, higher power view of lesion. epithelium. H & E, reduced from x 150.
Endometrial carcinoma 4 or a primary duct adenocarcinoma of the prostate' is ruled out in this case because of the lack of or of a glandular pattern in the lesion. 2 In 1913 Randall described as villous cases of polypoid lesions of the urethra a few thin similar to those in our case. 6 of the material show severe edema the entire transitional mucosa including the urethral folds; the latter coarse pap'Melicow, M. M. and carcinoma of uterus masculinus port of 6 cases. J. Hl6: 'Dube, V. Joyce, primary duct 107: 825, 1972. 'Randall, A.: A study of the urethra. Surg., Gynec. & ObsL, 17:
illary projections. Randall related the lesion previous gonococcal urethritis. We consider om lesion similar to these but with a greater of urethral fold edema, thus (that rather appearance --····----., and on tion. The suggestion that the papillary areas represent edematous urethral mucosa! folds is reinforced the facts that 1) prostatic ducts were often entering between them--this is the normal ana tomic "~'~v,v,rn,.«,.., between urethral 7 2) the resemblance to and prostatic urethral folds (fig. 3)--it is easy to see the loose 7 Stieve, H.: Ma:nnliche Genitalorgane. In: Handbuch der Mikroskopischen Anatomie des Menschen. Edited W. von Mollendorff. Berlin: Julius Springer Verlag, 7, part 2, p. 216, figs. 148-150, 1930.
40
SCHINELLA, THURM AND FEINER
FIG. 2. Transurethral prostatectomy specimen 5028-72. Note similar size and appearance of edematous urethral fold which can now be seen, in situ, within urethral mucosa of posterior prostate. This is interpreted as remnant of lesion shown. in figure 1. H & E, reduced from x80.
FIG. 3. Prostatic urethral mucosa from suprapubic prostatectomy for benign prostatic hypertrophy shown for comparison. Section of normal prostatic urethra. Normal prostatic urethral folds. Note loose stroma. Should latter become edematous it is easy to see how it could produce lesion similar to figure 1. H & E, reduced from x60.
stroma of these urethral folds how they could become edematous and 3) subsequent transurethral prostatectomy in this case revealed an edematous urethra fold still in situ and maintaining its normal relation to the urethral mucosa (fig;. 2). The similarity of the edematous fold in situ to the biopsy specimen suggests that this was indeed a remnant of the lesion previously biopsied. A possible cause of urethral mucosal fold edema in this patient may have been the benign prostatic hypertrophy. If so, this pseudopapillary lesion may be more common than has been realized.
SUMMARY
A case is reported of a papillary lesion of the prostatic urethra. The lesion is caused by edema of the urethral mucosal folds. Congenital and neoplastic papillary lesions are ruled out on clinical and histologic grounds. The slides were reviewed by Dr. E. B. Price, Jr. who agreed with our interpretation that the papillary lesion was due to edematous, inflamed prostatic urethral folds. He suggested the name "proliferative papillary urethritis" for the lesion.
Vol. 111, January
Copyright © 1974 by The Williams & Wilkins Co.
Printed in U.S.A.
PAPILLARY PSEUDOTUMOR OF THE PROSTATIC URETHRA: PROLIFERATIVE PAPILLARY URETHRITIS ROGER SCHINELLA,* JOEL THURM
AND
HELEN FEINER
From the Departments of Pathology and Urology, Bellevue Hospital and New York University Medical Center, New York, New York
Non-neoplastic growths in the prostatic urethra are usually congenital (ectopic prostate tissue and fibroepithelial polyps). A case is described of a papillary lesion of the verumontanum which is neither congenital nor neoplastic but is inflammatory in origin. The name papillary pseudotumor (proliferative papillary urethritis) is suggested.
August 23. The surgical specimen (5028-72) consisted of multiple whitish fragments of tissue weighing in aggregate 6.5 gm. Microscopic examination revealed adenomatoid and fibromuscular hyperplasia of the prostate (benign prostatic hypertrophy) with moderate to severe edema and mild chronic inflammation of the urethral mucosa. One fragment showed a large edematous urethral mucosa! fold of the same size and appearance as was seen in the biopsied lesion and was interpreted as a remnant of it (fig. 2). Convalescence was uneventful.
CASE REPORT
A 72-year-old man was admitted to Bellevue Hospital because of a burn on his buttock. He was found to have urinary tract infection. Urine cultures yielded Klebsiella organisms. The hematologic and blood chemical determinations were normal. An excretory urogram revealed moderate left hydronephrosis with relative ureteropelvic junction obstruction. The right kidney was normal. A post-void film revealed residual urine, suggesting bladder neck obstruction. At cystoscopy on July 26, 1972 a papillary lesion was noted arising from the right side of the verumontanum and posterior urethra. Biopsy (4429- 72) consisted of 2 reddish-brown fragments of unidentifiable tissue, each measuring about 4 mm. in diameter. On microscopic examination the specimen showed edematous, thick mucosa! fronds covered by an epithelium which varied from cuboidal to low columnar (fig. 1). Prostatic ducts entered in the sulci between the projections. Occasional thin-walled distended vessels were seen in the edematous stroma. On serial sections no prostatic glands were identified. Periodic acid, Schiff stain (PAS) before and after diastase digestion revealed diastase resistant PAS positive material only in the lumina of ducts and on the surfaces of the cells lining prostatic ducts and urethral mucosa. Similar staining reactions were found in randomly obtained autopsy sections of prostatic urethral and prostatic ductal epithelium used as controls, whereas within prostatic acini finely granular diastase resistant PAS positive material was seen within the cells as has been described. 1 Cystoscopic examination revealed trabeculation of the bladder. A 25 gm. occlusive prostate was found. No other papillary lesions were noted. Transurethral prostatectomy was performed on
Several lesions must be differentiated from the papillary pseudotumor described herein. The lesion most closely resembling it is a transitional cell papilloma. On microscopic examination the latter shows thin fibrovascular cores and thick layers of transitional cells over the surface. The pseudopapillary tumor shows thick edematous relatively avascular cores and is covered with stratified low columnar to cuboidal cells. In addition one can often identify prostatic ducts entering in the sulci between the projections of the papillary pseudotumor, whereas this would happen only fortuitously in a transitional cell papilloma in the prostatic urethra. The possibility that the lesion could be a variant form of ectopic prostatic glands 2 was ruled out by serial sections which did not show prostatic acini. PAS stain with and without diastase showed positive material only in the lumina of prostatic ducts or at the luminal surface of cells of the prostatic urethra and ducts. The small irregular deeply basophilic intracytoplasmic PAS positive particles described by Butterick and associates as characteristic of prostatic acinar cells were not found in our case. Another lesion in the category of congenital papillary or polypoid lesions of the prostatic urethra is the fibroepithelial polyp described in children. 3 The latter is coarsely polypoid rather than papillary, occurs in male children and microscopically shows glands entrapped in a myxoid edematous stroma.
Accepted for publication July 20, 1973. * Requests for reprints: Pathology Department, Bellevue Hospital, New York, New York 10016. 1 Brandes, D. and Bourne, G. H.: Histochemistry of the human prostate: normal and neoplastic. J. Path. Bact., 71: 33, 1956.
2 Butterick, J. A., Schnitzer, .B. and Abell, M. R.: Ectopic prostatic tissue in urethra: a clinicopathological entity and a significant cause of hematuria. J. Urol., 105: 97, 1971. 3 Downs, R. A.: Congenital polyps of the prostatic urethra. A review of the literature and report of two cases. Brit. J. Urol., 42: 76, 1970.
DISCUSSION
38
PAPILLARY PSEUDOTUMOR OF PROSTATIC URETHRA
FIG. 1. A, papillary pseudotumor of prostatic urethra. Note edematous stroma and sulci between projections. H & E, reduced from x60. B, higher power view of lesion. epithelium. H & E, reduced from x 150.
Endometrial carcinoma 4 or a primary duct adenocarcinoma of the prostate' is ruled out in this case because of the lack of or of a glandular pattern in the lesion. 2 In 1913 Randall described as villous cases of polypoid lesions of the urethra a few thin similar to those in our case. 6 of the material show severe edema the entire transitional mucosa including the urethral folds; the latter coarse pap'Melicow, M. M. and carcinoma of uterus masculinus port of 6 cases. J. Hl6: 'Dube, V. Joyce, primary duct 107: 825, 1972. 'Randall, A.: A study of the urethra. Surg., Gynec. & ObsL, 17:
illary projections. Randall related the lesion previous gonococcal urethritis. We consider om lesion similar to these but with a greater of urethral fold edema, thus (that rather appearance --····----., and on tion. The suggestion that the papillary areas represent edematous urethral mucosa! folds is reinforced the facts that 1) prostatic ducts were often entering between them--this is the normal ana tomic "~'~v,v,rn,.«,.., between urethral 7 2) the resemblance to and prostatic urethral folds (fig. 3)--it is easy to see the loose 7 Stieve, H.: Ma:nnliche Genitalorgane. In: Handbuch der Mikroskopischen Anatomie des Menschen. Edited W. von Mollendorff. Berlin: Julius Springer Verlag, 7, part 2, p. 216, figs. 148-150, 1930.
40
SCHINELLA, THURM AND FEINER
FIG. 2. Transurethral prostatectomy specimen 5028-72. Note similar size and appearance of edematous urethral fold which can now be seen, in situ, within urethral mucosa of posterior prostate. This is interpreted as remnant of lesion shown. in figure 1. H & E, reduced from x80.
FIG. 3. Prostatic urethral mucosa from suprapubic prostatectomy for benign prostatic hypertrophy shown for comparison. Section of normal prostatic urethra. Normal prostatic urethral folds. Note loose stroma. Should latter become edematous it is easy to see how it could produce lesion similar to figure 1. H & E, reduced from x60.
stroma of these urethral folds how they could become edematous and 3) subsequent transurethral prostatectomy in this case revealed an edematous urethra fold still in situ and maintaining its normal relation to the urethral mucosa (fig;. 2). The similarity of the edematous fold in situ to the biopsy specimen suggests that this was indeed a remnant of the lesion previously biopsied. A possible cause of urethral mucosal fold edema in this patient may have been the benign prostatic hypertrophy. If so, this pseudopapillary lesion may be more common than has been realized.
SUMMARY
A case is reported of a papillary lesion of the prostatic urethra. The lesion is caused by edema of the urethral mucosal folds. Congenital and neoplastic papillary lesions are ruled out on clinical and histologic grounds. The slides were reviewed by Dr. E. B. Price, Jr. who agreed with our interpretation that the papillary lesion was due to edematous, inflamed prostatic urethral folds. He suggested the name "proliferative papillary urethritis" for the lesion.