Holmium laser fulguration of superficial urothelial carcinoma of the pendulous urethra
The patient is a 83-year-old man with an history of noninvasive urothelial carcinoma 6 years prior to presentation previously treated with TURBT and an induction course of intravesical of BCG therapy. He presented to the spinal cord injury unit after a cauda equina syndrome developed following lumbar spine surgery. Due to his previous UC history, the standard surveillance of urothelial carcinoma was used to investigate for recurrence. A cytology was obtained and showed atypical cells in groups. The initial office flexible cystoscopy demonstrated a noninvasive appearing UC covering approximately 50% of his pendulous urethra with frondular lesions. The prostatic and membranous urethra were spared. The patient was taken to the operating room for cystourethroscopy under anesthesia, biopsies and upper urinary tract evaluation. The upper urinary tracts were negative for lesions on retrograde pyelogram and bladder and urethral biopsies were obtained with similar pathology as seen on office cystoscopy. On pathology, the biopsies showed low-grade superficial urothelial carcinoma (pTa) with a small focus of high-grade carcinoma []. Surgical options were then discussed and the patient wanted a bladder sparing minimally invasive surgery. Therefore, the patient was taken back to the operating room for a second look TURBT and a staged fulguration of urothelial carcinoma with the holmium laser [Figures and ]. Using holmium:YAG laser vaporization through a 21-Fr cystoscope, the lesions in the pendulous urethra were ablated using a 600 μm fiber with settings of 8 Hz and 1.0 Joules (8 Watts). Only one half of the urethra was treated for fear of urethral stricture. A total time of 20 minutes was taken for the procedure with minimal discomfort postoperatively. Mitomycin C was instilled (40 mg in 20 cc of sterile water) for 1 hour immediately after the procedure. This was done due to his history of UC in the bladder as well as cells from the ablation may have been introduced into the bladder with the irrigation fluid. A 22-F Silastic Foley catheter was placed and continued for 4 days after surgery. We subsequently performed the second stage of the procedure which included treatment of the other half of the lesions after one month once an office cystoscopy revealed there was no urethral stricture formation. After the second therapy he elected for BCG therapy and he has now been under surveillance for 18 months without cystoscopic evidence of a urethral recurrence and no formation of urethral stricture [].