A Case Of Extensive Condylomata Acuminate In Urinary Tract And Literature Review

BackgroundCondylomata acuminate(CA)is caused by human papilloma virus(HPV),the incubation period is 3 months on average,sexual transmission is the main pattern of infection,accounts for more than 95%,and involved mother-to-child vertical transmission,indirect contact transmission and iatrogenic transmission.In recent years,the average annual growth rate of CA in China is increasing,the number is the second in the sexually transmitted diseases,and the peak of onset age ranges between 20 and 29 years.For male,it is often found in urethra meatus,glans penis,coronal sulcus,frenulum of prepuce and penis.For female,it is often found in labium majus pudendi and labium minus,vagina,cervix,and perianal mucosa.Nearly 80 percent of the lesions of CA will be within the distal 3 cm of the urethra,rarely seen in the deep anterior urethra and posterior urethra,as for bladder,ureter,and pyelo and renal calyx are even rarer.Generally,they have a history of external genital or(and)perianal CA,or occurred secondary to external genital or(and)perianal CA,or occurred in isolation.The occurrence of CA is related to HPV infection,transmission pathway,susceptibility population,and so on.The infection mechanism in urinary tract is not clear.The CA in urinary tract,in particular,the upper urinary tract,is insidious,and the treatment is very difficult.Long-standing warts even can transform into malignant tumor,or be accompanied with malignant tumor.It will bring unbearable pressure of economy and psychology to patients and their familiy.Clinicians should pay high attention to it.ObjectiveTo explore the clinical features,auxiliary examinations,treatment and prognosis of the patients with CA in deep anterior urethra and posterior urethra,bladder,ureter,and pyelo and renal calyx,and pay attention to check the infection and malignant transformation of CA in the deep lower urinary tract and upper urinary tract in the clinical work.MethodsThe clinical data,laboratory examination,imaging and endoscopic manifestations,treatment and prognosis of the patients with CA in deep anterior urethra and posterior urethra,bladder,ureter,and pyelo and renal calyx treated in our hospital and published in domestic or abroad were induced and analyzed retrospectively.Results 1.Basic informationA total of 29 cases were included in the case,13 males and 16 females,of which 1 case from our hospital,28 cases from literatures.25~78 years old can be affected,the median age of all the cases is 34 years old.The course ranges from 2 weeks to 8 years.62.07%(18/29)patients involved one single organ,24.14%(7/29)of which involved urethral,34.48%(10/29)involved bladder,and 3.45%(1/29)involved ureteral orifice.37.93%(11/29)affected two organs,34.48%(10/29)of which affected urethral and bladder,and 3.45%(1/29)affected bladder and renal pelvis.The trigone of urinary bladder and bladder neck is the most common involved.27.59%(8/29)occurred secondary to external genital or(and)perianal CA;83.33%(15/18)have a history of external genitalia or(and)perianal CA;11.11%(2/18)occurred in isolation.5.55%(1/18)have a history of catheterization;16.67%(3/18)diagnosed with acquired immune deficiency syndrome(AIDS),one of which was accompanied with gastrointestinal malignant tumor;33.33%(6/18)have a long-term immunosuppressive agents or(and)glucocorticoid application history;66.67%(12/18)have a history of iterative urinary tract infection;5.55%(1/18)is normal.Only one patient’s family members had HPV related disease.2.Clinical features62.50%(15/24)of the patients have different degrees of symptoms of urinary tract obstruction,54.17%(13/24)show the microscopic or gross hematuria,mostly asymptomatic or painless,41.67%(10/24)have bladder irritation symptoms,12.50%(3/24)feel itching in urethra.There are differences in clinical manifestations of different patients.The endoscopic appearance demonstrating single or multiple reddish neoplasms of different sizes,presented as cauliflower-like,villous or papillary,part of them easy to fall off and bleeding,but necrosis is uncommon.3.Imaging manifestations5 cases performed urography and presented as partial filling defect of the urethra or bladder.15 cases performed ultrasound examination and presented as low or strong echo neoplasms of different sizes,single or multiple,cauliflower-like,lobulated or polypoid,endo-luminal growth;4 of which performed color doppler flow imaging(CDFI),3 cases can be detected with a little or abundant of blood flow signals.4.Pathological manifestationsThe histopathologic diagnosis of all the 29 cases is CA,characterized by squamous epithelium hyperkeratosis,acanthosis cell layer thickening,papillomatous hyperplasia,a little or abundant of typical koilocyte,and mild-to-moderate or significant cytologic atypia.Immunohistochemistry: the detection results of HPV are 6 and 11 almostly.5.Treatment and prognosis72.72%(16/22)were treated with endoscopic resection/electrocautery and 9.09%(2/22)were treated with cystectomy;4.55%(1/22)were treated with multiple surgeries;4.55%(1/22)were treated with the split of urethra first,then accepted 5-aminolevalinic acid photodynamic therapy(ALA-PDT).Postoperative adjuvant therapy included systemic or(and)topical treatment.In addition,4.55%(1/22)accepted radiotherapy and chemotherapy;4.55%(1/22)accepted antiretroviral therapy.The 13.64%(3/22)of patients lost to follow-up,54.55%(12/22)followed up for 50 days to 4 years without recurrence,1 case of which accompanied anal squamous cell carcinoma(SCC).5.26%(1/19)warts dwindled in size.10.53%(2/19)recurrent.15.79%(3/19)developed malignant tumors of urinary system,1 of them died.Another one died of AIDS’ complications,accounted for 10.53%(2/19)totally.Conclusion1.CA not only can occur in the external genitalia or(and)perianal skin or mucosa,but also can occur in deep anterior urethra and posterior urethra,bladder,ureter,and pyelo,renal calyx.It can be secondary to the former or after the treatment for several months to years.2.The CA of urinary tract,in particular,the upper urinary tract,is insidious,not easy to find,and the mechanism of ascending infection is not clear.Its clinical symptoms and physical signs,imaging manifestations are similar to tumors,histopathological examination combined with HPV immunohistochemical are necessary for the diagnosis.3.The CA in urinary tract is often treated by endoscopic resection or cauterization,and the effectiveness of ALA-PDT is also good.Most of patients have good prognosis without recurrence.A few long-standing warts in the urinary tract can transform into malignant tumor,or be accompanied with malignant tumor.Clinicians should pay attention to long-term dynamic follow-up.