Urethral skip metastasis from cancer penis or a second malignancy? A dilemma!

A 76-year old man presented with stricture of bulbar urethra for which he underwent urethral dilatation and was advised to perform self urethral dilatation. Four months later he noticed an ulcerative lesion over glans penis and its biopsy revealed a verrucous carcinoma. This was managed by partial penectomy. The resection margins were free of tumor. Two months following surgery, the patient again developed poor urinary stream. Physical examination revealed normal urethral meatus and there was a hard swelling in midperineal area suggestive of urethral calculus. Retrograde urethrogram showed an irregular filling defect in peno-bulbar urethra (Figure-1). Cystoscopy was inconclusive as only one surface of the lesion was visible and that too was covered by slough. In view of advance age and localized excisable disease, the patient underwent wide excision of the mass with permanent perineal urethrostomy. The histopathological examination of the mass showed hyperkeratinised stratified squamous epithelium showing acanthosis and papillomatosis suggestive of verrucous carcinoma (stage T2).