SMALL BLADDER AND MULTIPLE URETHRAL RECURRENCES AFTER INTRAVESICAL INSTILLATION OF BACILLUS CALMETTE-GUERIN FOR SUPERFICIAL TRANSITIONAL CELL CARCINOMA OF THE BLADDER PASQUALINO MANASIA, ANTONIO ALCARAZ, ALFREDO CETINA AND JUAN ALCOVER From the Department of Urology and Renal Transplantation, Hospital Clinic, University of Barcelona, Barcelona, Spain KEY WORDS: mycobacterium bovis; urethra; carcinoma, transitional cell; bladder Bacillus Calmette-Guerin (BCG) has been established as one of the most active agents for the management of super- ficial bladder tumors and carcinoma in situ. Although sys- temic reactions have been reported, adverse reactions are most often localized to the bladder. Dysuria (59%), frequency (40.4%) and hematuria (26%) are the 3 most common mani- festations. 1 To our knowledge we report the first case of a small bladder associated with multiple urethral recurrences of transitional cell carcinoma of the bladder. CASE REPORT A 63-year-old white man was followed at our institution for more than 10 years for recurrent (8) superficial low grade bladder tumors and rare positive cytological examinations. In January 1999 on routine followup cystoscopy a benign appearing papillary lesion was discovered. Transurethral re- section of the bladder tumor and random biopsies revealed atypical T1 grade 2 and associated carcinoma in situ. Immu- nohistochemistry did not demonstrate p53 abnormalities. The patient received a 6-week course of weekly intravesical instillation of BCG. He returned to the hospital 3 months later with gross hematuria, nocturia, severe urgency and urinary frequency, and initial urge incontinence. Urethrocystoscopy revealed 2 papillary tumors of the prostatic urethra and 1 papillary tumor of the bulbar urethra. Examination of the bladder could not be completed due to extreme contracture. A scout film of an excretory urogram demonstrated a small bladder, marked bilateral ureterohydronephrosis and small prostatic urethra expansion (fig. 1). Preoperative pelvic computerized tomography showed a small bladder with bilateral dilatation of the distal ureter without regional and metastatic disease (fig. 2). The patient underwent radical cystoprostatectomy with ileal loop diversion and urethrectomy. Final pathological evaluation indicated detrusor muscle fibrosis without inflam- mation, and multiple foci of transitional cell carcinoma into the prostate gland, 3 typical Ta grade 3 transitional cell carcinomas and associated carcinoma in situ of the prostatic bulbar urethra. Surgical margins were negative. Surgery achieved good results and the patient is disease-free 7 months postoperatively. DISCUSSION Local side effects of BCG instillation therapy are defined as those confined to the bladder or organs in contact with BCG bacilli. Toxicity has been reported to be substantially greater with intensive treatment but severe side effects have also been observed after only a few instillations. Bladder contrac- ture as a result of this treatment is a rare and serious local complication. It has been observed predominantly in patients on a maintenance schedule but it also has been reported after multiple transurethral resections and instillations with che- motherapeutic drugs. 2 Because of the low frequency (0.2%) of contracted bladder and pretreatment of most patients with Accepted for publication September 8, 2000. FIG. 2. Unenhanced computerized tomography of pelvis reveals microbladder. FIG. 1. Excretory urography shows retractile microbladder with bilateral ureterohydronephrosis and small prostatic urethra expan- sion. 0022-5347/01/1652-0529/0 THE JOURNAL OF UROLOGY ® Vol. 165, 529 –530, February 2001 Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION,INC. ® Printed in U.S.A. 529